Neurólises de plexos simpáticos têm sido utilizadas no tratamento da dor oncológica, mostrando ser um recurso terapêutico bastante eficaz e seguro. Alguns estudos apontam a utilização da neurólise de plexos simpáticos em estágios iniciais da doença por prevenir a dor e melhorar a qualidade de vida, contrariando a OMS que preconiza o uso de métodos invasivos em última instância. Em estudo prospectivo, randomizado e controlado, neurólise de plexos simpáticos realizada em estágios diferentes do tratamento da dor oncológica foi comparada com o tratamento farmacológico. Foram selecionados 60 pacientes com câncer abdominal ou pélvico e alocados em três grupos. No grupo I (precoce) os pacientes estavam em uso de AINEs e opióides fracos ou fortes (dose inferior a 90mg/dia de morfina) e reportavam dor (VAS  4) quando foram submetidos a neurólise plexo celíaco (NPC), neurólise do plexo hipogástrico superior (NPHS) ou neurólise plexo simpático lombar (NPSL) de acordo com o sítio de dor. No grupo II (tardio) a neurólise foi realizada quando a utilização de AINEs e morfina foram iguais ou superiores a 90mg/dia de morfina e VAS>4. No grupo III (controle) os pacientes fizeram uso somente de medicação analgésica. Os pacientes foram observados durante 8 semanas e avaliados quanto à intensidade da dor (VAS), consumo de opióides e qualidade de vida. Imediatamente após as neurólises e durante todo o tempo de observação, os pacientes dos grupos precoce e tardio apresentaram redução da intensidade da dor e do consumo de opióides, além disso melhora da qualidade de vida quando comparados com o grupo controle. Não houve diferenças entre os grupos precoce e tardio nestes aspectos. Efeitos adversos correlacionados com o uso de opióide, como náuseas e/ou vômitos, perda do apetite e constipação foram significativamente maiores no grupo controle. Complicações relacionadas às neurólises, tais como hipotensão e diarréia, foram transitórias e não deferiram significativamente do grupo controle. Não foram encontradas complicações sérias em nenhum dos grupos experimentais. A neurólise de plexos simpáticos foi efetiva na redução da intensidade da dor e do consumo de analgésicos e dos efeitos adversos relacionados com a administração de drogas, e na melhora da qualidade de vida dos pacientes. Embora não havendo diferenças entre os grupos precoce e tardio, os resultados apontam a necessidade de utilizar esta técnica como recurso não somente em fase terminal da doença. / Neurolytic sympathetic plexus blocks (NSPB) have been used as a quite effective and safe therapeutic resource for the treatment of cancer pain. Studies point to the use of NSPB in the early phases of the disease to prevent pain and to improve the life quality, contradicting WHO that extols the use of invasive methods ultimately. We compared the use of neurolytic plexus block in two different phases of the treatment of oncology pain with the pharmacological therapy. In prospective study, randomized and controlled, sixty patients with abdominal or pelvic oncology pain were allocated to tree groups. In group I (early block) the patients using NSAID and weak opioid or oral morphine at a dose of less than 90 mg/day and reporting pain (VAS  4) were submitted to a neurolytic celiac plexus block (NCPB), superior hypogastric plexus block (SHPB) or lumbar sympathetic ganglionic chain (LSGCB), in accordance to the site of pain. In group 2 (late block) the patients were submitted neurolysis when using NSAID and oral morphine at a dose equals to or more than 90 mg/day and VAS  4. In group 3 (control), patients were treated with pharmacological therapy only. The patients were observed for 8 weeks and appraised for the intensity of the pain (VAS), opioid consumption and quality of live. The patients of groups I and II had reduction of the intensity of the pain, opioid consumption and get better quality of live immediately after to the neurolytic and during the whole time of observation when compared with the group control. There were no significant differences between groups I and II with these aspects. Adverse effects correlated with the use of opioids, as nauseas and/or vomits, loss of the appetite and constipation were significantly larger in the group control. Neurolysis related complications such as hypotension and diarrhea, were transitory and statistically similar to these found in the control group. They were not found serious complications. The neurolysis of sympathetic plexus was shown to be effective to reduce the intensity of pain, analgesic consumption and adverse effects related to the use of opioids, and in the improvement of the quality of life. The results point to the usefulness of indicating neurolytic procedure for the management of cancer pain not only in terminal phase of the disease.

Neurólises de plexos simpáticos têm sido utilizadas no tratamento da dor oncológica, mostrando ser um recurso terapêutico bastante eficaz e seguro. Alguns estudos apontam a utilização da neurólise de plexos simpáticos em estágios iniciais da doença por prevenir a dor e melhorar a qualidade de vida, contrariando a OMS que preconiza o uso de métodos invasivos em última instância. Em estudo prospectivo, randomizado e controlado, neurólise de plexos simpáticos realizada em estágios diferentes do tratamento da dor oncológica foi comparada com o tratamento farmacológico. Foram selecionados 60 pacientes com câncer abdominal ou pélvico e alocados em três grupos. No grupo I (precoce) os pacientes estavam em uso de AINEs e opióides fracos ou fortes (dose inferior a 90mg/dia de morfina) e reportavam dor (VAS  4) quando foram submetidos a neurólise plexo celíaco (NPC), neurólise do plexo hipogástrico superior (NPHS) ou neurólise plexo simpático lombar (NPSL) de acordo com o sítio de dor. No grupo II (tardio) a neurólise foi realizada quando a utilização de AINEs e morfina foram iguais ou superiores a 90mg/dia de morfina e VAS>4. No grupo III (controle) os pacientes fizeram uso somente de medicação analgésica. Os pacientes foram observados durante 8 semanas e avaliados quanto à intensidade da dor (VAS), consumo de opióides e qualidade de vida. Imediatamente após as neurólises e durante todo o tempo de observação, os pacientes dos grupos precoce e tardio apresentaram redução da intensidade da dor e do consumo de opióides, além disso melhora da qualidade de vida quando comparados com o grupo controle. Não houve diferenças entre os grupos precoce e tardio nestes aspectos. Efeitos adversos correlacionados com o uso de opióide, como náuseas e/ou vômitos, perda do apetite e constipação foram significativamente maiores no grupo controle. Complicações relacionadas às neurólises, tais como hipotensão e diarréia, foram transitórias e não deferiram significativamente do grupo controle. Não foram encontradas complicações sérias em nenhum dos grupos experimentais. A neurólise de plexos simpáticos foi efetiva na redução da intensidade da dor e do consumo de analgésicos e dos efeitos adversos relacionados com a administração de drogas, e na melhora da qualidade de vida dos pacientes. Embora não havendo diferenças entre os grupos precoce e tardio, os resultados apontam a necessidade de utilizar esta técnica como recurso não somente em fase terminal da doença. / Neurolytic sympathetic plexus blocks (NSPB) have been used as a quite effective and safe therapeutic resource for the treatment of cancer pain. Studies point to the use of NSPB in the early phases of the disease to prevent pain and to improve the life quality, contradicting WHO that extols the use of invasive methods ultimately. We compared the use of neurolytic plexus block in two different phases of the treatment of oncology pain with the pharmacological therapy. In prospective study, randomized and controlled, sixty patients with abdominal or pelvic oncology pain were allocated to tree groups. In group I (early block) the patients using NSAID and weak opioid or oral morphine at a dose of less than 90 mg/day and reporting pain (VAS  4) were submitted to a neurolytic celiac plexus block (NCPB), superior hypogastric plexus block (SHPB) or lumbar sympathetic ganglionic chain (LSGCB), in accordance to the site of pain. In group 2 (late block) the patients were submitted neurolysis when using NSAID and oral morphine at a dose equals to or more than 90 mg/day and VAS  4. In group 3 (control), patients were treated with pharmacological therapy only. The patients were observed for 8 weeks and appraised for the intensity of the pain (VAS), opioid consumption and quality of live. The patients of groups I and II had reduction of the intensity of the pain, opioid consumption and get better quality of live immediately after to the neurolytic and during the whole time of observation when compared with the group control. There were no significant differences between groups I and II with these aspects. Adverse effects correlated with the use of opioids, as nauseas and/or vomits, loss of the appetite and constipation were significantly larger in the group control. Neurolysis related complications such as hypotension and diarrhea, were transitory and statistically similar to these found in the control group. They were not found serious complications. The neurolysis of sympathetic plexus was shown to be effective to reduce the intensity of pain, analgesic consumption and adverse effects related to the use of opioids, and in the improvement of the quality of life. The results point to the usefulness of indicating neurolytic procedure for the management of cancer pain not only in terminal phase of the disease.

Introduction: Parmi les structures anatomiques impliquées dans les fonctions génitales et urinaires, l’innervation autonome et somatique du rétro-péritoine, du pelvis et du périnée a un rôle contrôle déterminant. Cette innervation reste incomplètement systématisée et elle apparaît vulnérable lors d’interventions chirurgicales ou au cours de maladies neurologiques. Classiquement, deux voies nerveuses se situent de part et d’autre du muscle élévateur de l’anus (MEA) : la voie autonome est supra-lévatorienne ; la voie somatique est infra-lévatorienne. Les nerfs autonomes viennent du plexus hypogastrique supérieur (PHS) (fibres sympathiques) qui se divise en deux nerfs hypogastriques (NHs) s’engageant dans le pelvis. Les NHs reçoivent des nerfs splanchniques pelviens (fibres parasympathiques) qui forment le plexus hypogastrique inférieur (PHI). Les voies somatiques proviennent des nerfs pudendaux. Ces notions établies par la dissection conventionnelle peuvent aujourd’hui être complétées par l’analyse de marqueurs nerveux en Dissection Anatomique Assisté par Ordinateur (DAAO). Celle-ci est susceptible de préciser les connaissances anatomiques et d’éclairer la compréhension des dysfonctions génito-urinaires.Objectifs: L’objectif était de décrire le système nerveux autonome rétro-péritonéal et pelvi-périnéal dans ses aspects morphologiques (origine, topographie, trajet, rapports) et fonctionnels (nature des fibres, terminaisons viscérales) pour mettre en perspective les implications potentielles dans les dysfonctions génito-urinaires.Matériel et méthodes: Des coupes histologiques sériées de 5 µm d’épaisseur ont été effectuées dans les régions lombaire et pelvienne de onze fœtus humains âgés de 14 à 31 semaines de gestation, et au niveau pénien chez cinq sujets anatomiques adultes masculins. Pour chaque niveau de coupe, des lames ont été colorées puis traitées en immunohistochimie pour détecter : l’ensemble des fibres nerveuses (anticorps anti-protéine S100), les fibres nerveuses somatiques (anti-PMP 22), les fibres autonomes adrénergiques (anti-TH), les fibres autonomes cholinergiques (anti-VAChT), les fibres autonomes nitrergiques (anti-nNOS), et les fibres musculaires lisses (anti-actine lisse). Les coupes ont ensuite été numérisées par un scanner de haute résolution optique et les images ont été reconstruites en 3D avec le logiciel Winsurf®.Résultats: Au niveau rétro-péritonéal, le PHS est formé de fibres adrénergiques, cholinergiques et nitrergiques. Ses fibres proviennent à la fois du plexus mésentérique inférieur, des ganglions sympathiques voisins et des nerfs splanchniques lombaires. Au niveau pelvien, le PHI se systématise en : une portion supérieure recevant ses fibres du PHS et innervant détrusor, uretères et vésicales séminales ; une portion inférieure recevant ses fibres des nerfs splanchniques pelviens et innervant trigone, prostate et corps érectiles. La jonction uretéro-vésicale est une zone richement innervée par des fibres adrénergiques, cholinergiques et nitrergiques provenant du PHI et des NHs. En outre, le PHI fournit un contingent nerveux autonome au MEA par voie supra-lévatorienne, tandis que le nerf pudendal (NP) lui fournit un contingent somatique par voie infra-lévatorienne. Au niveau pénien, la composante autonome prédomine dans les 2 tiers proximaux quand, en distalité, l’innervation est presque exclusivement somatique. Trois niveaux de communication entre les voies autonome et somatique ont été observés : pré- trans- et post-lévatorien.Conclusion: L’intrication des voies autonomes et somatiques rétropéritonéo-pelvi-périnéales, la diversité de leurs origines, leurs communications et répartition depuis les plexus jusqu’aux viscères s’établissent par DAAO. Ces voies méritent d’être au mieux préservées au cours d’interventions chirurgicales ou instrumentales. Elles représentent de potentielles voies de modulation, de plasticité ou de régénération à explorer. / Introduction: The autonomous and somatic innervations of the retro-peritoneum, the pelvis and the perineum have a determining control role among the anatomical structures involved in the genital and urinary functions. The innervations remain incompletely systematized and appear vulnerable during surgical procedures or during neurological diseases. Normally, two nerve pathways are located on both side of levator ani muscle (LAM): the autonomic pathway is supra-levatorian and the somatic pathway is infra-Levatorian. The autonomic nerves come from the superior hypogastric plexus (SHP) (sympathetic fibers) which divides into two hypogastric nerves (HNs) engaging in the pelvis. The HNs receive pelvic splanchnic nerves (parasympathetic fibers) which form the inferior hypogastric plexus (IHP). The somatic pathways come from the pudendal nerves. These notions which are established by conventional dissection can now be supplemented by the analysis of nerve markers in computer-assisted anatomic dissection (CAAD). This is likely to clarify anatomical knowledge and illuminate the understanding of genitourinary dysfunction.Objectives: The objective of this study was to describe the retro peritoneal and pelvic -perineal autonomic nervous system, its morphological (origin, topography, path and relationships) and functional (nature of fibers, visceral endings) aspects and to put into perspective the potential implications on genitourinary dysfunction.Materials and methods: Serial histological sections of 5 μm of thickness were performed in the lumbar and pelvic regions of eleven human fetuses aged 14 to 31 weeks of gestation and at the penile level in five male adult anatomical subjects. For each level, slides were stained and then treated in immunohistochemistry to detect: general nerve fibers (anti-protein S100), somatic nerve fibers (anti-peripheral myelin protein 22), autonomic adrenergic fibers (anti-tyrosine hydroxylase), autonomic cholinergic fibers (anti-VAChT), autonomic nitrergic fibers (anti-nNOS), and smooth muscle fibers (anti-actin). The slides were then digitized by a high-resolution optical scanner and the images were reconstructed in 3D using the Winsurf® software.Results: At the retroperitoneal level, the SHP is composed of adrenergic, cholinergic and nitrergic fibers. Its fibers come from inferior mesenteric plexus, the adjacent ganglions and the lumbar splanchnic nerves. At the pelvic level, the IHP is systematized into: a superior portion receiving its fibers of the SHP and innervating detrusor, ureters and seminal vesicles, a inferior portion receiving its fibers from the pelvic splanchnic nerves and innervating trigone of bladder, prostate and erectile bodies. The ureterovesical junction is an area richly innervated by adrenergic, cholinergic and nitrergic fibers from the IHP and the HNs. In addition, the IHP provides an autonomic nervous to the LAM via the supra-levatorian route, while the pudendal nerve provides a infra-levatorian somatic nervous. At the penile level, the autonomic component predominately innervates in the proximal two thirds where, in distal third, the innervation is almost exclusively somatic. Three levels of communications between the autonomic and somatic pathways were observed: pre- trans- and post-levatorian.Conclusions: The interaction of the autonomic and somatic retroperitoneo-pelvic-perineal pathways, the diversity of their origins, their communications and distribution from the plexus to the viscera are established by CAAD. These pathways deserve to be best preserved during surgical or instrumental procedures. They represent potential pathways of modulation, plasticity or regeneration to be explored in future studies.