Nerve injury during uterosacral ligament fixation: a cadaver study (original) (raw)
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Sensory nerve injury after uterosacral ligament suspension
American Journal of Obstetrics and Gynecology, 2006
Objective: Uterosacral ligament suspension is a technique that is performed commonly to suspend the prolapsed vaginal apex. This case series describes our experience with the clinical evaluation and management of lower extremity sensory nerve symptoms after uterosacral ligament suspension. Study design: Hospital and office medical records from our 2 institutions were reviewed from January 2002 to August 2005, and all women who underwent uterosacral ligament suspension through a vaginal approach were identified. Women with symptoms of buttock and posterior thigh pain during the 6-week postoperative period were identified, and detailed clinical information was abstracted from the charts. Results: From182 uterosacral ligament suspension procedures, 7 women were identified. The age range was 42 to 70 years. Concurrent procedures included 6 vaginal hysterectomies, 5 anterior repairs, 4 posterior repairs, 2 slings, and 1 bilateral salpingo-oophorectomy. Within 24 hours of the surgical procedure, all the women experienced similar, substantial sharp buttock pain and numbness that radiated down the center of the posterior thigh to the popliteal fossa in 1 or both lower extremities. The ipsilateral uterosacral ligament suture was removed within 2 days of the procedure in 3 women who had immediate subjective reduction in their pain and complete resolution of pain by 6 weeks. The remaining 4 women were treated with gabapentin and narcotics. Three women had resolution of the pain by 12 to 14 weeks after the operation, and the last woman's pain resolved gradually by 6 months. Conclusion: Women who undergo uterosacral ligament suspension are at risk of postoperative pain and numbness in a S2-4 distribution. These symptoms appear to be related to the placement of uterosacral ligament sutures and may be relieved either by prompt removal of the ipsilateral uterosacral ligament suture or with prolonged medical therapy.
Relationship of the uterosacral ligament to the sacral plexus and to the pudendal nerve
International Urogynecology Journal, 2006
We describe the anatomy of the uterosacral ligament with respect to the sacral plexus. In six adult female embalmed cadavers, we identified the uterosacral ligament and its lateral nerve relations. Using the ischial spine as the starting point and measuring along the axis of the uterosacral ligament, we noted that the S1 trunk of the sacral plexus passes under the ligament 3.9 cm [95% confidence interval (CI), 2.1-5.8 cm] superior to the ischial spine. The S2 trunk passes under the ligament at 2.6 cm (95% CI; 1.5, 3.6 cm), the S3 trunk passes under the ligament at 1.5 cm (95% CI; 0.7, 2.4 cm), and the S4 trunk passes under the ligament at 0.9 cm (95% CI; 0.3, 1.5 cm) superior to the ischial spine. The pudendal nerve forms lateral to the uterosacral ligament. Our data demonstrate that the S1-S4 trunks of the sacral plexus, not the pudendal nerve, are vulnerable to injury during uterosacral ligament suspension.
International Urogynecology Journal, 1997
The aim of the study was to investigate the histology of the sacrospinous ligament to determine whether nerve fibers exist within the substance of the sacropinous ligament itself. Six sacrospinous ligaments were removed from 4 fixed female cadavers. Representative segments were taken from the lateral (ischial), middle and medial (sacral) portions of these specimens, sectioned by microtome, mounted, and stained with hematoxylin and eosin dyes. The fixed and stained sections were then examined using light microscopy. Nerve tissue was found to be concentrated in the medial portions of the sacrospinous ligaments, but nerves were found in all segments of the ligament. It was concluded that, nervous tissue is present and widely distributed within the body of the sacrospinous ligament. A wide variety of sizes and thicknesses are also demonstrated, suggesting a variety of functions, including possible pain reception. This fact should be taken into consideration when planning operative procedures for pelvic prolapse.
Etiology of post-uterosacral suspension neuropathies
International Urogynecology Journal, 2009
Introduction and hypothesis The goal of our investigation was to find a neurological explanation for neuropathies reported following some uterosacral ligament suspension (USLS) . Methods We dissected the neural structures beneath the USL in seven female, adult, embalmed cadavers. We made a literature review to determine the spinal nerve sensory fiber composition of each exposed neural structure and the dermatome(s) that it innervates. We then compared anticipated sensory neuropathies for each neural structure with neuropathies following USLS to determine which neural structure entrapment could explain the reported symptoms.
Surgical anatomy of the uterosacral ligament
International Urogynecology Journal, 2010
Introduction and hypothesis This study aims to elucidate and expand current knowledge of the uterosacral ligament (USL) from a surgical viewpoint. Methods Studies were performed on 12 unembalmed cadaveric pelves and five formalin-fixed pelves. Results The USL, 12-14-cm long, can be subdivided into three sections: (1) distal (2-3 cm), intermediate (5 cm), and proximal (5-6 cm). The thick (5-20 mm) distal section, attached to cervix and upper vagina, is confluent laterally with the cardinal ligament. The proximal section is diffuse in attachment and generally thinner. The relatively unattached intermediate section is wide, and thick, well defined when placed under tension, more than 2 cm from the ureter and suitable for surgical use. The strength of the USL is perhaps derived not only from the ligament itself, but also from the addition of extraperitoneal connective tissue. Conclusions The USL can be subdivided into three sections according to thickness and attachments with the intermediate section suitable for surgical use, particularly for vaginal vault support.
Nerve Entrapment - An Important Complication of Transverse Lower Abdominal Incisions
The Australian and New Zealand Journal of Obstetrics and Gynaecology, 1994
Eleven patients with atypical lower abdominal pain following gynaecological surgery were clinically assessed for the features of nerve entrapment syndrome. Eight iliohypogastric nerves in 6 patients were subsequently explored and divided with satisfactory results in all patients. Diagnostic criteria for this syndrome are suggested, and the surgical management is described. 5% AUST. AND N.Z. JOURNAL OF OBsrETRiCS AND GYNAECOWGY 2. Harms BA, De Haas DR, Starling JR. Diagnosis and management of genitofemoral neuralgia. Arch Surg 1984; 119 339-341. 3. Magee RK. Genitofemoral causalgia (new syndrome). Can Med A s m J 194% 46: 326-329. 4. Sippo WC, Burghardt A, Gomez AC. Nerve entrapment after Pfannenstiel incisions. Am J Obstet Gynecol 1987; 157: 420-421. 5. Sippo WC, Gomez AC. Nerve entrapment syndromes from lower abdominal surgery. J. Fam Pract 1987; 25: 585-587. 6. Gallegos NC, Hobsley M. Abdominal wall pain: an alternative diagnosis. B J Surg 1990; 77: 1167-1170. 7. Miyazaki F, Shok J. Ilioinguinal nerve entrapment during needle suspension for stress incontinence. Obstet Gynecol 1992; 80: 8. Knockaert DC, D'Heygere FG, Bobbaers HJ. llioinguinal nerve entrapment: a little known cause of iliac fossa pain. Postgrad Med J 1989; 65: 632-635. 9. Hahn L. Clinical findings and results of operative treatment in ilioinguinal nerve entrapment syndrome. Br J Obstet Gynaecol 1980; 9 6 1080-1083.
Dorsal clitoral nerve injury following transobturator midurethral sling
Journal of pain research, 2016
Transobturator slings can be successfully used to treat stress urinary incontinence and improve quality of life through a minimally invasive vaginal approach. Persistent postoperative pain can occur and pose diagnostic and therapeutic dilemmas. Following a sling procedure, a patient complained of pinching clitoral and perineal pain. Her symptoms of localized clitoral pinching and pain became generalized over the ensuing years, eventually encompassing the entire left vulvovaginal region. The aim of this study was to highlight the clinical utility of conventional pain management techniques used for the evaluation and management of patients with postoperative pain following pelvic surgery. We described a prototypical patient with persistent pain in and around the clitoral region complicating the clinical course of an otherwise successful sling procedure. We specifically discussed the utility of bedside sensory assessment techniques and selective nerve blocks in the evaluation and manag...
The Tohoku Journal of Experimental Medicine, 2007
Radical hysterectomy has been performed for invasive cervical cancer, and autonomic nerve-sparing procedures have been developed to preserve bladder function. To perform and improve the nerve-sparing radical hysterectomy, it is important to understand anatomy of the intra pelvic fasciae, specially vesico-uterine ligament (VUL), because most of injuries to the nerves occurred during incision of the VUL in radical hysterectomy procedures. The objectives of the present study were to provide histological understanding of major structures found in nervesparing radical hysterectomy. Serial macroscopic slices (15-20 mm thick) from five female pelves were trimmed and prepared for paraffin-embedded histology. We noted an anatomical entity as "the visceroparietal fascial bridge", which corresponds with the macroscopically identified arcus tendineus fasciae pelvis. A histologically identifiable neurovascular pedicle to the bladder neck corresponded with the deep portion of VUL. These findings could help better preservation of autonomic nerves during radical hysterectomy and improve patient's quality of life after the operation. Translation of surgical anatomy into anatomic terminology enables us to have fruitful discussions with persuasive power by excluding any bias from individual surgeons. vesico-uterine ligament; paracolpium; parietal fascia; levator ani; radial hysterectomy; autonomic nerve