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.

IntroductionL’anatomie nerveuse pelvienne est imprécise dans la littérature. ObjectifsReprésenter en 3D l’innervation autonome du pelvis. Démontrer la capacité de l’IRM voir cette innervation.Matériels et méthodesDes coupes ont été faites sur le bassin de fœtus et d’adultes, puis traitées par des colorations et immunomarquages. Les lames ont été numérisées et reconstruites en 3D.Nous avons effectué une confrontation anatomo-radiologique entre des images d’IRM et de dissection.RésultatsNous avons pu décrire l’innervation autonome du pelvis et faire une cartographie des neuromédiateurs. Nous avons également pu suggérer des plans d’épargne nerveuse lors de la chirurgie. Les acquisitions IRM ont permis une visualisation de l’innervation de façon précise avec une bonne concordance.ConclusionCe travail permet une meilleure description de l’innervation pelvienne et des plans chirurgicaux à emprunter en chirurgie pelvienne. L’IRM permet bien de visualiser l’innervation pelvienne. / Introduction :Pelvis nervous anatomy is imprecise in literature. Objectives:1-To describe and represent in 3D pelvic autonomic innervation. 2-To demonstrate the capacity of MRI to visualize pelvic autonomous innervation.Materiel/patients and methods:Serial histological sections were made from foetuses and adults. Sections were treated with conventional and immunostainings. Sections were digitalized and reconstructed in 3D. An anatomo-radiological comparison was made between MRI images and dissection. Results:Our study enabled to localize the pelvic autonomous innervation and to realize a complete neuro-mediators cartography.MRI acquisition allowed an good visualization of the autonomous innervation, with a good correlation with dissection.Conclusion and perspectives:This study enabled a better understanding of pelvic nervous anatomy and physiology. It also demonstrated that this anatomy is visible on MRI.

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.

Introduction : L’utilisation des méthodes anatomiques classiques rend difficile la localisationprécise des micro-fibres nerveuses et ne permet pas de déterminer leur nature ni leur fonction.La chirurgie pelvienne est associée à des séquelles urinaires et sexuelles fréquentes causéespar lésion iatrogène des nerfs pelviens. La connaissance de l’anatomie et de la physiologie del’innervation intra-pelvienne est fondamentale pour tenter de réduire le taux de troublesfonctionnels postopératoires.Objectifs : i) étudier l’anatomie topographique et la nature de fibres nerveuses intrapelvienneen utilisant la reconstruction tridimensionnelle des coupes histologiques immunomarquéesii) standardiser la technique de Dissection Anatomique Assistée par Ordinateur(DAAO) et vérifier sa faisabilité sur des sujets adultes et iii) établir grâce à cette technique deDAAO des modèles pédagogiques tridimensionnels afin d’améliorer la compréhension desdysfonctions sphinctériennes et sexuelles survenant après la chirurgie (rectale et prostatique)et d’adapter éventuellement la technique opératoire.Matériel et méthodes : Des coupes histologiques sériées de pelvis ont été réalisées chez septfoetus masculins, sept foetus féminins et six cadavres adultes masculins. Les coupes ont ététraitées par des méthodes histologiques (Hématoxyline-Eosine et trichrome de Masson) etimmuno-histochimiques pour détecter les fibres nerveuses (anti-S100), les fibres somatiques(anti-PMP22), les fibres adrénergiques (anti-TH), cholinergiques (anti-VAChT), sensitives(anti-SP/CGRP) et nitrergiques (anti-nNOS) ainsi que l’actine lisse des sphincters. Les lamesont ensuite été numérisées par un scanner de haute résolution optique et les imagesbidimensionnelles ont été reconstruites en trois dimensions grâce au logiciel WinSurf.Résultats: La reconstruction tri-dimensionnelle des coupes histologiques immuno-marquéesa permis d'identifier l’anatomie topographique et structurelle de l’innervation intra-pelvienne.Les structures nerveuses afférentes du plexus hypogastrique inférieur (PHI) : nerfssplanchniques pelviens (NSP) et nerfs hypogastriques (NH) véhiculent de façon mixte l’influxsympathique et parasympathique pelvien.Les fibres nerveuses issues de la partie distale du PHI sont responsables de la continenceurinaire et de la fonction sexuelle. Elles sont regroupées et associées au pédicule vasculairepour former la bandelette neuro-vasculaire (BNV). Trois efférences principales sont issues decette BNV : i) des fibres antérieures destinées au sphincter urétral, ii) des fibres antérolatérales,par rapport à la prostate et au vagin, constituant le nerf caverneux destiné aux corpscaverneux du pénis/clitoris et iii) des fibres nerveuses postéro-latérales, par rapport à laprostate et au vagin, formant le « nerf spongieux » destiné aux corps spongieux/bulbesvestibulaires.Les communications autonomiques-somatiques entre le PHI supra-lévatorien et le nerfpudendal infra-lévatorien existent à trois niveaux ; proximal, intermédiaire et distal. Lacommunication distale caverno-pudendale est responsable de l’activité érectile segmentaireobservée au sein du nerf dorsal du pénis/clitoris.Conclusion: La DAAO est une méthode originale de recherche anatomique qui a étéprogressivement améliorée au sein de notre unité de recherche. Cette évolution illustre le faitque l'anatomie descriptive est encore une science dynamique. Notre étude a permis dedévelopper des modèles anatomo-physiologiques d’innervation pelvienne contribuant àaméliorer du point de vue morphologique, chirurgical et pédagogique la compréhension derégions anatomiques complexes comme le petit bassin. / Introduction: Classic anatomical methods have limitations in micro determination of nervefibre location. Furthermore, the precise detection of the nerve fibres nature is not possible bymeans of dissection. Pelvic surgery is associated with urinary and sexual consequence causedby iatrogenic damage of the pelvic nerves. Anatomic and physiologic knowledge of the intrapelvicinnervation is essential to reduce the rate of postoperative functional complication.Objectives: i) to study the topographic anatomy and the nature of intra-pelvic nerve fibersusing three-dimensional reconstruction of histological immuno-labeled sections ii)standardize the technique of Computer-Assisted Anatomic Dissection (CAAD) and check itsfeasibility on adult subjects iii) reconstructe three dimensional teaching models to improveunderstanding of urinary and sexual dysfunction occurring after surgery (of rectal and ofprostate) to ameliorate the operative technique.Materials and methods: serial histological sections of pelvic portion were performed inseven male foetuses, seven female foetuses and six adult male cadavers. The sections weretraited by histological methods (Hematoxylin-Eosin and Masson's trichrome) and immunohistochemicalmarker of the nerve fibers (anti-S100), the somatic fibers (anti-PMP22), theadrenergic (anti-TH), cholinergic (anti-VAChT), sensory (anti-SP/CGRP) and nitrergic (antinNOS)fibers and the actin smooth muscles. The slides were then digitized by a scanner ofhigh optical resolution and two-dimensional images were reconstructed in three dimensionsusing WinSurf software.Results: The three dimensional reconstruction of histological immuno-labelled sectionsidentified structural and topographic anatomy of intra-pelvic innervation. The afferencenerves of the inferior hypogastric plexus (IHP): pelvic splanchnic nerves (PSN) andhypogastric nerves (HN) contain both sympathetic and parasympathetic fibers.The nerve fibers from the distal part of the IHP is responsible for urinary continence andsexual function. They are grouped and associated with the vascular pedicle to form theneurovascular bundles (NVB). Efferences of this NVB are distributed in three maindirections: i) anterior fibers the urethral sphincter, ii) anterolateral fibers, compared withprostate / vagina, which constitute the cavernous nerve for the corpora cavernosa of the penis/ clitoris and iii) " spongious nerve”, which is the continuity of posterior-lateral nerve fibers,compared with prostate / vagina, for the corpus spongiosum / vestibular bulbs.Autonomic-somatic communications between supra-lavator IHP and infra-levator pudendalnerve are present at three levels; proximal, intermediate and distal communications. Cavernopudendaldistal communication provides segmental erectile activity of the dorsal nerve of thepenis / clitoris.Conclusion: The CAAD is an original method in anatomical research which has beenprogressively improved. This illustrates the fact that descriptive anatomy is still a dynamicscience. Our study has developed anatomico-physiological models of intra-pelvic innervationcontributing to a better understanding of complex anatomical