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Drive safely through the pelvis – know your pelvic roads:

Presacral space
K C D P Silvaa, P J S Randombageb, W I Gankandac, S N Samarakkodyd, I G D C Ilukpitiyae,
R D Jeewanthaf

This is the fifth article in the series of articles unfolding on the left. The floor is continuous with the laevator
avascular spaces of the pelvis. Authors recommend ani muscles. It also communicates with the pararectal
reading the series of articles starting from “Drive safely spaces anterolateraly.
through the pelvis – know your pelvic roads:
Retropubic space of Retzius” published in the Sri Lanka This space contains the sacral venous plexus (lateral
Journal of Obstetrics and Gynaecololgy1. and medial sacral veins, and the middle sacral vessels),
left and right hypogastric nerves (which connects the
Entry in to the presacral space is by division of the superior and inferior hypogastric plexuses) and the
peritoneum overlying the sacral promontory. It is a superior hypogastric plexus (the sympathetic supply
thin, small retroperitoneal space situated behind the to the pelvis) and the anterior longitudinal ligament of
rectosigmoid which is partially covered by the
the spine4.
mesorectum anteriorly2. Care must be taken to dissect
only the peritoneum as there are numerous essential
Figure 1 gives an overview of the anatomy of the pelvic
structures underlying the presacral space3.
spaces.
The boundaries of the presacral space are; roof formed
by the sigmoidmesentery and the peritoneum, posterior Table 1 describes the surgical procedures, which use
border by the sacral promontory, anterior border by these spaces.
the posterior surface of the rectum and mesorectum.
The lateral borders are formed by the common iliac Figure 2 gives a schematic representation of the
vessels, ureters and by the inferior mesenteric vessels presacral space.

Sri Lanka Journal of Obstetrics and Gynaecology 2020; 42: 87-90

DOI: http://doi.org/10.4038/sljog.v42i2.7945

a
Senior Lecturer and Head of Department of Obstetrics and Gynaecology, Faculty of Medical Sciences, University of
Sri Jayewardenepura, Sri Lanka.
b
Senior Registrar in Department of Obstetrics and Gynaecology, Faculty of Medical Sciences, University of Sri
Jayewardenepura, Sri Lanka.
c
Senior Registrar in Department of Obstetrics and Gynaecology, Faculty of Medical Sciences, University of Sri
Jayewardenepura, Sri Lanka.
d
Senior Registrar in Department of Obstetrics and Gynaecology, Faculty of Medical Sciences, University of Sri
Jayewardenepura, Sri Lanka.
e
Registrar in Department of Obstetrics and Gynaecology, Faculty of Medical Sciences, University of Sri
Jayewardenepura, Sri Lanka.
f
Senior Registrar in Department of Obstetrics and Gynaecology, Faculty of Medical Sciences, University of Sri

Correspondence: KCDPS, e-mail: [email protected]

https://orcid.org/0000-0001-7438-4789

Received 1st March 2020

Accepted 2nd April 2020

This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License, which
permits unrestricted use, distribution and reproduction in any medium provided the original author and source are credited.

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a: retropubic space; b: Paravesical space;

c: Pararectal space; d: retrorectal space;
e: presacral space
1. Parietal pelvic fascia; 2. Lateral vesical ligament.
3. Vesico-uterine ligament. 4. Paracervix.
5. Parametrium. 6. Uterosacral ligament.
7. Recto-uterine pouch.
8. Medial umbilical ligament.
9. Umbilicovesical fascia. 10. Obturator artery.
11. Superior vesical artery. 12. Vesicovaginal artery.
13. Uterine artery. 14. Vaginal artery.
15. Middle rectal artery. 16. Posterior vaginal fornix.
17. Ureter.

Figure 1. The schematic representation of anatomy of the pelvic spaces.

Table 1. Surgical procedures carried out in each retroperitoneal pelvic space

Retroperitoneal pelvic spaces Surgical procedures carried out

Medial spaces Retropubic Burch colposuspension

Paravaginal repair
Bladder mobilization in ureteric re-implantation
Mesh removals

Vesicouterine Mesh repair for cystocele

Total laparoscopic hysterectomy
Radical hysterectomy
Vesicovaginal fistula repair
Bladder endometriosis resection
Vaginal cuff resection
Sacrocolpopexy / Hysterocolpopexy
Laparoscopic abdominal cerclage
Scar ectopic excision
Rectovaginal Sacrocolpopexy
DIE of rectosigmoid
Vaginal endometriotic nodule dissection
Bowel resection
Retrorectal/ presacral Bowel resection for DIE
Sacrocolpopexy, sacrohysteropexy, enterocele repair
with a mesh
Pre-sacral neurectomy
Initiation of para-aortic lymphadenectomy
Lateral Paravaginal Pelvic lymphadenectomy
Paravesical Radical hysterectomy
Pararectal Excision of ureteric endometriosis
Ureteric reimplantation/ psoas hitch
Bowel resection in DIE
Excision of endometriosis involving sacral nerve roots

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(a) (b)

Figure 2. The pararectal space.

(a) Schematic representation of the presacral space. (b) Boundaries of the presacral space.

List 1 – Contents of paravaginal space

• Parasympathetic nerves innervating bladder

• Left and right hypogastric nerves

• Superior hypogastric plexus

• Anterior longitudinal ligament of the spine

Sacrocolpopexy, sacrohysteropexy and sacrocervi- maybe used instead. The author’s preference is to use
copexy requires dissection into the presacral space. permanent suture material to anchor the mesh to the
The mesh is anchored to the anterior longitudinal anterior longitudinal ligament of the vertebra. The mesh
ligament of the vertebra with tacks orpermanent must be anchored without tension and covered by
sutures. The use of metal tacks will preclude the use peritoneum afterwards5.
of MRI and therefore is discouraged; non-metallic tacks

Figure 3. Laparoscopic view of the pararectal space.

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One out of four patients with central dysmenorrhea surgical excellence while minimizing morbidity. Articles
fails to respond to medical management and presacral describing the other pelvic spaces will follow in future
neurectomy continues to be a useful alternative for issues.
these women. Approximately 50-75% of patients who
have severe midline chronic pelvic pain will achieve a
cure. It is a useful addition for women undergoing
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