Anatomical feasibility of performing intercostal and ilioinguinal nerve to pelvic nerve transfer: a possible technique to restore lower urinary tract innervation

Laboratory investigation

Restricted access

Object

Nerve transfers are effective for restoring control to paralyzed somatic muscle groups and, recently, even to denervated detrusor muscle in a canine model. A pilot project was performed in cadavers to examine the feasibility of transferring somatic nerves to vesical branches of the pelvic nerve as a method for potentially restoring innervation to control the detrusor muscle in humans.

Methods

Eleven cadavers were dissected bilaterally to expose intercostal, ilioinguinal, and iliohypogastric nerves, along with vesical branches of the pelvic nerve. Ease of access and ability to transfer the former 3 nerves to the pelvic vesical nerves were assessed, as were nerve cross-sectional areas.

Results

The pelvic vesical nerves were accessed at the base of the bladder, inferior to the ureter and accompanied by inferior vesical vessels. The T-11 and T-12 intercostal nerves were too short for transfer to the pelvic vesical nerves without grafting. Ilioinguinal and iliohypogastric nerves (L-1 origin) were identified retroperitoneally and, with full dissection, were easily transferred to the pelvic vesical nerves intraabdominally. The mean cross-sectional area of the dominant pelvic vesical branch was 2.60 ± 0.169 mm2; ilioinguinal and iliohypogastric branches at the suggested transection site were 2.38 ± 0.32 mm2 (the means are expressed ± SEM).

Conclusions

Use of the ilioinguinal or iliohypogastric nerves for heterotopic transfer to pelvic vesical nerves is surgically feasible, based on anatomical location and cross-sectional areas.

Abbreviation used in this paper:SCI = spinal cord injury.

Article Information

Address correspondence to: Michael R. Ruggieri Sr., Ph.D., Temple University School of Medicine, 3400 North Broad Street, Philadelphia, Pennsylvania 19140. email: rugg@temple.edu.

Please include this information when citing this paper: published online August 10, 2012; DOI: 10.3171/2012.7.SPINE12214.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Photographs documenting identification of vesical branches of the pelvic nerve. A: The abdomen was opened (legs are located on the upper left side of this panel). B: The vesical branches of the pelvic nerve (arrow) were identified at the base of the bladder in the retroperitoneal space. Two dominant branches arose from the plexus in this cadaver, although several other cadavers showed only 1 dominant trunk. Forceps have been placed inferior to vesical branches of the pelvic nerve at the base of the bladder (which is being held superiorly by the blue-gloved hand at the upper right side of the panel). The index finger of the beige-gloved hand indicates the inferior epigastric artery and vein.

  • View in gallery

    Photographs showing an attempt to transfer the left subcostal (T-12) and T-11 intercostal nerves to the left vesical branches of the pelvic nerve. A: The subcostal and T-11 intercostal nerves were identified on the thoracic wall and are indicated by arrows. B: The subcostal nerve was traced through the intercostal space, as was the T-11 intercostal nerve (arrows). C: The width of the subcostal nerve was measured using a metric ruler, and was noted to be 2 mm in diameter. D: Both nerves were traced as far anteriorly as possible on the thoracic wall. Arrows indicate the subcostal (T-12) nerve. E: Note the distance between vesical branches of the pelvic nerve (P; indicated by green arrow and lying on a green surgical cloth) and the subcostal nerve (I; black arrow). We determined that the distance between vesical branches of the pelvic nerve and the intercostals was too large to make this a viable nerve transfer without an additional nerve graft.

  • View in gallery

    Artist's illustration showing the transfer of a lower intercostal nerve to the dominant branch of the pelvic nerve to the bladder, using a lateral femoral cutaneous nerve as a graft.

  • View in gallery

    Photographs showing transfer of the ilioinguinal nerve (L-1) to vesical branches of the pelvic nerve. A: The ilioinguinal nerve was identified on the lateral abdominal wall in the retroperitoneal space (left side in photograph; legs are located on the right side of the panel) and is indicated by the black suture. B: The length of the ilioinguinal nerve is indicated by a ruler (> 14 cm). C: The main vesical branch of the pelvic nerves is indicated by the black suture at the base of the bladder (Bl). The ilioinguinal nerve was transferred to the base of the bladder and placed onto a piece of green surgical cloth. The legs are located on the right side of the panel; the muscle reflected over the pubic wall is the rectus abdominis muscle. D: Higher-power photograph of the same image as in panel C. E: The main vesical branch of the pelvic nerve (P) is at the base of the bladder, proximal to its branches to the bladder. Both the main vesical branch of the pelvic nerve (P; right nerve) and the ilioinguinal nerve (Ilio; left nerve) are now on the green cloth. F: Higher-power photograph showing how the 2 nerves were “anastomosed.” Note that they are of similar diameters. The visceral peritoneum that covers the intestines is located on the left side of this panel.

  • View in gallery

    Artist's illustrations showing the transfer of the iliohypogastric nerve (L-1) to the dominant branch of the pelvic nerve to the bladder. Left: Both the ilioinguinal and iliohypogastric nerves branch extensively once they reach the abdominal wall musculature. Right: The iliohypogastric nerve (or the ilioinguinal nerve) can be transected before the site of extensive branching and then transferred to the bladder and sutured to the main vesical branch(es) of the pelvic nerve.

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