The inferior hypogastric plexus (IHP) is a triangle with a posterior base and an anterior inferior top. It can be described as having three edges and three angles; its inferior edge stretches constantly from the fourth sacral root to the ureter's point of entry into the posterior layer of the broad ligament; its cranial edge is strictly parallel to the posterior edge of the hypogastric artery, along which it runs at a distance of 10 mm; its posterior (dorsal) edge is at the point of contact with the sacral roots, from which it receives its afferences. They most frequently originate from S3 or S4 (60%) and then, in one or two branches, often from S2 (40%), never from S1 and in exceptional cases from S5 (20%). There are sympathetic afferences in 30% of cases, usually through a single branch of the second, third or fourth sacral ganglion. All IHPs have at least one sacral afference and sometimes there may be up to three afferences from the same sacral root. Its dorsal cranial angle, which is superior, comes after the SHP (hypogastric nerve or presacral nerve filament); its anterior inferior angle is located exactly at the ureter's point of entry into the posterior layer of the broad ligament. This is the top of the IHP; its posterior inferior angle is located at the point of contact with the fourth sacral root. At its entrance at the base of the parametrium the pelvic ureter is the anterior, fundamental positional reference for the IHP. The vaginal efferences come out of the top of the IHP through branches leading to the bladder, the vagina and the rectum, which originate through two trunks exactly underneath the crossing point of the ureter and the uterine artery: (i) one trunk leading to the bladder runs along and underneath the ureter and divides into two groups, which are lateral and medial, trigonal. (ii) the trunk leading to the vagina runs along the inferior edge of the uterine artery. At the point of contact with the lateral edge of the vagina, it splits into two groups: anterior thin and posterior voluminous. Some of its branches perforate the posterior wall of the vagina and are distributed to the rectovaginal septum in a tooth comb pattern. The inferior branches, which emerge from the inferior edge of the IHP, reach the rectum directly. The dissection of the 22 specimens allowed us to describe three efferent plexuses: a vaginal rectal plexus, a vesical plexus and a inferior rectal plexus. So the IHP's anterior, fundamental positional reference is the pelvic ureter at the point where it enters at the base of the parametrium, then at the crossing point of the uterine artery. The ureter is the vector for vesical efferences, the uterine artery is the vector for vaginal efferences, which are thus sent into the vesicovaginal septum and the rectovaginal septum. This surgical point of reference is of vital importance in nerve sparing during the course of a simple or extended hysterectomy. Any dissection carried out underneath and outside of the ureter inevitably carries a risk of lesions to its efferent, lateral ...

The purpose of this paper is to present our experience with real-time computed tomography (CT) fluoroscopy guided percutaneous nephrostomy (PNT) and to describe this technique involving puncture under laser guidance. We attempted 30 placements in 25 patients: puncture was directed by laser guidance and placement of the tube was made under real time CT fluoroscopy. 25 procedures were performed in prone position and 5 procedures in the supine position. The time necessary for the procedure ranged from 10 to 45 min (mean 25 min). The average duration of CT fluoroscopy per placement was 49 seconds (range 7-110 s). The PNT placement was successful as a sole procedure including puncture and catheter placement in 24 of 30 cases; in the remainder of cases, puncture was performed under CT guidance but the catheter was definitively positioned in conventional fluoroscopy. The CT fluoroscopy technique allows routine, efficient and safe PNT placement, especially when encountering difficult access to the pelvicaliceal system.

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