PRECISE pelvic nerve identification can support nerve sparing gynaecological surgery and help protect neurological bladder function, according to a laparoscopic demonstration of the inferior hypogastric nerve and plexus presented at the 35th Annual Congress of the European Society for Gynaecological Endoscopy.
Two approaches were demonstrated for identifying the inferior hypogastric nerve. The first involved mobilisation of the ureter. The nerve was described as lying approximately 2–3 cm below the ureter and running within the same tissue plane.
The second approach began around the sacral promontory. Here, the superior hypogastric plexus could be identified and followed towards the inferior hypogastric nerve.
However, identification of the nerve alone was described as insufficient for nerve sparing radical hysterectomy. The inferior hypogastric nerve must be followed towards the inferior hypogastric plexus, which connects with the pelvic splanchnic nerves in the region of the cardinal ligament.
Three areas were highlighted as particularly important for avoiding pelvic nerve injury during radical dissection.
First, dissection of the cardinal ligament without identifying the inferior hypogastric plexus can result in plexus injury. Second, the inferior hypogastric nerve can be damaged during dissection of the uterosacral ligament if it has not been identified and preserved.
The third area is the bladder pillar. During radical hysterectomy, mobilisation of the ureter enables identification of the vesical branches of the inferior hypogastric plexus before further dissection. Failure to recognise these branches can lead to their inadvertent resection and subsequent neurological bladder dysfunction, particularly following bilateral injury.
The demonstration showed how these anatomical landmarks can guide nerve sparing radical hysterectomy, including careful mobilisation of the ureter and preservation of autonomic nerve structures during radical dissection.
The extent of nerve identification may also depend on the surgical indication. During radical hysterectomy, a complete nerve sparing approach can extend from the inferior hypogastric nerve to the vesical branches. In surgery for deep infiltrating endometriosis, however, dissection to the vesical branches may not always be necessary. In some cases, identifying the inferior hypogastric nerve may be sufficient.
The findings highlight detailed pelvic neuroanatomical knowledge as an important component of radical gynaecological surgery, allowing surgeons to balance the required extent of dissection with preservation of nerve structures involved in bladder function.
Reference
Kavallaris A et al. Laparoscopic Anatomic Identification of the Inferior Hypogastric Plexus and Nerve. Presentation. ESGE 35th Annual Congress, 4–7 October, 2026.
Framestock on AdobeStock
Each article is made available under the terms of the Creative Commons Attribution-Non Commercial 4.0 License.
