TME-Pelvic dissection Two phases Dorsal mobilisation Anterolateral dissection.

TME-Pelvic dissection

Two phases•Dorsal mobilisation•Anterolateral dissection

Below the aortic bifurcationPreserving superior hypogastric plexusPosterior dissectionPreserving left and right hypogastric nerveCutting rectosacral fascia (Waldeyer)

TME-Dorsal mobililsation

The start of TME: Below the Aortic Bifurcation

Preserving superior hypogastric plexus

Possible Injuries to Hypogastric Plexus

Bladder dysfunction:

Urinary retentionParasympathetic nerves - detrusor muscleSympathetic nerves - bladder neck, trigone and urethral area

Sexual dysfunction:

Impotence Parasympathetic nerves (nervi errigentes) - erectionSomatic nerves (pudendal n.) - penile rigidity

Ejaculatory dysfunctions Sympathetic nerves (from thoracolumbar region of spinal cord along the

sympathetic ganglia down hypogastric nerves to pelvic plexus)

Injuries to autonomic nerves in the pelvis

Y. Moriya, Eur J of Cancer 1995.

Urinary Function after the injury to hypogastric Plexus

Y. Moriya, Eur J of Cancer 1995.

Sexual Function after the injury to hypogastric Plexus

Rectosacral fascia (Waldeyer)

Division of rectosacral fascia is one of greatest dangers of blunt Division of rectosacral fascia is one of greatest dangers of blunt manual dissection manual dissection

CRITICAL POINT: Division of Waldeyer‘s Fascia