FIGURE 15 Hypogastric nerve descending into the right pelvis
The right and left hypogastric nerves leave the hypogastric plexus and descend into the pelvis parallel to the ureter and 2 cm medial. It passes dorsal to the ureter as it goes through the cardinal ligament (FIGURE 5).
This plexus then supplies autonomic innervation of the bladder, rectum, uterus, and ureter. Complete disruption of the hypogastric nerve will lead to a hypertonic, noncontractile bladder and the necessity for self-catheterization to eliminate urine. Preservation of this nerve during radical hysterectomy or endometriosis resection is a high priority.
Laparoscopic uterosacral nerve ablation procedures divide the uterosacral ligament medial and caudad to the ureter and do not disrupt the main hypogastric nerve. Only the medial branches to the uterus are affected. Successful uterosacral nerve ablation has been reported in approximately 44% of women who have dysmenorrhea without visible endometriosis and approximately 62% of women who have visible endometriosis.7,8 The efficacy of this procedure is controversial, however. Removal of the superior hypogastric plexus (presacral neurectomy) has not proved to be more effective in controlling pelvic pain than conservative surgery that only destroys endometrial implants. Presacral neurectomy is no longer advised.9