Clinical Anatomy Required in Identifying Pelvic Autonomic Nerve System

Abstract

Video Objective Comprehension of structure of pelvic autonomic nerve system is mandatory for constant preservation of voiding function while maintaining oncological outcome of radical hysterectomy. Setting 47 years old, cervical cancer T1bN0M0. Total laparoscopic nerve sparing radical hysterectomy is presented. Interventions Superior hypogastric nerve plexus and inferior hypogastric nerves are in the same layer between pararectal space of Latzko and Okabayashi. Two subperitoneal fasciae are identified in pelvic retroperitoneal space: pre-hypogastric nerve fascia in ventral side, ureterohypogastric fascia in dorsal side of ureter and hypogastric nerves. Pelvic splanchnic nerves are identified in lateral side of pre-hypogastric nerve fascia, so preservation of these fasciae during operation result in protection of hypogastric and pelvic splanchnic nerves. Pelvic nerve plexus is identified in dorsal side of deep uterine vein and superior vesical vein. Careful slice up of these veins and preserve underlying fasciae result in protection of pelvic nerve plexus. Vesical nerve branch is identified in caudal side of posterior leaf of vesicouterine ligament (VUL). Division of posterior leaf of VUL is required to visualize vesical nerve branch, but constant preservation of voiding function is feasible once location of vesical nerve branch is understood. Outline of surgical procedure to identify and preserve hypogastric nerves and vesical nerve branch is presented in the video of TLRH for cervical cancer stage 1B1. Conclusion Once visualization of pelvic autonomic nerve system is experienced, stable preservation of voiding function in radical hysterectomy is realized.