Safe surgery requires an understanding of the anatomic boundaries and neurovascular structures of the presacral space.

The aim of the study was to characterize anatomy of the presacral space applicable to sacrocolpopexy or rectopexy while highlighting cadaveric findings of the lateral border of the space.

Structures and boundaries of the presacral space of 18 unembalmed female cadavers were studied. Anatomic relationships and distances to landmarks were established.

A dense connective tissue layer ≤1 mm thick on the piriformis muscle's medial surface attaches to the anterior sacrum just medial to the sacral foramina, separating the lateral sacral vein and sacral nerves laterally from the presacral space contents medially. Median transverse distance from midsacral promontory to right sympathetic trunk was 19.5 (range, 15-31) mm. Distances from right S1, S2, S3, and S4 foramina to midsacral promontory were 28.8 (22-47.5), 48.3 (38.5-72.5), 65.8 (54.5-89.5), and 80.8 (65-104.5) mm and to midline sacrum were 16.5 (14-22), 15.3 (13-20.5), 13.5 (10.5-19.5) and 13.3 (10.5-19.5) mm, respectively. Transverse communicating veins, measuring 3 (2-4) mm in width, penetrated the piriformis fascia, joining the lateral sacral vein to form the sacral venous plexus. Vertical distance from midsacral promontory to the most cephalad communicating vein was 38.3 (7.5-60.5) mm.

During presacral space surgical procedures, avoiding suture placement and mesh fixation beyond 1.5 cm from the sacrum midline should prevent injury to the sacral sympathetic trunk, sacral nerves, and lateral sacral vein. Transverse communicating vessels of the sacral venous plexus are usually encountered below the S1 foramina level. The piriformis fascia is the lateral boundary of the presacral space over the greater sciatic foramen.

Surgical approaches to the equine rectum and perirectal area are described in the literature. However, surgeries in this region can be challenging.

To describe the surgical anatomy of the presacral space and to evaluate its access using a retroperitoneoscopic approach.

Ex vivo experiment.

Preliminary dissections were performed in two cadavers to define the boundaries of the presacral space and to determine portal locations for the surgical approach. After that, nine cadavers were used for experimental presacral retroperitoneoscopic procedure in a standing position. Following retroperitoneoscopy, cadavers were dissected to confirm the anatomical structures observed during the endoscopic procedures, to control the location of each portal and to record iatrogenic trauma.

The presacral space was bordered by the vertebral column from the ventral aspect of lumbosacral promontorium to the first coccygeal vertebra dorsally and by the presacral fascia and peritoneum ventrally. Lateral limits were composed of the sacrosciatic ligament and transversalis fascia. Cranial and caudal borders were composed of the peritoneum and coccygeal and levator ani muscles respectively. Retroperitoneoscopic portals were placed between the external anal sphincter and semimembranosus muscles and between the base of the tail and the external anal sphincter muscle through the anococcygeal fascia to enter the space by its caudal border. The retroperitoneal space was reached in all cases and the dorsal and lateral aspects of the rectum were visualised after creation of a working space.

Use of cadaver specimens do not permit to evaluate the tolerance in living animals and the surgical complications such as rectal damage, haemorrhage and infection.

This study provides an anatomical description and surgical access of the presacral space with a minimal invasive approach. Retroperitoneoscopy allows access to the rectum and the dorsal aspect of the pelvis.

Complications can arise secondary to anorectal suppurative diseases, with infections spreading along the extraperitoneal space, such as the peri-vesical, prevesical, pre-sacral, and pararectal spaces, resulting in abscesses at remote sites, which can make diagnosis more challenging. Due to the absence of peritonitis symptoms, there is a delay in presentation among such patients. Comprehending the intricacies of these areas and the way infection can spread within them is crucial for promptly identifying and effectively draining the extraperitoneal abscess. We present a case series of six patients with a mean age of 45, all males. A total of three patients had undergone incision and drainage after being diagnosed with anorectal suppurative disease and remained symptomatic after the initial surgical intervention of incision and drainage. Two patients initially diagnosed with anterior abdominal abscesses patients, after being treated with incision and drainage, continued to have purulent discharge from the drainage site. Finally, the last patient continued to present with perianal pain after an open hemorrhoidectomy. CT scans of all six patients showed collections in the extraperitoneal spaces correlated with the observed complications. To deepen our understanding of pelvic extraperitoneal spaces, cadaver dissections were conducted and compared with CT images. Through cadaver dissections and CT imaging, the study provides insights into the anatomy and interconnections of pelvic extraperitoneal spaces, emphasizing the importance of early CT scans for diagnosis. Understanding these intricate anatomical structures is essential for accurate diagnosis and efficient and effective treatment. Timely diagnosis is vital to prevent prolonged illness and reduce the risk of complications and mortality. The importance of early CT scans in suspected patients is underscored, which is highly important to expedite appropriate actions.

Venous injury may occur during exposure of the anterior longitudinal ligament at the anterior sacral promontory (SP). We aimed to quantitatively measure the extent of the vascular window (VW) in front of the SP in patients with internal iliac vein (IIV) variations using preoperative three-dimensional computed tomography angiography (3DCTA). We hypothesized that patients with IIV variations would have a narrow VW.

This prospective observational study included patients scheduled for laparoscopic sacrocolpopexy (LSC) between July 2022 and April 2023 who underwent preoperative 3DCTA. The primary endpoint was the VW measurement in the standard and variant IIV groups using 3DCTA before LSC. The secondary endpoint was the difference between the two IIV groups adjusted for age, body mass index, hypertension, and diabetes using an analysis of covariance (ANCOVA) model. Multiple regression analysis was performed to analyze the effect of factors on the distance from the SP to great vascular bifurcations.

There were 20 cases of IIV variation (20.2%). VW was 28.8 ± 12.4 mm in the variant group and 39.6 ± 12.6 mm in the standard group (p = 0.001). In the ANCOVA model, IIV variations affected VW (coefficient, -11.8; 95% confidence interval [CI], -18.4 to -5.08, p < 0.001). Multivariate analysis revealed that the aorta-SP distance decreased with age (coefficient, -0.44; 95% CI, -0.77 to -0.11, p = 0.009).

One in five women has a vascular variant at the SP that restricts the "safe" zone of fixation to < 3 cm.

Presacral venous bleeding (PSVB) is an intractable situation during rectal mobilization. Till now, various methods for PSVB are introduced, but each of them has limitations. This article aims to introduce an effective approach for PSVB, which is created by Professor Xiaogang Bi. In the case of PSVB, a purse-string suture which highlighted each stitch penetrates periosteum of sacrum was performed around the bleeding site. After that, the branches of presacral venous plexus around the bleeding site were compressed to the sacrum when the stitches were tightened, the blood flow of the venous branches was blocked by the thread across them, the bleeding was controlled, and then, the knot was tied. From April 24th 2017 to November 6th 2022, ten patients who suffered PSVB during surgery accepted Bi's suture. With Bi's suture, all of the ten cases of PSVB were controlled effectively. Nine of ten cases were controlled immediately only by Bi's suture, one case which accompanied with blood oozing of sacrum wound was controlled by Bi's suture, bone wax, and pelvic gauze packing. Bi's suture is an effective approach for PSVB. It could be easily performed without the need of special materials.

Although anatomic level of mesh attachment to the sacrum varied during minimally invasive sacrocolpopexy with a large proportion above S1, this was not associated with pelvic organ prolapse recurrence.

This study aimed to describe the anatomic level of sacral mesh attachment and its association with prolapse recurrence after minimally invasive sacrocolpopexy.

This study included a retrospective cohort of women who underwent minimally invasive sacrocolpopexy with subsequent abdominal and pelvic imaging (magnetic resonance imaging or computed tomography) between 2010 and 2019 at a single academic institution. Anatomic level of attachment was determined by a radiologist. Prolapse recurrence was defined as a composite of self-reported bulge symptoms, any prolapse measure beyond the hymen, and any retreatment with pessary or surgery. χ 2 Tests were used for comparative outcomes.

Analyses included 212 women. The mean ± SD age was 58.8 ± 9.9 years, the majority have preoperative stage III/IV prolapse (81.1%), and the median follow-up was 269 days (interquartile range, 57-825 days). Mesh was attached using titanium tacks (n = 136 [64.2%]) and suture (n = 76 [35.8%]) at the level of the L5-S1 intervertebral space (n = 113 [53.3%]) or overlying S1 (n = 89 [42.0%]).The surgical approach was significantly associated with attachment location with a greater proportion of laparoscopy cases demonstrating mesh attachment above S1 (85 [62.5%] vs robotically, 30 [39.5%]; P < 0.01). Dichotomized level of attachment was not associated with composite prolapse recurrence (above S1, n = 18 [22.2%] vs below S1, n = 24 [24.7%]; P = 0.69) or any compartment recurrence ( P ≥ 0.36).

Mesh was primarily attached to the anterior longitudinal ligament at the level of the L5-S1 intervertebral space or S1. Level of mesh attachment was not associated with composite prolapse recurrence.

The pelvic venous system is complex, with the potential for numerous pathways of collateralization. Owing to stenosis or occlusion, both thrombotic and nonthrombotic entities in the pelvis may necessitate alternate routes of venous return. Although the pelvic venous anatomy and collateral pathways may demonstrate structural variability, a number of predictable paths often can be demonstrated on the basis of the given disease and the level of obstruction. Several general categories of collateral pathways have been described. These pathway categories include the deep pathway, which is composed of the lumbar and sacral veins and vertebral venous plexuses; the superficial pathway, which is composed of the circumflex and epigastric vessels; various iliofemoral collateral pathways; the intermediate pathway, which is composed of the gonadal veins and the ovarian and uterine plexuses; and portosystemic pathways. The pelvic venous anatomy has been described in detail in cadaveric and anatomic studies, with the aforementioned collateral pathways depicted on CT and MR images in several imaging studies. A comprehensive review of the native pelvic venous anatomy and collateralized pelvic venous anatomy based on angiographic features has yet to be provided. Knowledge of the diseases involving a number of specific pelvic veins is of clinical importance to interventional and diagnostic radiologists and surgeons. The ability to accurately identify common collateral patterns by using multiple imaging modalities, with accurate anatomic descriptions, may assist in delineating underlying obstructive hemodynamics and diagnosing specific occlusive disease entities. ^©RSNA, 2022.

Correct tack placement at the sacral promontory for mesh fixation in ventral mesh rectopexy is crucial to avoid bleeding, nerve dysfunction, and spondylodiscitis.

The present cadaver study was designed to assess the true location of tacks after mesh fixation during laparoscopic ventral mesh rectopexy in relation to vascular and nerve structures and bony landmarks.

This was an interventional cadaver study.

This study was conducted after laparoscopic mesh fixation detailed pelvic dissection was performed following a standardized protocol. In addition, 64-row multidetector computed tomography was conducted to further define lumbosacral anatomy and tack positioning.

Eighteen fresh cadavers (10 female, 8 male) were included in this study.

True tack position and vascular and neuronal involvement served as outcome measures.

A total of 52 tacks were deployed (median 3, range 2-3 tacks). Median tack distance to the midsacral promontory was 16.1 mm (0.0-54.2). Only a total of 22 tacks (42.3%) were found on the right surface of the S1 vertebra, correlating with the planned deployment area. In 7 cadavers (38.8%), all tacks were deployed on the planned deployment area. The median distance to the major vessels was 10.5 mm (0.0-35.0), which was the internal iliac artery in half of the cases. Median distance of tacks to the right ureter was 32.1 mm (7.5-46.1). Neither major vessels nor the ureter was injured. Dissection of the hypogastric plexus was undertaken in 14 cadavers, and in each cadaver, tacks affected the hypogastric nerve plexus.

This study was limited by the moderate number of cadavers.

Tack placement showed significant variation in our specimen, emphasising the need for reliable anatomic landmarks and sufficient exposure during ventral mesh rectopexy. Hypogastric nerve plexus involvement is common, thus detailed functional assessment after surgery is required. It also points out the importance of cadaver studies before implementing new surgical techniques into clinical practice. See Video Abstract at http://links.lww.com/DCR/B827.

ANTECEDENTES:La colocación correcta de la tachuela en el promontorio sacro para la fijación de la malla en la rectopexia con malla ventral es crucial para evitar hemorragias, disfunción nerviosa y espondilodiscitis.OBJETIVO:El presente estudio en cadáveres fue diseñado para evaluar la verdadera ubicación de las tachuelas después de la fijación de la malla durante la rectopexia laparoscópica con malla ventral en relación con las estructuras vasculares y nerviosas y los puntos de referencia óseos.DISEÑO:Estudio intervencionista de cadáveres.AJUSTE:Después de la fijación laparoscópica de la malla, se realizó una disección pélvica detallada siguiendo un protocolo estandarizado. Además, se realizó una tomografía computarizada multidetector de 64 cortes para definir mejor la anatomía lumbosacra y la posición de la tachuela.PACIENTES:Se incluyeron en este estudio dieciocho cadáveres frescos (10 mujeres, 8 hombres).PRINCIPALES MEDIDAS DE RESULTADO:Posición real de tachuela y compromiso vascular y neuronal.RESULTADOS:Se utilizaron un total de 52 tachuelas (mediana 3, 2-3 tachuelas). La distancia media de tachuela al promontorio sacro medio fue de 16,1 mm (0,0-54,2). Solo se encontraron un total de 22 tachuelas (42,3%) en la superficie derecha de la vértebra S1, correlacionándose con el área planificada. En siete cadáveres (38,8%) todas las tachuelas se utilizaron en el área de planificada. La distancia media a los vasos principales fue de 10,5 mm (0,0-35,0), que era la arteria ilíaca interna en la mitad de los casos. La distancia media de las tachuelas al uréter derecho fue de 32,1 mm (7,5-46,1). No se lesionó ni los grandes vasos ni el uréter. La disección del plexo hipogástrico se realizó en 14 cadáveres y en cada cadáver, las tachuelas afectaron el plexo nervioso hipogástrico.LIMITACIONES:Número moderado de cadáveres incluidos en el estudio.CONCLUSIONES:La colocación de tachuelas mostró una variación significativa en nuestra muestra, enfatizando la necesidad de puntos de referencia anatómicos confiables y una exposición suficiente durante la rectopexia con malla ventral. La afectación del plexo nervioso hipogástrico es común, por lo que se requiere una evaluación funcional detallada después de la cirugía. También destaca la importancia de los estudios sobre cadáveres antes de implementar nuevas técnicas quirúrgicas en la práctica clínica. Consulte Video Resumen en http://links.lww.com/DCR/B827. (Traducción-Dr Yolanda Colorado).

The purpose of the study was to analyze anatomical and functional outcomes after sacrocolpopexy (SCP) for vaginal vault prolapse pelvic organ prolapse quantification (POPQ) II-III by random use of absorbable (Vicryl) and non-absorbable sutures (Ethibond) for vaginal mesh fixation.

This study was designed as a two-center randomized controlled study (RCT). The primary objective was to evaluate the anatomical outcome. Success was defined when the vaginal apex (point C; POPQ) did not descend more than 50% of the total vaginal length (tvl) during Valsalva. Patients completed a pelvic examination incorporating the POPQ and questionnaires (the German pelvic floor questionnaire and the PISQ-12 questionnaire) at baseline and 6 months postsurgery. Perioperative adverse events (AE) were recorded. Sample size calculations, based on a 10% non-inferiority limit required 100 participants per group, with power = 90%.

In 190 out of 195 women (ETH group n = 96; VIC group n = 94) anatomical success was achieved. The relative risk of anatomical success failure in the VIC group versus the ETH group was 0.69, with a 95% confidence interval 0.12-4.02. The change in the symptom scores did not differ significantly between the ETH and the VIC group. In the ETH group, three suture penetrations into the vagina were observed, and none in the VIC group 6 months postoperatively.

Anatomical success after SCP for vaginal vault prolapse POPQ II-III is not affected by suture type for vaginal monofilament mesh attachment. Moreover, we did not see any differences in functional outcomes between the two groups. Three suture penetrations into the vagina were observed in the ETH group, and none in the VIC group 6 months postoperatively.

This study aimed to assess anatomy relative to sacral sutures 20 to 24 months after robotic sacrocolpopexy.

This was an institutional review board-approved prospective anatomy study of women undergoing robotic sacrocolpopexy. After placement of suture into the anterior longitudinal ligament, a small vascular clip was secured on the base of the suture. Subjects were imaged at 6 weeks and between 20 and 24 months after surgery. Measurements were calculated by the primary investigator and radiologist coinvestigator.

Of the 11 subjects enrolled in the initial 6-week postoperative study, 5 (45%) completed the long-term follow-up. Regarding the vascular anatomy, no significant changes were documented. Similarly, the major urologic structure, the right ureter, was stable at 16 mm from the clip. A significant change was noted, however, in the distance from the apex of the vagina to the sacral suture. At 6 weeks postoperatively, the mean (SD) distance from the vaginal apex to the clip was 69.3 (14) mm; this increased to 85.2 (11.3) mm at the long-term follow-up (P = 0.004).

Reassuringly, the position of the clip remained stable, which is reflected in the constancy of the measurements to the vascular landmarks. Nevertheless, alteration in the distance to the vaginal apex suggests elongation of the mesh or vaginal tissue with time. Although the increase in length was greater than 1.5 cm, it may bear clinical relevance in certain patients. This information may help guide surgeons regarding appropriate mesh tensioning during this critical step of the procedure.

To evaluate whether gadolinium enhanced 3D SPACE STIR sequence technique increases the visualization of the lumbosacral plexus (LSP) and its small branches.

A retrospective study was performed on 24 patients who had underwent 3D SPACE STIR sequences scan with and without the administration of gadolinium contrast. In this study, we focused on the healthy sides of the LSP and its branches in each patient. The contrast ratio (CR), contrast-to-noise ratio (CNR) and signal-to-noise ratio (SNR) were objectively calculated by two experienced radiologists. The subjective visualization scores of the branches that were vitally important to therapeutic decision-making including femoral nerves, obturator nerves, lumbosacral trunks, superior gluteal and extra-pelvic sciatic nerves, were assessed using post-processing images.

Of the 24 subjects, all LSP nerve roots, femoral nerves, lumbosacral trunks and sciatic nerves were illustrated on both contrast-enhanced and non-contrast images. The enhanced images were found to have higher nerve to vein CNRs compared to non-contrast images. Compared to non-contrast images, the CRs of nerves versus surrounding fat tissues, bones, veins and muscles were improved in contrast-enhanced images, while the SNRs were better but not significantly so. Targeted maximum intensity projection (MIP) nerves including femoral, obturator, superior gluteal and extra-pelvic sciatic nerves obtained significantly higher subjective scores when gadolinium was administered.

The gadolinium enhanced 3D SPACE STIR sequence provided superior vascular suppression, resulting in increased conspicuity of LSP and its small branches. Altogether, this shows great potential for therapeutic decision-making in traumatic LSP lesions cases.

The robotic-assisted laparoscopic surgical approach has improved complex gynecologic surgeries. It has the advantages of excellent visualization through the high-resolution 3-dimensional view, a wrist-like motion of the robotic arms and improved ergonomics. Similar to conventional laparoscopic surgeries, it is associated with a decrease in long-term surgical morbidity, early recovery and return to work, and improved esthetics. We discuss preoperative planning, surgical techniques, and some of the latest clinical results of robotic-assisted laparoscopic gynecologic surgery.

During high sacrectomies and lateral pelvic compartment exenterations, isolating the external and internal iliac veins within the presacral area is crucial to avoid inadvertent injury and severe hemorrhage. Anatomical variations of external iliac vein tributaries have not been previously described, whereas multiple classifications of internal iliac vein tributaries exist.

We sought to clarify the iliac venous system anatomy using soft-embalmed cadavers.

This is a descriptive study.

This study was conducted in Chulalongkorn University, Thailand.

We examined 40 iliac venous systems from 20 human cadavers (10 males, 10 females).

Blue resin dye infused into the inferior vena cava highlighted the iliac venous system, which was meticulously dissected and traced to their draining organs.

Iliac vein tributaries and their valvular system were documented and analyzed.

The external iliac vein classically receives 2 tributaries (inferior epigastric and deep circumflex iliac) near the inguinal ligament. However, external iliac vein tributaries in the presacral area were found in 20 venous systems among 15 cadavers (75%). The mean diameter of each tributary was 4.0 ± 0.35 mm, with 72% arising laterally. We propose a simplified classification for internal iliac vein variations: pattern 1 in 12 cadavers (60%) where a single internal iliac vein joins a single external iliac vein to drain into the common iliac vein; pattern 2 in 7 cadavers (35%) where the internal iliac vein is duplicated; and pattern 3 in 1 cadaver (5%) where bilateral internal iliac veins drain into a common trunk before joining the common iliac vein bifurcation.

This study is limited by the number of cadavers included.

A comprehensive understanding of previously unreported highly prevalent external iliac vein tributaries in the presacral region is vital during complex pelvic surgery. A simplified classification of internal iliac vein variations is proposed. See Video Abstract at http://links.lww.com/DCR/A900.

To introduce an alternative surgical technique of laparoscopic inguinal ligament suspension (LILS) with uterine preservation and evaluate its efficacy and safety for patients with severe pelvic organ prolapse (POP).

Between June 2014 and December 2015, 35 patients with symptomatic stage III or IV were treated by LILS with uterine preservation. The perioperative parameters including surgical time, blood loss, hospital stay and complications were recorded. The anatomical cure rate was evaluated according to the Pelvic Organ Prolapse Questionnaire (POP-Q) assessment. The anatomical points were analyzed by dynamic Magnetic Resonance Imaging (MRI). Validated questionnaire of the Pelvic Floor Distress Inventory (PFDI-20), the Pelvic Floor Impact Questionnaire (PFIQ-7) and the Pelvic organ prolapse urinary Incontinence Sexual Questionnaire (PISQ-12) were recorded to evaluate the symptom severity, quality of life and sexual activity.

The mean surgical time was 163.8 ± 42.3 min (range: 120-280 min), the mean estimated blood loss was 48.6 ± 60.5 ml (range: 10-200 ml), and the mean hospital stay was 5 days (range: 3-7 days). No intra-operative complications were encountered. The anatomical success rate at postoperative 6-month and 12-month was 97.1% and 94.3%, respectively. The postoperative anatomical points on straining showed a significant improvement on dynamic MRI as compared to baselines. The symptom severity, quality of life and sexual activity also presented significant improvement both 6-month and 12-month after surgery. After a minimal 12 months follow-up, no postoperative complications occurred and the recurrence prolapse were low.

LILS with uterine preservation is a feasible, effective and safe surgical alternative in the treatment of POP for patients who desire to reserve uterus. Longer follow-up data from larger studies are required to confirm the benefits of LILS with uterine preservation as a minimally invasive surgical approach.

Because of problems with vaginal meshes and the high rate of recurrences of native tissue repair, more and more surgeons treat pelvic organ prolapse with laparoscopic sacrocolpopexy. This surgery requires skilled surgeons. The first step of sacrocolpopexy is the dissection of tissues in front of the sacral promontory to reach the anterior longitudinal ligament. Some complications can occur during this dissection and the attachment of the mesh. This step is dangerous for surgeons because of the proximity of vessels, nerves, and ureters. The lack of knowledge of anatomy can lead to severe complications such as vascular, ureteral, or nerve injuries. These complications can be life-threatening. To show anatomic concerns when surgeons dissect and affix the mesh on the anterior longitudinal ligament, we have developed a video of the promontory anatomy. By reviewing anatomic articles about vessels, nerves, and ureters in this localization, we propose an educational tool to increase the anatomic knowledge to avoid severe complications. In this video, we show an alternative location for dissection and graft fixation when the surgeon believes that mesh cannot be fixed safely on the anterior surface of S1, as currently recommended.

The recommended location of graft attachment during sacrocolpopexy is at or below the sacral promontory on the anterior surface of the first sacral vertebra. Graft fixation below the sacral promontory may potentially involve the first sacral nerve.

The objectives of this study were to examine the anatomy of the right first sacral nerve relative to the midpoint of the sacral promontory and to evaluate the thickness and ultrastructural composition of the anterior longitudinal ligament at the sacral promontory level.

Anatomic relationships were examined in 18 female cadavers (8 unembalmed and 10 embalmed). The midpoint of the sacral promontory was used as reference for all measurements. The most medial and superior point on the ventral surface of the first sacral foramen was used as a marker for the closest point at which the first sacral nerve could emerge. Distances from midpoint of sacral promontory and the midsacrum to the most medial and superior point of the first sacral foramen were recorded. The right first sacral nerve was dissected and its relationship to the presacral space was noted. The anterior longitudinal ligament thickness was examined at the sacral promontory level in the midsagittal plane. The ultrastructural composition of the ligament was evaluated using transmission electron microscopy. Height of fifth lumbar to first sacral disc was also recorded. Descriptive statistics were used for data analyses.

Median age of specimens was 78 years and median body mass index was 20.1 kg/m². Median vertical distance from midpoint of sacral promontory to the level of the most medial and superior point of the first sacral foramen was 26 (range 22-37) mm. Median horizontal distance from the midsacrum to the first sacral foramen was 19 (range 13-23) mm. In all specimens, the first sacral nerve was located just behind the layer of parietal fascia covering the piriformis muscle, and thus, outside the presacral space. Median anterior longitudinal ligament thickness at the sacral promontory level was 1.9 (range 1.2-2.5) mm. Median fifth lumbar to first sacral disc height was 16 (8.3-17) mm.

Awareness of the first sacral nerve position, approximately 2.5 cm below the midpoint of the sacral promontory and 2 cm to the right of midline, should help anticipate and avoid somatic nerve injury during sacrocolpopexy. Knowledge of the approximate 2-mm thickness of the anterior longitudinal ligament should help reduce risk of discitis and osteomyelitis, especially when graft is affixed above the level of the sacral promontory.

The integrity of the pelvic autonomic nervous system is essential for proper bowel, bladder, and sexual function.

The purpose of this study was to characterize the anatomic path of the pelvic autonomic system and to examine relationships to clinically useful landmarks.

Detailed dissections were performed in 17 female cadavers. Relationships of the superior hypogastric plexus to aortic bifurcation and midpoint of sacral promontory were examined; the length and width of plexus was documented. Path and width of right and left hypogastric nerves were recorded. The origin and course of the pelvic splanchnic nerves were documented. Individual nerve tissue that contributed to the inferior hypogastric plexus was noted. Relative position of nerves to arteries, viscera, and ligaments was documented. In a subset of specimens, biopsy specimens were obtained to confirm gross findings by histologic analysis. Descriptive statistics were used for data analyses and reporting.

In all specimens, the superior hypogastric plexus was embedded in a connective tissue sheet within the presacral space, just below the peritoneum. In 14 of 17 specimens (82.4%), the plexus formed a median distance of 21.3 mm (range, 9-40 mm) below aortic bifurcation; in the remaining specimens, it formed a median distance of 25.3 mm (range, 20.5-30 mm) above bifurcation. In 58.8% of specimens, the superior hypogastric plexus was positioned to the left of midline. The median length and width of the plexus was 39.5 (range, 11.5-68) mm and 9 (range, 2.5-15) mm, respectively. A right and left hypogastric nerve was identified in all specimens and formed a median distance of 23 mm (range, 5-32 mm) below the promontory. The median width of the hypogastric nerve was 3.5 mm (range, 3-4.5 mm) on the right and 3.5 mm (range, 2-6.5 mm) on the left. The median distance from midportion of uterosacral ligament to the closest nerve branch was 0.5 mm (range, 0-4.5 mm) on right and 0 mm (range, 0-27.5 mm) on left. In all specimens, the inferior hypogastric plexus was formed by contributions from the hypogastric nerves and branches from S3 and S4. In 47.1% of hemipelvises, S2 branches contributed to the plexus. The sacral sympathetic trunk contributed to the plexus in 16 of 34 hemipelvises where this structure was identified. The inferior hypogastric plexus formed 1-3 cm lateral to the rectum and upper third of the vagina. From this plexus, 1-3 discrete branches coursed deep to the ureter toward the bladder. A uterine branch that coursed superficial to the ureter followed the ascending branch of the uterine artery. An S4 branch was found directly attaching to lateral walls of the rectum in 53% of specimens. Pelvic splanchnic nerves merged into the inferior hypogastric plexus on the lower and medial surface of the coccygeus muscle. Histologic analysis confirmed neural tissue in all tissues that were sampled.

Anatomic variability and inability to visualize the small caliber fibers that comprise the inferior hypogastric plexus grossly likely underlines the reasons that some postoperative visceral and sexual dysfunction occur in spite of careful dissection and adequate surgical technique. These findings highlight the importance of a discussion with patients about the risks that are associated with interrupting autonomic fibers during the preoperative consent.

The aim of the study is to facilitate the suture on the sacral promontory for laparoscopic sacrocolpopexy. We hypothesised that a new method of sacral anchorage using a biosynthetic material, the polyether ether ketone (PEEK) harpoon, might be adequate because of its tensile strength, might reduce complications owing to its well-known biocompatibility, and might shorten the duration of surgery.

We verified the feasibility of insertion and quantified the stress resistance of the harpoons placed in the promontory in nine fresh cadavers, using four stress tests in each case. Mean values were analysed and compared using the Wilcoxon and Fisher's exact tests.

The harpoon resists for at least 30 s against a pulling force of 1 N, 5 N and 10 N. Maximum tensile strength is 21 N for the harpoon and 32 N for the suture. Harpoons broke in 6 % and threads in 22 % of cases. Harpoons detached owing to ligament rupture in 64 % of the cases. Regarding failures of the whole complex, the failure involves the harpoon in 92 % of cases and the thread in 56 %. The four possible placements of the harpoon in the promontory were equally safe in terms of resistance to traction.

The PEEK harpoon can be easily anchored in the promontory. Thread is more resistant to traction than the harpoon, but the latter makes the surgical technique easier. Any of the four locations tested is feasible for anchoring the device.

This study aimed to characterize pertinent anatomy relative to the sacral suture placed at time of robotic sacrocolpopexy using postoperative computed tomography and magnetic resonance imaging.

A vascular clip was placed at the base of the sacral suture at the time of robotic sacrocolpopexy. Six weeks postoperatively, subjects returned for a computed tomography scan and magnetic resonance imaging.

Ten subjects completed the study. The middle sacral artery and vein coursed midline or to the left of midline in all the subjects. The left common iliac vein was an average of 26 mm from the sacral suture. To the right of the suture, the right common iliac artery was 18 mm away. Following the right common iliac artery to its bifurcation, the right internal iliac was on average 10 mm from the suture. The bifurcations of the inferior vena cava and the aorta were 33 mm and 54 mm further cephalad, respectively.The right ureter, on average, was 18 mm from the suture. The thickness of the anterior longitudinal ligament was 2 mm.The mean angle of descent of the sacrum was 70 degrees. Lastly, we found that 70% of the time, a vertebral body was directly below the suture; the disc was noted in 30%.

We describe critical anatomy surrounding the sacral suture placed during robotic sacrocolpopexy. Proximity of both vascular and urologic structures within 10 to 18 mm, as well as anterior ligament thickness of only 2 mm highlights the importance of adequate exposure, careful dissection, and surgeon expertise.

To investigate the distribution of iliac veins posterior to common iliac artery bifurcation (CIAB) for pelvic lymphadenectomy.

After IRB approval was obtained, computer tomography angiography data of 442 female pelvises were acquired. After vascular three-dimensional (3D) reconstructions, the structural types, frequencies and diameters of iliac veins immediately posterior to CIAB were investigated and measured. To quantify iliac vein courses, linear distances and their distances on sagittal, coronal and vertical axes from CIAB to external/internal iliac veins confluence (EIIVC) were geometrically measured.

There were five structural types of iliac veins distribution immediately posterior to CIAB: common iliac vein (CIV, 13.8%), no occurrence of great vein (N, 71.27%, 0), EIIVC (1.58%) and external iliac vein (EIV, 13.35%) on the left side, while confluence of common iliac veins (CCIV, 8.82%), CIV (77.38%), N (1.58%, 0), EIIVC (6.11%), and EIV (6.11%) on right. The venous diameters immediately posterior to CIAB in "CCIV", "CIV" and "EIIVC" were significantly larger than that in "EIV" (P<0.05). Their linear distances and their distances on each axis from CIAB to external/internal iliac veins confluence (EIIVC) from CIAB to EIIVC were obtained.

In this study, we presented new distribution of iliac veins posterior to CIAB, including structural types, frequencies, venous diameters immediately posterior to CIAB, and their quantified courses from CIAB to EIIVC. It could help surgeons reduce the risk of vascular injury, hemorrhage or transfusion in pelvic lymphadenectomy.

The purpose of this study was to classify anatomical variations of the internal iliac vein (IIV) in relation to robotic or laparoscopic extended lymphadenectomy. Between March 2011 and July 2012, 60 consecutive patients underwent robotic or laparoscopic extended lymphadenectomy. We retrospectively reviewed surgical video clips and analyzed the pattern of the IIVs in the presacral area. IIV variations were classified into seven types: Type A, normal (n = 39, 65.0%); Type A with a dilated middle sacral vein (n = 5, 8.3%); Type B, left IIV connecting centrally to the left external iliac vein (n = 5, 8.3%); Type C, a separated trunk of the left IIV draining into the left central common iliac vein (CIV; n = 1, 1.7%); Type D, a separated trunk of the right IIV draining into the left central CIV (n = 8, 13.3%); Type E, a separated trunk of the right IIV draining into the right central CIV (n = 0, 0%); and Type F, separated trunks of the bilateral IIV connecting with each other before draining into the left central CIV (n = 2, 3.3%). The prevalence of IIV anomalies was 26.7%; the incidence of separated IIV trunks was 18.3%. To prevent life-threatening IIV injury during extended lymphadenectomy or sacral colpopexy, the anatomical variations of the IIVs should be known exactly.

The purpose was to investigate the median sacral artery (MSA) anatomical pathway in terms of its relationship to the lumbosacral spine.

The posterior wall and lumbosacral spine of 54 adult embalmed cadavers were dissected. The MSA emerging point was identified. The distance from its emerging point to the lateral border of the vertebral body was measured bilaterally. The pathway of the MSA from the emerging point to the sacral promontory was described together with the MSA length. All outcomes were independently measured by two observers. Statistics on obtained data were calculated.

Most of the MSA emerging points were at the L5 vertebral body (94.4 %). The emerging point from the right and left lateral border of the L5 vertebral body was 3.31 ± 0.54 cm and 2.39 ± 0.51 cm, respectively. The MSA then lay along the middle one-third of the anterior surface of the lumbosacral junction. The mean length between the emerging point and the sacral promontory was 2.73 ± 0.97 cm.

The MSA anatomy is important for prevention of intra-operative bleeding. For anterior lumbosacral surgery, the MSA should be identified and controlled before proceeding with the spinal surgery. For posterior bicortical sacral screw placement, the screw tip should be fluoroscopically checked to avoid inserting the screw tip into the mid sacral promontory. By first approaching the anterior sacral promontory, the surgeon will find the MSA within the middle one-third zone, and 2.47-2.99 cm cephalad to this, the iliac vessels. Knowledge of the MSA helps the surgeon to operate more safely.

To determine the variation in vaginal axis and posterior cul-de-sac depth when the lowest suture used to attach the sacrocolpopexy mesh to the anterior longitudinal ligament is anchored at different levels.

At five lumbosacral mesh attachment sites, the anterior vaginal wall axis angle was measured relative to a line between the lowest border of the pubic symphysis and fourth sacral (S4) foramen in 9 unembalmed cadavers. The vertical distance from S4 to the posterior mesh was measured as a surrogate of cul-de-sac depth.

From a mesh fixation point at the lower border of S2 to a point at the lower border of L5, there was a 3-fold increase in both vaginal axis angle (13.04 ± 3.19 vs 42.88 ± 4.16 cm) and distance from S4 to the posterior mesh (2.50 ± 0.61 vs 7.38 ± 1.30 cm) between these points.

During sacrocolpopexy, progressively cephalad sacral attachment increases vaginal axis angle and cul-de-sac depth.

The objective of the study was to further characterize the vascular and ureteral anatomy relative to the midsacral promontory, a landmark often used during sacrocolpopexy, and suggest strategies to avoid complications.

Distances between the right ureter, aortic bifurcation, and iliac vessels to the midsacral promontory were examined in 25 unembalmed female cadavers and 100 computed tomography (CT) studies. Data were analyzed using Pearson χ(2), unpaired Student t test, and analysis of covariance.

The average distance between the midsacral promontory and right ureter was 2.7 cm (range, 1.6-3.8 cm) in cadavers and 2.9 cm (range, 1.7-5.0 cm) on CT (P = .209). The closest cephalad vessel to the promontory was the left common iliac vein, the average distance being 2.7 cm (range, 0.95-4.75 cm) in cadavers and 3.0 cm (range, 1.0-6.1 cm) on CT (P = .289). The closest vessel to the right of the promontory was the internal iliac artery, with the average distance of 2.5 cm (range, 1.4-3.9 cm) in cadavers and 2.2 cm (range, 1.2-3.9 cm) on CT (P = .015). The average distance from the promontory to the aortic bifurcation was 5.3 cm (range, 2.8-9.7 cm) in cadavers and 6.6 cm (range, 3.1-10.1 cm) on CT (P < .001). The average distance from the aortic bifurcation to the inferior margin of the left common iliac vein was 2.3 cm (range, 1.2-3.9 cm) in cadavers and 3.5 cm (range, 1.7-5.6 cm) on CT (P < .001).

The right ureter, right common iliac artery, and left common iliac vein are found within 3 cm from the midsacral promontory. A thorough understanding of the extensive variability in vascular and ureteral anatomy relative to the midsacral promontory should help avoid serious intraoperative complications during sacrocolpopexy.

Sacral colpopexy is a well established method of vaginal prolapse correction. Although it is capable of restoring the physiologic axis of the vagina, this method also bears some serious operative risks [1]. The aim of the study was to compare the laparoscopic sacral colpopexy with a laparoscopic bilateral fixation of the vagina/cervix to the iliopectineal ligaments via a PVDF-mesh (pectopexy).

This part of a single-center randomized prospective clinical trial (Canadian Task Force Classification) compared the short-term operative outcome of laparoscopic sacropexy and pectopexy. We evaluated the operating time, blood loss, hospital stay duration, occurrence of major complications, episodes of constipation, urinary retention, de novo urinary incontinence, urinary tract infections, body mass index and postoperative Creactive protein values. The 1-year follow up examination will be carried out to evaluate the occurrence of relapse as well as late complications. Local symptoms and sexual activity will be evaluated using a German version of the ICIQ Vaginal Symptoms Questionnaire.

We carried out 43 pectopexies and 40 sacropexies in conjunction with other laparoscopic and/or vaginal procedures, as indicated. No major complications occurred in both groups during the hospital stay. There were no significant differences in the body mass index, average age, hospital stay duration and occurrence of constipation. The average operating time (43.1 vs. 52.1 min) and blood loss (4.6 vs. 15.3 ml) were significantly lower in the pectopexy group (p < 0.001).

Although laparoscopic pectopexy cannot yet be generally recommended as an alternative to sacropexy until the follow-up data is obtained, the new method can be considered in patients where the presacral preparation bears a higher risk of injury.

We sought to compare the pullout strengths of the sacral end of the sacrocolpopexy mesh when attached using one suture at the first versus second sacral vertebral level (S1 vs. S2) in female cadaveric pelvises.

The sacral vertebrae were isolated in 9 unembalmed female cadavers, and segments of polypropylene mesh were attached to the sacrum using stitches at either the S1 or S2 level. The free end of the mesh was pulled at a constant rate. Maximum tension prior to system failure was recorded for each specimen. Suture pullout strengths between the two groups were compared using the two-sample Wilcoxon rank-sum test.

In all but one specimen, failure of the system occurred at the point of suture attachment to the anterior longitudinal ligament. Among the nine specimens, median pullout strengths were 7.49 lb (interquartile range 7.95) at S1 and 3.15 lb (interquartile range 2.975) at S2 (p = 0.028).

The pullout strength of sutures used to attach the sacrocolpopexy mesh to the sacrum is significantly higher at the S1 level than at the S2 level.

The aim of our study is to describe the course of the autonomic nerves in the presacral space and to find the best nerve-preserving approach for sacrocolpopexy.

The autonomic nerves of the presacral space were dissected on six specially preserved female cadavers.

The superior hypogastric plexus is located in front of the abdominal aorta and its bifurcation and deviates to the left of the midsagittal plane. At the level of the promontory, or just below, the superior hypogastric plexus branches into two hypogastric nerves that run in front of the sacrum. In the presacral space the parasympathetic pelvic splanchnic nerves from the ventral rami of the sacral spinal nerves (S2-S3) join the hypogastric nerves, forming the inferior hypogastric plexus on both sides. From the inferior hypogastric plexus, nerve fibres spread out bilaterally to the pelvic organs. In two of the six cadavers sacral splanchnic nerves could be identified leading from the sacral sympathetic ganglion S1 of the sympathetic trunk to the inferior hypogastric plexus.

Longitudinal incision of the peritoneum along the right common iliac artery and above the promontory allows for a safe approach for sacrocolpopexy. After exposing the vascular structure (e.g. medial sacral vessels) above the promontory, the anterior longitudinal ligament becomes visible and can be prepared for the fixation of the mesh for vaginal suspension. By protecting the superior hypogastric plexus and the part of the presacral area below the promontory we can preserve the hypogastric nerves, the sacral and pelvic splanchnic nerves and thus the autonomic innervation of the pelvic organs. Awareness of the course of the autonomic nerves in the presacral space will significantly improve the functional outcome of sacrocolpopexy and reduce bowel, urinary and sexual dysfunctions.

Normal physiologic function of the pelvic organs depends on the anatomic integrity and proper interaction among the pelvic structures, the pelvic floor support components, and the nervous system. Pelvic floor dysfunction includes urinary and anal incontinence; pelvic organ prolapse; and sexual, voiding, and defecatory dysfunction. Understanding the anatomy and proper interaction among the support components is essential to diagnose and treat pelvic floor dysfunction. The primary aim of this article is to provide an updated review of pelvic support anatomy with clinical correlations. In addition, surgical spaces of interest to the gynecologic surgeon and the course of the pelvic ureter are described. Several concepts reviewed in this article are derived and modified from a previous review of pelvic support anatomy.

To estimate the strongest location and optimal orientation of suture placement in the anterior longitudinal ligament for abdominal sacrocolpopexy in female cadavers.

The anterior longitudinal ligament was exposed below the level of the aortic bifurcation in 23 unembalmed female cadavers. To the right of midline of the vertebral column, sutures were placed in a horizontal orientation into the ligament at the sacral promontory, 1 and 2 cm above (sacral promontory+1 and sacral promontory+2), and 1, 2, and 3 cm below (sacral promontory-1, sacral promontory-2 and sacral promontory-3). At these same locations, but to the left of midline, sutures were placed in a vertical orientation. Pull-out force and ligament thickness at each level of testing were measured. Data were analyzed using Student t test and repeated measures analysis of variance.

Sutures (either horizontally or vertically placed) had greater pull-out strengths at or above, compared with those placed below, the level of the sacral promontory. At sacral promontory and sacral promontory+1, there were no differences in the pull-out strengths of the ligament when sutures were placed in either orientation. However, horizontally placed sutures had significantly greater pull-out strengths than vertically placed sutures at sacral promontory+2, sacral promontory-1 and sacral promontory-2. Ligament thickness decreased from 2 cm above (mean+/-standard error of the mean sacral promontory+2, 1.8+/-0.1 mm) to 3 cm below (sacral promontory-3, 1.3+/-0.1 mm) the sacral promontory.

Sutures placed in the anterior longitudinal ligament at or above the sacral promontory are more secure than those placed below. Horizontally oriented sutures should be considered for mesh attachment below the sacral promontory because they are significantly stronger when compared with vertically placed sutures.