Editing Male Pelvis (section)

== Pelvic Vasculature ==

=== Arterial supply ===

* '''Abdominal aorta branches into:'''
** '''Middle sacral artery'''
*** Arises posteriorly at the bifurcation of the aorta and travels on the pelvic surface of the sacrum
*** Supplies branches to the sacral foramina and the rectum
** '''Paired common iliac arteries'''
*** '''Arise at the level of the L4'''
*** '''Run anterior and lateral to their accompanying veins'''
*** '''Bifurcate into the external and internal iliac arteries at the SI joint.'''

==== External iliac artery ====

* '''Source: branch of the common iliac artery'''
* '''Location: Follows the medial border of the iliopsoas muscle''' along the arcuate line '''<span style="color:#ff0000">and leaves the pelvis beneath the inguinal ligament and continues as the femoral artery'''
* '''Surgical considerations'''
** '''Only vessel in the pelvis without adequate collateral circulation; if ligated will cause significant sequella'''
* '''<span style="color:#ff0000">Branch (1):'''
** '''<span style="color:#ff0000">Inferior epigastric artery'''§
*** '''Source: branch of the external iliac artery'''
*** '''Location'''
**** Branches off of the external iliac artery proximal to the inguinal ligament and '''ascends medially along the anterior abdominal wall, medial to the internal inguinal ring; enveloped by lateral umbilical ligament'''
**** Insert figure
*** '''Hesselbach triangle borders (3):'''
**** '''Lateral: inferior epigastric vessels'''
**** '''Medial: rectus abdominus muscle'''
**** '''Inferior: inguinal ligament'''
*** Pierces transversalis fascia as it continues to ascend superiorly and superficially, until it levels posterior to rectus once is crosses the arcuate line/linea semicircularis. Continues to rise superiorly until it terminates by piercing rectus abdominis and branches and forms and anastamosis with the superior epigastric arteries, at approximately the level of the superior epigastric arteries.
*** '''<span style="color:#ff0000">Branches (3):'''
***# '''<span style="color:#ff0000">Deep circumflex iliac</span> – supplies inguinal ligament and surrounding structures laterally (See Figure), can also arise directly from external iliac'''
***# '''<span style="color:#ff0000">Pubic</span>''' – supplies inguinal ligament and surrounding structures medially
***# '''<span style="color:#ff0000">Cremesteric</span> – supplies vas deferens and testis'''
***## '''In 25% of people, an accessory obturator artery arises from the inferior epigastric artery''' and runs medial to the femoral vein to reach the obturator canal. This vessel must be avoided during obturator lymph node dissection
***## '''Rectus muscle and overlying skin'''
** '''Surgical considerations'''
*** '''Can be ligated without complication because the rectus is richly collateralized''' from above and laterally

==== Internal iliac artery ====

* '''Also known as hypogastric artery'''
* '''Source: common iliac artery'''
* '''Location: Descends in front of the SI joint'''
* '''<span style="color:#ff0000">Branches (2): divides into an anterior and a posterior trunk''' approximately 3-4 cm from the bifurcation.
** '''<span style="color:#ff0000">Posterior trunk'''
*** '''Surgical considerations'''
**** '''Rarely seen during pelvic surgery'''
*** '''<span style="color:#ff0000">Branches (3) S-GALLS'''
***# '''<span style="color:#ff0000">Superior Gluteal'''
***#* '''Exits the greater sciatic foramen'''
***#* Supplies gluteus muscles and overlying skin
***# '''<span style="color:#ff0000">Ascending Lumbar'''/iliolumbar
***#* Supplies the posterior abdominal wall (psoas and quadratus lumborum muscles and adjacent structures)
***# '''<span style="color:#ff0000">Lateral Sacral'''
***#* Passes medially to join the middle sacral branches from the aorta at the sciatic foramina
***#* Supplies sacral nerves and sacrum
** '''<span style="color:#ff0000">Anterior trunk'''
*** '''Surgical considerations'''
**** '''The primary branches identified during retroperitoneal surgery include the superior vesical artery, the uterine artery, and occasionally the obturator artery.'''
*** '''<span style="color:#ff0000">Branches (6) Mr. U IPIG SVIVO'''
***# '''<span style="color:#ff0000">Umbilical'''
***#* In fetus, paired arteries surroud bladder and extend into umbilical cord.
***#* '''After birth, a portion regresses to become the medial umbilical ligaments, while a portion remains open as the''' '''first branch off of the anterior trunk'''
***#* '''Obliterated umbilical artery is lateral to the ureter at the pelvic brim'''
***#* '''The open portion gives rises to the Superior Vesical''' '''artery'''
***#** '''Superior Vesical artery'''
***#*** '''Surgical considerations'''
***#**** '''Most prominent branch of the internal iliac artery and in most cases appears to be a continuation of it.'''
***#**** '''Identification is possible with development of the paravesical space and during dissection of the obturator space.'''
***#*** Supplies
***#**** Bladder, ureter, vas deferens, and seminal vesicle
***#*** '''Branch (1)'''
***#**** '''Artery of the vas'''
***#***** Supplies seminal vesicles and vas deferens
***#***** Can also come off the umbilical artery or the inferior vesical artery.
***#***** Travels the length of the vas to meet the cremasteric and testicular arteries distally. Because of these anastomoses, the testicular artery may be sacrificed without compromising the viability of the testis.
***# '''<span style="color:#ff0000">Obturator'''
***#* Variable in origin
***#* '''Travels through the obturator fossa''' '''medial and posterior to the obturator nerve'''
***#* Supplies adductor muscles of the thigh and overlying skin
***# '''<span style="color:#ff0000">Inferior Vesical'''
***#* Supplies bladder base, seminal vesicle, prostate, lower ureter, and the neurovascular bundle
***# '''<span style="color:#ff0000">Middle Rectal'''
***#* Gives small branches to the seminal vesicles and prostate and anastomoses with the inferior and superior rectal arteries in the rectal wall.
***#* Supplies rectum, ureter, and bladder
***# '''<span style="color:#ff0000">Internal Pudendal'''
***#* Terminal branch of the internal iliac artery
***#* '''Location'''
***#** '''Leaves the pelvis through the greater sciatic foramen''', passes around the sacrospinous ligament, and enters the lesser sciatic foramen to gain access to the perineum.
***#** After entering the perineum through the lesser sciatic foramen, the artery runs in a fascial sheath on the '''medial aspect of obturator internus, which is the pudendal canal (of Alcock)'''.
***#* '''<span style="color:#ff0000">Branches (5): IPP BC'''
***#*# '''<span style="color:#ff0000">Inferior rectal artery'''
***#*# '''<span style="color:#ff0000">Perineal artery'''
***#*# '''<span style="color:#ff0000">Posterior scrotal/labial'''
***#*# '''<span style="color:#ff0000">Artery of Bulb of penis'''
***#*# '''<span style="color:#ff0000">Common penile artery (terminal branch)'''
***#*#* '''<span style="color:#ff0000">The common penile artery branches into the (3):'''
***#*#*# '''<span style="color:#ff0000">Cavernosal artery'''
***#*#*# '''<span style="color:#ff0000">Bulbourethral artery'''
***#*#*# '''<span style="color:#ff0000">Dorsal artery'''
***#* Supplies rectum, perineum, and external genitalia
***#* '''Note that the external pudendal artery comes from the femoral artery and the superior rectal artery comes from the inferior mesenteric artery'''
***# '''<span style="color:#ff0000">Inferior Gluteal'''
***#* '''Travels through the greater sciatic foramen'''
***#* Supplies gluteus muscles and overlying skin
***# '''<span style="color:#ff0000">Vaginal''' '''(if female)'''
***# '''<span style="color:#ff0000">Uterine (if female)'''
***#* Often branches off of superior vesical artery
***#* '''Passes anterior to ureter''' and enters the lateral uterus at the level of the internal cervical os to meet ovarian artery

=== Venous drainage ===

==== Internal iliac vein ====

* Joined by tributaries corresponding to the branches of the internal iliac artery
* '''Ascends medial and posterior to the artery'''
* Relatively thin walled and at risk for injury during dissection of the artery or the nearby pelvic ureter

==== External iliac vein ====

* '''A continuation of the femoral vein'''
* '''Ascends medial and posterior to its artery'''
* '''Joins the internal iliac vein behind the internal iliac artery'''
* '''Drains the inferior epigastric vein, deep circumflex iliac, and pubic veins'''
* '''In 50% of patients, one or more accessory obturator veins drain into the underside of the external iliac vein''' and can be easily torn during lymphadenectomy