Surgical Anatomy and Dissection of the Hypogastric Plexus in Nerve-Sparing Radical Hysterectomy

Abstract

Radical hysterectomy is a central surgical procedure in gynecological oncology. A nerve-sparing approach is essential to minimize complications from iatrogenic injury to the pelvic nerves, resulting in postoperative urinary, anorectal, and sexual dysfunction. The hypogastric plexus (HP), a complex network of sympathetic and parasympathetic nerves, plays a critical role in pelvic autonomic innervation. This article offers a comprehensive overview of the surgical anatomy of the HP and provides a step-by-step description of HP dissection, with a particular emphasis on preserving the bladder nerve branches of the inferior HP. A thorough understanding and mastery of the anatomical and surgical nuances of HP dissection are crucial for optimizing outcomes in nerve-sparing gynecologic-oncological procedures.

Anatomical Location of the Vesical Branches of the Inferior Hypogastric Plexus in Human Cadavers

“…The course of vesical branches of the IHP has been described as consistent with two terminal branches by Mauroy et al [5,18], matching our findings. These branches have been shown to travel with the ureter as it approaches the bladder in a recent anatomical study describing nervesparing radical hysterectomy methods (see Figure 16 of [10]; the vesical branches of the IHP are termed "bladder nerve branches" in that study). Another study has also reported that the vesical branches join the last segment of the ureter at the base of the bladder along its lateral border (see Figure 5 in [9]).…”

“…These parasympathetic pelvic splanchnic nerves join inferior branches of the hypogastric nerves to form the inferior hypogastric plexus (IHP, also termed the pelvic plexus [4]), located on both the right and left sides of the pelvis [5][6][7][8]. Sympathetic sacral splanchnic nerves from sacral located sympathetic ganglia also send branches into the IHP [9][10][11]. The anterior division of the IHP supplies nerve fibers to the bladder and ureter (i.e., vesical branches of the IHP, also known as vesical branches of the pelvic nerve [12][13][14][15][16], anterior branches of the IHP [9,17,18], and bladder nerve branches [10]).…”

“…Sympathetic sacral splanchnic nerves from sacral located sympathetic ganglia also send branches into the IHP [9][10][11]. The anterior division of the IHP supplies nerve fibers to the bladder and ureter (i.e., vesical branches of the IHP, also known as vesical branches of the pelvic nerve [12][13][14][15][16], anterior branches of the IHP [9,17,18], and bladder nerve branches [10]). The anterior division of the IHP also supplies nerve branches to the uterus and vagina, or prostate [7]; see [9][10][11] for more regarding the anatomy of this entire plexus.…”

“…The anterior division of the IHP supplies nerve fibers to the bladder and ureter (i.e., vesical branches of the IHP, also known as vesical branches of the pelvic nerve [12][13][14][15][16], anterior branches of the IHP [9,17,18], and bladder nerve branches [10]). The anterior division of the IHP also supplies nerve branches to the uterus and vagina, or prostate [7]; see [9][10][11] for more regarding the anatomy of this entire plexus. The pre-ganglionic parasympathetic motor axons to the bladder synapse on post-ganglionic parasympathetic motor neurons in pelvic ganglia located near yet external to the bladder wall.…”

“…Another group has transferred the obturator nerve to the pelvic splanchnic nerve for recovery of urination function after sacral plexus injury in patients, although the outcomes have yet to be reported [25]. Several nerve-sparing techniques and concepts for radical pelvic surgery have been proposed (such as for radical hysterectomy) [4,10,[26][27][28][29]. However, further clarification of the anatomical location and relationships of the vesical branches of the IHP and pelvic ganglion (the latter for sparing purposes) is warranted to assist with their identification during laparoscopic surgical procedures for the transfer of somatic nerves to the vesical branches of the IHC for the purposes of restoration of bladder function.…”