1. TME-Pelvic dissection Two phases Dorsal mobilisation Anterolateral dissection

2. Below the aortic bifurcation Preserving superior hypogastric plexus Posterior dissection Preserving left and right hypogastric nerve Cutting rectosacral fascia (Waldeyer) TME-Dorsal mobililsation

3. The start of TME: Below the Aortic Bifurcation

4. Preserving superior hypogastric plexus

5. Possible Injuries to Hypogastric Plexus

6. Bladder dysfunction: Urinary retention Parasympathetic nerves - detrusor muscle Sympathetic nerves - bladder neck, trigone and urethral area Sexual dysfunction: Impotence Parasympathetic nerves (nervi errigentes) - erection Somatic 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

7. Y. Moriya, Eur J of Cancer 1995. Urinary Function after the injury to hypogastric Plexus

8. Y. Moriya, Eur J of Cancer 1995. Sexual Function after the injury to hypogastric Plexus

14. Rectosacral fascia (Waldeyer) Division of rectosacral fascia is one of greatest dangers of blunt manual dissection CRITICAL POINT: Division of Waldeyer‘s Fascia