Neural entrapment during uterosacral ligament suspension: an anatomic study of female cadavers.

OBJECTIVE: To describe retroperitoneal neural structures at risk during uterosacral ligament suspension and to estimate risk of neural injury based on uterosacral ligament suspension suture placement technique. METHODS: Uterosacral ligament suspension was performed in 10 unembalmed female cadavers. In each cadaver, bilateral uterosacral ligament suspension sutures were placed using different techniques, as described in the literature. Distances from the ischial spine and instances of neural entrapment were recorded. Biopsy specimens of the deepest (most dorsal) tissue that each suture traversed were immunostained with a nerve-specific (S100) antibody, and the largest nerve diameter was recorded. RESULTS: Median location of sutures relative to the ischial spine did not differ significantly by suture technique. Portions of sacral nerve roots were encircled by uterosacral ligament suspension sutures in seven cadavers. There were no instances of nerve entrapment when sutures were placed while tenting the ligament with an Allis clamp, although these sutures contained a less substantial purchase of connective tissue. In six cadavers, sacral nerves were encircled by sutures placed using a dorsal and posterior arc, regardless of the needle size. In one instance, only the larger CT-1 needle encircled sacral nerve roots. S100 immunostaining confirmed gross findings, with nerve tissue in all specimens (diameter 30-1,225 micrometers). Mean nerve diameter was significantly larger in biopsy specimens in which entrapment was noted grossly (472 micrometers compared with 108 micrometers; P<.001). CONCLUSION: Sacral nerve roots are the most vulnerable neural structures during uterosacral ligament suspension. Suture placement directly into the uterosacral ligament with a dorsal and posterior needle arc results in a higher risk of nerve entrapment compared with ventral tenting of the ligament.

Laparoscopic uterosacral nerve ablation for alleviating chronic pelvic pain: a randomized controlled trial.

CONTEXT: Chronic pelvic pain is a common condition with a major effect on health-related quality of life, work productivity, and health care use. Operative interruption of nerve trunks in the uterosacral ligaments by laparoscopic uterosacral nerve ablation (LUNA) is a treatment option for patients with chronic pelvic pain. OBJECTIVE: To assess the effectiveness of LUNA in patients with chronic pelvic pain. DESIGN, SETTING, AND PARTICIPANTS: Randomized controlled trial of 487 women with chronic pelvic pain lasting longer than 6 months without or with minimal endometriosis, adhesions, or pelvic inflammatory disease, who were recruited to the study by consultant gynecological surgeons from 18 UK hospitals between February 1998 and December 2005. Follow-up was conducted by questionnaires mailed at 3 and 6 months and at 1, 2, 3, and 5 years. INTERVENTION: Bilateral LUNA or laparoscopy without pelvic denervation (no LUNA); participants were blinded to the treatment allocation. MAIN OUTCOME MEASURES: The primary outcome was pain, which was assessed by a visual analogue scale. Data concerning the 3 types of pain (noncyclical pain, dysmenorrhea, and dyspareunia) were analyzed separately as was the worst pain level experienced from any of these 3 types of pain. The secondary outcome was health-related quality of life, which was measured using a generic instrument (EuroQoL EQ-5D and EQ-VAS). RESULTS: After a median follow-up of 69 months, there were no significant differences reported on the visual analogue pain scales for the worst pain (mean difference between the LUNA group and the no LUNA group, -0.04 cm [95% confidence interval {CI}, -0.33 to 0.25 cm]; P = .80), noncyclical pain (-0.11 cm [95% CI, -0.50 to 0.29 cm]; P = .60), dysmenorrhea (-0.09 cm [95% CI, -0.49 to 0.30 cm]; P = .60), or dyspareunia (0.18 cm [95% CI, -0.22 to 0.62 cm]; P = .40). No differences were observed between the LUNA group and the no LUNA group for quality of life. CONCLUSION: Among women with chronic pelvic pain, LUNA did not result in improvements in pain, dysmenorrhea, dyspareunia, or quality of life compared with laparoscopy without pelvic denervation. TRIAL REGISTRATION: controlled-trials.com Identifier: ISRCTN41196151.

Investigación anatómica de los plexos autónomos génito-vesicales; su importancia en la cirugía del cáncer del recto / Anatomic investigation of autonomous urogenital innervations: importance in rectum cancer surgery

Antecedentes: En la cirugía del cáncer de recto, próstata y útero es necesario conocer la inervación autónoma urogenital a fin de realizar una resección radical con preservación de dicha inervación. Objetivo: Determinar los jalones apropiados para la investigación del plexo presacro, nervios y plexo hipogástrico inferior, erectores en su origen y trayecto que siguen hacia los órganos genitourinarios. Lugar de aplicación: Hospital Público. Diseño: Trabajo de investigación anatómico. Población: 7 especímenes, 5 masculinos y 2 femeninos, se disecaron en total 10 plexos. Método: a) investigación del plexo presacro, nervios y plexo hipogástrico inferior y erectores; b) resección en bloque con un segmento de órganos vecinos; c) estaqueada la pieza es sumergida en formol y Complucad; d) disección de los plexos, fotografías y esquemas; e) biopsias de segmentos de dichos plexos. Resultados: Los erectores dependientes del 3º y 4º nervio espinal estuvieron presentes en todas las piezas. Los originados en S3 eran de mayor envergadura y alcanzaban el plexo hipogástrico inferior, los originados en S4 eran finos y discurrían directamente hacia el pene, 1 caso se integraba al plex

Functional properties of afferent fibers supplying reproductive and other pelvic organs in pelvic nerve of female rat.

1. Electrophysiological techniques were used to characterize responses of afferent fibers in pelvic nerve of adult, virgin female rats to mechanical or chemical stimulation of internal reproductive organs and to mechanical stimulation of other pelvic organs. 2. In an in vivo barbiturate-anesthetized preparation, pelvic nerve afferent fibers responded to a wide variety of mechanical stimulation applied to restricted regions of the vaginal canal, caudal uterus (body and cervix), bladder, ureter, colon, or anus. 3. Single-fiber mechanoreceptive fields were invariably confined to a single organ. Notably, responses could be evoked not only by gentle stimulation of the unit's receptive field directly on the organ itself, but also by stimulating the field indirectly with intense stimulation through the appropriate part of a contiguous organ. This innervation feature is consistent with the separability of pelvic organ functions under innocuous conditions but their confusion under noxious ones. 4. Receptive fields on the reproductive organs extended from the caudal edge of the vagina to the uterine body (including the cervix) but were most often located in the fornix (vaginocervical junction). Most units had no or low levels of spontaneous activity. Their responses to mechanical stimuli were usually slowly or moderately adapting and time-locked to the stimulus. 5. Fibers with vaginal receptive fields (including the fornix) responded best either to vaginal distension with a balloon or, more often, to a probe moving along the internal vaginal surface in a direction toward the cervix. They were observed most frequently during the proestrus stage of the rat's estrous cycle. These fibers, therefore, seem particularly suited for relaying information about stimuli that occur during mating. 6. Fibers with receptive fields on the uterine cervix and body responded best to static pressure and were observed less frequently than those with vaginal fields, regardless of estrous stage. They were, however, sensitized by hypoxia. In addition, irritation of the uterus increased the probability of observing them. These fibers, therefore, may exert their primary function during reproductive conditions different from those of virgin rats, such as parturition. 7. Response activity of most of the mechanoreceptive afferent fibers supplying reproductive organs increased as the stimulus intensity increased into the noxious range; i.e., into a range in which the stimulus momentarily produced ischemia at the stimulus site. In addition, in an in vitro preparation, pelvic nerve fibers responded in a dose-dependent manner to injections through the uterine artery of bradykinin (BRAD) as well as to other algesic chemicals, 5-hydroxytryptamine (5-HT) and KCl.(ABSTRACT TRUNCATED AT 400 WORDS)

Surgical ablation of oviductal extrinsic innervation changes GABA levels in the rat fallopian tube.

The origin of gamma-aminobutyric acid (GABA) in the rat oviduct was investigated by measuring GABA levels in the oviduct after selective ablation of the extrinsic oviductal innervation. Rats killed 20 days after ablation of nerves connected with the left oviduct showed no differences in GABA levels in the left vs the right oviduct. Rats killed 50 days after ablation of the left ovarian vascular nerve bundle showed a decreased GABA content in the left vs the right (intact) oviduct which was more pronounced in rats killed 90 days after ablation. In contrast, GABA levels were unchanged 50 days after ligation of either the suspensory ligament of the ovary or the uterine artery. Our results indicate the involvement of a GABAergic component in the extrinsic innervation of the rat oviduct.

Neural factors affecting the muscle activity of the human mesotubarium ovarica at ovulatory phase.

Histochemical and in vitro investigations of the autonomic innervation in the human mesotubarium ovarica (MTO) are described here in the course of our studying its physiologic role in the capture of released oocytes at ovulation. The present results imply that the muscle activity of MTO is under the excitatory control of cholinergic nerves and under a reciprocal (predominantly excitatory) control of adrenergic nerves, and that both adrenergic and cholinergic neural factors (at least postsynaptic ones) are related in the enhancement of the muscle activity of MTO around the time of ovulation.

The aberrant course of the cutaneous component of the ilioinguinal nerve.

The ilioinguinal nerve was dissected in 196 adult human cadavers. A normal pattern of distribution, consistent with modern textual descriptions, was defined in 60% of inguinal regions. In 35% of the inguinal regions a previously undescribed aberrant course for the cutaneous component of the ilioinguinal nerve was observed in which it is incorporated within the genitofemoral nerve, entered the inguinal canal at the deep inguinal ring, coursed within the cremasteric layer and emerged into the subcutaneous tissue at the superficial inguinal ring on the dorsal side of the spermatic cord or the round ligament of the uterus. The cutaneous component of the ilioinguinal nerve is most frequently found on the ventral surface of the spermatic cord or round ligament during inguinal hernia operations thus an unrecognized aberrant course of this nerve within the spermatic cord is particularly susceptible to accidental trauma.