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Kim: Robotic sacrocolpopexy with nerve sparing dissection technique
For apical uterine prolapse and multi-compartment prolapse, sacrocolpopexy is considered the most effective treatment [1]. However, de novo bladder, bowel and sexual dysfunctions have been reported after sacrocolpexy and may be caused by intraoperative damage of the pelvic autonomous nerves [2-4].
The superior hypogastric plexus is situated at the level of the aortic bifurcation and include sympathetic fibers from sympathetic trunk. Then superior hypogastric plexus (SHP) spreads out to form the bilateral inferior hypogastric plexus (IHP), which take up parasympathetic fibers from the splanchnic and inferior mesenteric nerves [5,6]. During robotic sacrocolpopexy, dissection of the presacral space in the sacral promontory and right pelvic side wall alongside the uterosacral ligament and crossing to the rectovaginal space can damage fibers of the superior and IHP. This results in postoperative side effects such as incomplete voiding, defecatory dysfunction, pain, and sensory problems [7,8].
This video demonstrates our robotic sacrocolpopexy with nerve sparing dissection technique. The patient is a 62-year-old woman with symptomatic stage III apical uterine prolapse. The steps of technique include opening the peritoneum at the level of the sacral promontory, identification of the fibers of the SHP and right hypogastric nerve, displacement of the nerve fibers to the left side, deep posterior dissection to expose the longitudinal ligament of S1 vertebral body. Then we extended the peritoneal dissection superficially along the lateral side of right uterosacral ligament to the rectovaginal space. After attachment of the mesh to the vagina and sacrum, the surgery is completed after peritonealization. This nerve sparing dissection technique is feasible and can be considered by surgeons who perform robotic sacrocolpopexy.

Video related to this article

The video related to this article can be found online at 10.36637/grs.2022.00136.

Notes

Conflict of interest

No potential conflict of interest relevant to this article was reported.

References

1. Maher C, Feiner B, Baessler K, Schmid C. Surgical management of pelvic organ prolapse in women. Cochrane Database Syst Rev 2013;(4):CD004014.
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2. Serbetcioglu GC, Simsek SY, Alemdaroglu S, Aytac PC, Kalayci H, Celik H. Outcomes of nerve-sparing laparoscopic sacropexy on one hundred fifteen cases. J Gynecol Obstet Hum Reprod 2020;49:101795.
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3. Christmann-Schmid C, Koerting I, Ruess E, Faehnle I, Krebs J. Functional outcome after laparoscopic nerve-sparing sacrocolpopexy: a prospective cohort study. Acta Obstet Gynecol Scand 2018;97:744–50.
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4. Cosma S, Petruzzelli P, Danese S, Benedetto C. Nerve preserving vs standard laparoscopic sacropexy: postoperative bowel function. World J Gastrointest Endosc 2017;9:211–9.
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5. Alkatout I, Wedel T, Pape J, Possover M, Dhanawat J. Review: pelvic nerves - from anatomy and physiology to clinical applications. Transl Neurosci 2021;12:362–78.
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6. Lemos N, Souza C, Marques RM, Kamergorodsky G, Schor E, Girão MJ. Laparoscopic anatomy of the autonomic nerves of the pelvis and the concept of nerve-sparing surgery by direct visualization of autonomic nerve bundles. Fertil Steril 2015;104:e11–2.
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7. Cosma S, Menato G, Ceccaroni M, Marchino GL, Petruzzelli P, Volpi E, et al. Laparoscopic sacropexy and obstructed defecation syndrome: an anatomoclinical study. Int Urogynecol J 2013;24:1623–30.
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8. Huber SA, Northington GM, Karp DR. Bowel and bladder dysfunction following surgery within the presacral space: an overview of neuroanatomy, function, and dysfunction. Int Urogynecol J 2015;26:941–6.
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