{"paper_id":"a8a2bda7-3f18-4cac-8ec4-71a4bd387519","body_text":"REVIEW ARTICLE\n299\nAnatomy of the lower hypogastric plexus applied to \nendometriosis: a narrative review______________________________________________________________________________________________\nGisele Silva Ribeiro-Julio 1, Jorge Alves Pereira 1, Eduardo Ribeiro 1, Carla M. Gallo 1, Luciano A. \nFavorito 1\n1 Unidade de Pesquisa Urogenital - Universidade do Estado do Rio de Janeiro – Uerj, Rio de Janeiro, RJ, \nBrasil\nABSTRACT\n \nObjective: The objective of the present study is to evaluate the anatomy of the inferior \nhypogastric plexus, correlating it with urological pathologies, imaging exams and sur-\ngeries of the female pelvis, especially for treatment of endometriosis.\nMaterial and Methods:  We carried out a review about the anatomy of the inferior \nhypogastric plexus in the female pelvis. We analyzed papers published in the past 20 \nyears in the databases of Pubmed, Embase and Scielo, and we included only papers \nin English and excluded case reports, editorials, and opinions of specialists. We also \nstudied two human fixed female corpses and microsurgical dissection material with a \nstereoscopic magnifying glass with 2.5x magnification.\nResults: Classical anatomical studies provide few details of the morphology of the in -\nferior hypogastric plexus (IHP) or the location and nature of the associated nerves. The \nfusion of pelvic splanchnic nerves, sacral splanchnic nerves, and superior hypogastric \nplexus together with visceral afferent fibers form the IHP. The surgeon’s precise know-\nledge of the anatomical relationship between the hypogastric nerve and the uterosacral \nligament is essential to reduce the risk of complications and postoperative morbidity of \npatients surgically treated for deep infiltrative endometriosis involving the uterosacral \nligament.\nConclusion: Accurate knowledge of the innervation of the female pelvis is of funda -\nmental importance for prevention of possible injuries and voiding dysfunctions as \nwell as the evacuation mechanism in the postoperative period. Imaging exams such as \nnuclear magnetic resonance are interesting tools for more accurate visualization of the \ndistribution of the hypogastric plexus in the female pelvis.\nARTICLE INFO \n Luciano A. Favorito\nhttp://orcid.org/0000-0003-1562-6068\nKeywords:\nHypogastric Plexus; Anatomy; \nEndometriosis; Magnetic \nResonance Imaging\nInt Braz J Urol. 2023; 49: 299-306\n_____________________\nSubmitted for publication:\nNovember 01, 2022\n_____________________\nAccepted after revision:\nNovember 15, 2022\n_____________________\nPublished as Ahead of Print:\nDecember 18, 2022\nINTRODUCTION\nThe hypogastric plexus is responsible for \nthe autonomic innervation of the pelvic viscera. \nInjury to these nerves during surgical interven -\ntions can be associated with voiding dysfunctions \nand the evacuation process. Knowledge of the ana-\ntomy of the hypogastric plexus is very important \nin female pelvic surgeries, especially operations \nfor the treatment of endometriosis. Endometriosis \nis a pelvic dysfunction in women that requires a \ndelicate and thorough surgical approach. The sur-\ngeon must have skill and knowledge of this region \nin order to avoid injury to the viscera, vessels and \nVol. 49 (3): 299-306, May - June, 2023\ndoi: 10.1590/S1677-5538.IBJU.2022.9980\n\nIBJU | ANATOMY OF THE LOWER HYPOGASTRIC PLEXUS APPLIED TO ENDOMETRIOSIS\n300\nnerves of the pelvis. In recent times, laparosco -\npic and robotic surgery have greatly improved the \nvisualization of the anatomical structures of the \npelvis during these procedures (1-3).\nClassical anatomical studies provide few \ndetails about the morphology of the inferior hy -\npogastric plexus (IHP) or the location and nature \nof the associated nerves. The aim of the present \nwork is to evaluate the surgical anatomy of the \nhypogastric plexus through a narrative review of \nthe literature, highlighting its importance during \ndiagnosis and its approach during surgical proce-\ndures for the treatment of endometriosis.\nMATERIAL AND METHODS\nIn this study we carried out a review of \nthe anatomy of the inferior hypogastric plexus in \nthe female pelvis. We analyzed papers published \nin the past 20 years in the databases of Pubmed, \nEmbase and Scielo, found by using the key ex -\npressions “Hypogastric plexus”; “Inferior hypo -\ngastric plexus”; “MRI”; “Endometriosis”; “Robotic \nsurgery”; and “Laparoscopic surgery” . We found \nseveral papers in these databases and we included \nonly papers in English and excluded case reports, \neditorials and opinions of specialists (Figure-1).\nWe also studied two human fixed fema -\nle corpses and microsurgical dissection material \nwith the aid of a stereoscopic magnifying glass \nwith 2.5x magnification. A detailed dissection of \nthe female pelvis was performed, identifying the \nsuperior hypogastric plexus at the level of the sa-\ncral promontory and its distribution in the female \npelvis.\nRESULTS\nAnatomy of the Hypogastric Plexus\nThe autonomic innervation of the pelvis \noriginates from the continuation of the aortic \nplexus in the downward direction. Fibers of the \ninferior mesenteric plexus, situated below the in -\nferior mesenteric artery, receive sympathetic fibers \nfrom the paravertebral trunk. Anterior to the fifth \nlumbar vertebra and in the region of the sacral \npromontory, these fibers unite with branches of \nthe lower lumbar splanchnic nerves and form the \nso-called superior hypogastric plexus (SHP) or \npresacral nerve (4, 5). The SHP is located below \nthe bifurcation of the aorta artery and anterior to \nthe sacral promontory (6). This set of fibers has a \nretroperitoneal position, forming a single, median \nstructure, as can be seen in Figure-2.\nThe SHP divides anteriorly to the sacrum \ninto two narrow and elongated networks with va-\nriable diameter, just below the sacral promontory, \ngiving rise to the presacral nerves, better known \nas hypogastric nerves, which in general gather \nin a trunk and are called the hypogastric nerves \n(right and left) (Figure-2). The hypogastric nerves \nrun inferiorly and obliquely in relation to the sa -\ncrum, without passing through the region anterior \nto the sacral foramina (6).\nThe hypogastric nerves have an important \nrelationship with the internal iliac vessels, being \nlocated medially and inferiorly to them, surroun -\nded by retroperitoneal fat, also maintaining a re -\nlationship with the sigmoid colon on the left side \nand the rectum before the inferior hypogastric \nplexus is formed. Each nerve or hypogastric ner -\nve passes inferiorly over the lateral part of the \nrectum (or the rectum and vagina in women). In \nthe inferior and anterior region of the sacrum, \neach hypogastric nerve receives the pelvic splan -\nchnic nerves from the sacral roots from S2 to \nS4, giving rise to the inferior hypogastric plexus \n(IHP) (5) (Figure-2).\nThe IHP is formed by the union of the hy-\npogastric nerves with the pelvic splanchnic ner -\nves (nerves of Eckhardt) in the region posterior \nand medial to the internal iliac artery (hypogastric \nartery) (Figure-3). The distance between the IHP \nand the internal iliac artery is around 10 mm (6). \nThe HPI, when passing close to the pelvic surface \nof the sacrum, also has an important relationship \nwith the inner iliac vein (hypogastric vein), being \nlocated in the posterosuperior region of the main \nvenous trunk of the internal iliac vein. Some au -\nthors consider that the fusion of the pelvic splan-\nchnic nerves, sacral splanchnic nerves and su -\nperior hypogastric plexus together with visceral \nafferent fibers form the IHP (6).\nThe IHP branches out maintaining impor -\ntant relationships with the pelvic viscera in wo -\nmen.  The ureter is an essential positional referen-\n\nIBJU | ANATOMY OF THE LOWER HYPOGASTRIC PLEXUS APPLIED TO ENDOMETRIOSIS\n301\nce for the IHP: not in terms of its superior angle, \nthe distance to which to the ureter is variable, but \nin terms of its top, in other words its (anterior) in-\nferior angle: in all cases this top is at the ureter’s \npoint of contact where it perforates the posterior \nlayer of the broad ligament. In the region of the \nintersection with the uterine artery, branches of \nthe IHP originate and go to the bladder and vagi-\nna (Figure-2). Two groups of branches can be ob-\nserved in this region, one lateral and one medial. \nThe efferent innervation of the vagina then runs \nalong the uterine artery and the vesical efferent \nruns along the terminal segment of the ureter, un-\nderneath and outside of it. At the point where the \nureter leads into the bladder wall, it divides into \ntwo groups: a lateral group spreads out over the \nlateral and inferior wall of the bladder (Figure-2); \nand a medial trigonal group heads towards the \nposterior lateral angle of the trigone and perfora -\ntes the muscularis without ever directly reaching \nthe vesical sphincter.\nIn the dissected parts, we observed that the \nsuperior hypogastric plexus was divided into right \nand left hypogastric nerves in the sacral promon-\ntory region and the pelvic splanchnic nerves joi -\nned these nerves, forming the IHP. In turn, the IHP \noriginated fibers that innervate the viscera of the \nanterior and posterior compartments of the pelvis. \nThere are few imaging-related studies enabling vi-\nsualization of the pelvic region (Figure-2).\nFigure 1 - The figure shows the flow chart of the present review.\n 1 \n \n \n \n \n \n \nRecords\t\r  identified\t\r  through\t\r  \ndatabase\t\r  searching\t\r  \n(n\t\r  =74)\t\r  \nScreening\t\r  \nIncluded\t\r  \n Eligibility\t\r  \n Identification\t\r  \nRecords\t\r  after\t\r  duplicates\t\r  removed\t\r  \n(n\t\r  =10)\t\r  \nRecords\t\r  screened\t\r  \n(n\t\r  =64\t\r  )\t\r  \nRecords\t\r  excluded\t\r  \n(n\t\r  =\t\r  10\t\r  )\t\r  \nFull-­‐text\t\r  articles\t\r  assessed\t\r  \nfor\t\r  eligibility\t\r  \n(n\t\r  =\t\r  54)\t\r  \nFull-­‐text\t\r  articles\t\r  excluded,\t\r  \nwith\t\r  reasons\t\r  \n(n\t\r  =\t\r  32)\t\r  \nStudies\t\r  included\t\r  in\t\r  \nqualitative\t\r  synthesis\t\r  \n(n=\t\r  22)\t\r  \n\nIBJU | ANATOMY OF THE LOWER HYPOGASTRIC PLEXUS APPLIED TO ENDOMETRIOSIS\n302\nAnatomy of the IHP in MRI\nThe radiologist’s role in the management \nof endometriosis is becoming increasingly impor-\ntant as more centers move towards the use of fe -\nmale pelvic MRI exams to diagnose, delineate, or \nfollow-up endometriosis lesions (7). The European \nSociety of Urogenital Radiology provides recom -\nmendations on the optimal MRI protocol and gui-\ndelines for the diagnosis of pelvic endometriosis \nbased on evidence from the literature and consen-\nsus of experts’ opinions (8).\nIt is important to diagnose endometriosis \nand thoroughly assess its extent, especially when \nsurgical treatment is being considered. Magnetic \nresonance imaging (MRI) is a careful examination \nand interpretation technique that allows more ac-\ncurate and complete diagnosis and staging than \nultrasonography, especially in cases of deep pel -\nvic endometriosis. In addition, MRI can identify \nimplants in hard-to-reach places in endoscopic \nor laparoscopic explorations (9).\nMRI has been used routinely in patients \nwith suspected deep endometriosis, where it and \ncan identify lesions in different sites in a single \nevaluation, allowing assessment of the extent \nof the disease. MRI is also an effective techni -\nque for the preoperative diagnosis and staging \nof deep infiltrative endometriosis (IEM). Howe -\nFigure 2 - Superior hypogastric plexus (SHP). \nA) Schematic drawing of the superior hypogastric plexus in a female pelvis. It is possible to observe the relationships and the division of the SHP; B) The figure shows \ndissection of a female pelvis, indicating the division and the relationships of the SHP . 1- Superior hypogastric plexus; Right hypogastric nerve; Left hypogastric nerve; 4- Right \ncommon iliac artery; 5- Left common iliac artery and 6- Promontory.\n\nIBJU | ANATOMY OF THE LOWER HYPOGASTRIC PLEXUS APPLIED TO ENDOMETRIOSIS\n303\nver, the usefulness of MRI, because of sequences \nsusceptible to chronic blood degradation products \nsuch as T2*-weighted images, remains uncertain \n(10). In an interesting previous study, MRI was \nused before surgery, dysmenorrhea, deep dyspa -\nreunia, and non-cyclical pelvic pain. Patients were \nevaluated using a 10-point visual analog scale. \nMRI allowed a three-dimensional reconstruction \nof S1, S2 and S3. Laparoscopic treatment of endo-\nmetriosis was performed in 56 patients (9).\nIn the MRI analysis, some anatomical \npoints are highlighted due to their intimate rela -\ntionship with the inferior hypogastric plexus and \nits branches, which must be carefully evaluated \nduring the interpretation of the exam: posterior \ninferior surface of the bladder (sacral splanch -\nnic nerves); lateral surface of the rectum; pelvic \nureter; and particularly the region of the crossing \nwith the uterine artery, pararectal space, paracer -\nvix, hypogastric artery, piriformis muscle, levator \nani muscle, round ligament and bladder (11).\nPelvic Nerves and Endometriosis Surgery\nDuring the performance of pelvic endome-\ntriosis surgeries, whether laparoscopic, conven -\ntional or robotic, knowledge of the relationships \nFigure 3 - Inferior hypogastric plexus (IHP).\nA) The figure shows the right hypogastric nerve in a female pelvis and the formation of the IHP , indicating the splanchnic nerves (2) joining to the hypogastric nerve (1); B) \nSchematic drawing of the inferior hypogastric plexus in a female pelvis, indicating the relationships and the formation of the IHP , 1- hypogastric nerve, 2 – Splanchnic pelvic \nnerve and 3 – Inferior hypogastric plexus; C) The figure shows a female pelvis in one of the corpses dissected in our sample. It is possible to observe the uterus (U), the \nrelationship between the ureter (UR) and the iliac vessels (IIV – internal iliac vessels and EIV – external iliac vessels), R- Rectum and D) The figure shows the same female \npelvis of figure 2C after the dissection of the IHP . It is possible to observe the uterus (U), the peritoneum and the relationship between the nerves (N) of the inferior hypogastric \nplexus with the peritoneum and the uterus.\n\nIBJU | ANATOMY OF THE LOWER HYPOGASTRIC PLEXUS APPLIED TO ENDOMETRIOSIS\n304\nbetween the hypogastric plexus and the pelvic \nviscera is of great importance. Endometriosis is \na disease defined by the presence of endometrial \ntissue outside the uterine cavity. It is a progressive \ndisease, without a clearly established etiopatho -\ngenesis, influenced by genetic and environmental \nfactors (12). The disease affects 6 to 10% of wo -\nmen of reproductive age and more than 50% of \nwomen with infertility and pelvic pain, being the \nmain cause of these conditions (13).\nThe identification and prompt treatment of \nendometriosis are essential and are facilitated by \nprecise clinical diagnosis. Endometriosis is clas -\nsically defined as a chronic gynecological disea -\nse characterized by the presence of tissue similar \nto the endometrium outside the uterus. It is be -\nlieved to arise due to retrograde menstruation. \nHowever, this description is outmoded and does \nnot reflect the true scope and manifestations of \nthe disease. The clinical presentations are varied, \nthe presence of pelvic lesions is heterogeneous \nand the manifestations of the disease outside the \nfemale reproductive tract remain poorly unders -\ntood. Endometriosis is now considered to be a \nsystemic disease instead of a disease that predo -\nminantly affects the pelvis (14).\nOf the pathogenic theories proposed (re -\ntrograde menstruation, coelomic metaplasia and \nMüllerian remnants), none explains all the di -\nfferent types of endometrioses. According to the \nmost convincing model, the hypothesis of retro -\ngrade menstruation, endometrial fragments that \nreach the pelvis via the retrograde transtubal flow \nbecome lodged in the peritoneum and abdominal \norgans and proliferate and cause chronic inflam -\nmation with the formation of adherences (15). \nThe lesions can be of three types: superficial pe -\nritoneal lesions, ovarian endometriomas or deep \nendometriosis, when ectopic implants infiltrate \nmore than 5 mm in relation to the surface. (16). \nClinical examination has relatively low sensitivity \nand specificity for diagnosing deep endometriosis. \nRegardless of the sites of deep endometriosis, for \nall transvaginal ultrasound techniques, combined \nsensitivity, and specificity of 79% and 94% is ob-\nserved, approaching the criteria for a screening \ntest. Whatever the protocol and MRI devices, the \ncombined sensitivity and specificity for diagno -\nsing pelvic endometriosis were 94% and 77%, res-\npectively. For rectosigmoid endometriosis, the com-\nbined sensitivity and specificity of MRI were 92% \nand 96%, respectively, fulfilling the replacement \ntest criteria. Surgery remains the gold standard for \ndefinitive diagnosis, but it must be weighed against \nthe risks of surgical morbidity and potential decre-\nase in ovarian reserve, especially in the case of en-\ndometriomas. Accurate knowledge of the surgeon \nregarding the anatomical relationship between the \nhypogastric nerve and the uterosacral ligament is \nessential to reduce the risk of complications and \npostoperative morbidity of patients surgically trea-\nted for deep infiltrative endometriosis involving the \nuterosacral ligament (6, 17).\nIn robotic surgery, pelvic autonomic \nnerves end up being easier to identify with the \nmagnification provided by an endoscopic came -\nra (Figure-4). These should be dissected and pre -\nserved whenever possible due to their important \nfunction (18-19).\nZakhari et al. (20) carried out a study of \ndidactic schemes and medical drawings and dis -\ncussed and illustrated the autonomic neuroana -\ntomy of the pelvis. With annotated laparoscopic \nimages, they demonstrated a step-by-step appro -\nach to identifying, dissecting, and preserving the \nhypogastric nerve during pelvic surgery (20).\nThe superior hypogastric plexus has been \ndescribed along with the hypogastric nerve, the \nmost superficial and easily identifiable component \nof the inferior hypogastric plexus. It was identi -\nfied and used as a reference point to preserve the \nautonomous bundles in the pelvis. The following \nsteps, illustrated with laparoscopic images, descri-\nbe a surgical technique designed to identify and \npreserve the hypogastric nerve and deeper inferior \nhypogastric plexus without the need for more ex-\ntensive pelvic dissection to the level of the sacral \nnerve roots: (1) transperitoneal identification of \nthe hypogastric nerve, with a traction maneuver \nfor confirmation; (2) opening of the retroperito -\nneum at the level of the pelvic rim and retrope -\nritoneal identification of the ureter; (3) medial \ndissection and identification of the hypogastric \nnerve; and (4) lateralization of the hypogastric \nnerve, allowing safe resection of deep infiltrating \nendometriosis (20).\n\nIBJU | ANATOMY OF THE LOWER HYPOGASTRIC PLEXUS APPLIED TO ENDOMETRIOSIS\n305\nFigure 4 - The figure shows a robot-assisted nerve-plane-preserving eradication of deep endometriosis. We can observe the \nidentification of the pelvic autonomic nerves with the magnification provided by an endoscopic camera near to the utero-\nsacral ligament.\nRobot-assisted nerve-plane-preserving \neradication of deep endometriosis is as technically \nfeasible as the conventional laparoscopic approa-\nch. The step-by-step technique should help surge-\nons perform each part of the surgery in a logical \nsequence, making the procedure easier and safer \nto complete. However, the latent benefits of robot-\n-assisted nerve-sparing surgery in the treatment \nof deep endometriosis remain unclear (21).\nA meta-analysis confirmed that robotic \nsurgery is safe and feasible in patients afflicted \nwith endometriosis. The articles examined sug -\ngested that robotic surgery is a valid option and \ncan be considered an alternative to conventio -\nnal laparoscopic surgery, especially in advanced \ncases (22).\nCONCLUSIONS\nThe precise knowledge of the innervation \nof the female pelvis is of fundamental importan -\nce for prevention of injuries, voiding dysfunctions \nand problems in the evacuation mechanism in the \npostoperative period. Imaging exams such as nu -\nclear magnetic resonance are an interesting tool \nfor more accurate visualization of the distribution \nof the hypogastric plexus in the female pelvis.\nCONFLICT OF INTEREST\nNone declared.\n \nREFERENCES\n1. Fermaut M, Nyangoh Timoh K, Lebacle C, Moszkowicz D, \nBenoit G, Bessede T. Identification des sites anatomiques à \nrisque de lésion nerveuse lors de chirurgie pour endométriose \npelvienne profonde. [Deep infiltrating endometriosis surgical \nmanagement and pelvic nerves injury]. Gynecol Obstet Fertil. \n2016;44:302-8. French.\n2. 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J Robot Surg. 2020;14:687-94.\n_______________________\nCorrespondence address:\nLuciano Alves Favorito, MD, PhD\nUnidade de Pesquisa Urogenital\nUniversidade do Estado do Rio de Janeiro – Uerj\nRua Professor Gabizo, 104/201 - Tijuca\nRio de Janeiro, RJ, 20271-320, Brasil\nFax number: +55 21 3872-8802\nE-mail: lufavorito@yahoo.com.br","source_license":"CC0","license_restricted":false}