Grégoire Rocher1,2, Henri Azaïs1,2, Amélia Favier1,2, Catherine Uzan1,2,3,4, Mathieu Castela5, Gaby Moawad6, Vincent Lavoué7,8, Xavier Morandi9,10,11, Krystel Nyangoh Timoh7,8,10,11, Geoffroy Canlorbe12,13,14,15. 1. Assistance Publique des Hôpitaux de Paris (AP-HP), Department of Gynecological and Breast Surgery and Oncology, Pitié-Salpêtrière University Hospital, 75013, Paris, France. 2. Ecole de Chirurgie, Assistance-Publique Hôpitaux de Paris, 7, rue du Fer à Moulin, 75005, Paris, France. 3. Sorbonne University, INSERM UMR_S_938, Cancer Biology and Therapeutics, Centre de Recherche Saint-Antoine (CRSA), 75020, Paris, France. 4. Institut Universitaire de Cancérologie (IUC), 75020, Paris, France. 5. Scarcell Therapeutics, 101 rue de Sèvres, 75006, Paris, France. 6. Gynecology Department, The George Washington University School of Medicine and Health Science, Washington, DC, USA. 7. Department of Obstetrics and Gynecology Gynecology, Rennes Hospital, Rennes University 1, Rennes, France; Université de Rennes 1, Rennes, France. 8. Université de Rennes 1 : 2 avenue de Professeur Léon Bernard, 35000, Rennes, France; SAFE CIC 1414 Thematic Team, University Hospital Rennes, Rennes, France. 9. Department of Neurosurgery, Rennes University Hospital, Pontchaillou University Hospital, CHU Pontchaillou, 2 rue Henri Le Guilloux, 35033, Rennes Cedex 9, France. 10. Anatomy Laboratory, Faculty of medicine of Rennes, 2 Avenue du Professeur Léon Bernard, 35043, Rennes, France. 11. INSERM, UMR 1099, Rennes, F-35000, France; Université de Rennes 1, LTSI, F-35000, Rennes, France. 12. Assistance Publique des Hôpitaux de Paris (AP-HP), Department of Gynecological and Breast Surgery and Oncology, Pitié-Salpêtrière University Hospital, 75013, Paris, France. geoffroy.canlorbe@aphp.fr. 13. Ecole de Chirurgie, Assistance-Publique Hôpitaux de Paris, 7, rue du Fer à Moulin, 75005, Paris, France. geoffroy.canlorbe@aphp.fr. 14. Sorbonne University, INSERM UMR_S_938, Cancer Biology and Therapeutics, Centre de Recherche Saint-Antoine (CRSA), 75020, Paris, France. geoffroy.canlorbe@aphp.fr. 15. Institut Universitaire de Cancérologie (IUC), 75020, Paris, France. geoffroy.canlorbe@aphp.fr.
Abstract
BACKGROUND: The placement of posterior mesh during pelvic organ prolapse laparoscopic surgery has been incriminated as responsible for postoperative adverse outcomes such as digestive symptoms, chronic pelvic pain, and sexual dysfunction. These complications may be related to neural injuries that occur during the fixation of the posterior mesh on the levator ani muscle. OBJECTIVES: The aim of our study was to describe the course of the autonomic nerves of the pararectal space and their anatomical relationship with the posterior mesh fixation zone on the levator ani muscle. STUDY DESIGN: Twenty hemi-pelvis specimens from 10 fresh female cadavers were dissected. We measured the distance between the posterior mesh fixation zone on the levator ani, and the nearest point of adjacent structures: the hypogastric nerve, inferior hypogastric plexus, uterosacral ligament, uterine artery, and ureter. Measurements were repeated starting from the inferior hypogastric plexus. RESULTS: Nerve fibers of the inferior hypogastric plexus spread out systematically above the superior aspect of the levator ani muscle. Median distance from the posterior mesh fixation zone and the inferior hypogastric plexus was around 2.8 (range 2.1-3.5) cm. CONCLUSIONS: The inferior hypogastric plexus lies above the superior aspect of the levator ani muscle. A short distance between the posterior mesh fixation zone on the levator ani muscle and inferior hypogastric plexus could explain in part postoperative digestive symptoms. These observations support the development of nerve-sparing procedures for posterior mesh placement in the context of pelvic organ prolapse repair and suggest that postoperative complications could be improved by changing the fixation zone.
BACKGROUND: The placement of posterior mesh during pelvic organ prolapse laparoscopic surgery has been incriminated as responsible for postoperative adverse outcomes such as digestive symptoms, chronic pelvic pain, and sexual dysfunction. These complications may be related to neural injuries that occur during the fixation of the posterior mesh on the levator ani muscle. OBJECTIVES: The aim of our study was to describe the course of the autonomic nerves of the pararectal space and their anatomical relationship with the posterior mesh fixation zone on the levator ani muscle. STUDY DESIGN: Twenty hemi-pelvis specimens from 10 fresh female cadavers were dissected. We measured the distance between the posterior mesh fixation zone on the levator ani, and the nearest point of adjacent structures: the hypogastric nerve, inferior hypogastric plexus, uterosacral ligament, uterine artery, and ureter. Measurements were repeated starting from the inferior hypogastric plexus. RESULTS: Nerve fibers of the inferior hypogastric plexus spread out systematically above the superior aspect of the levator ani muscle. Median distance from the posterior mesh fixation zone and the inferior hypogastric plexus was around 2.8 (range 2.1-3.5) cm. CONCLUSIONS: The inferior hypogastric plexus lies above the superior aspect of the levator ani muscle. A short distance between the posterior mesh fixation zone on the levator ani muscle and inferior hypogastric plexus could explain in part postoperative digestive symptoms. These observations support the development of nerve-sparing procedures for posterior mesh placement in the context of pelvic organ prolapse repair and suggest that postoperative complications could be improved by changing the fixation zone.
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