Pelvic neurovascular anatomy and avascular spaces: a pictorial essay of key surgical landmarks.

A precise understanding of pelvic neurovascular anatomy is essential for minimizing complications during advanced gynecological and pelvic surgery. Retroperitoneal dissection requires a clear appreciation of spatial relationships between vascular, neural, and fascial structures. This pictorial essay provides an anatomically oriented overview of key pelvic compartments and pelvic avascular spaces, including the paraaortic, presacral, pararectal, paravesical, prevesical, and laterovascular spaces, through a curated series of our high-resolution intraoperative and cadaveric dissections. These illustrations emphasize surgical landmarks and neurovascular trajectories that are critical during radical hysterectomy, pelvic lymphadenectomy, deep endometriosis surgery, and other pelvic procedures. The anatomical content correlates with practical surgical applications, including the identification of danger zones, safe dissection planes, and routes for nerve-sparing techniques. Autonomic plexuses, somatic nerves, and vascular variants are also highlighted to support accurate and reproducible dissection. In particular, visual representations of the hypogastric nerve, pelvic splanchnic nerves, and inferior hypogastric plexus aid understanding of the pelvic autonomic pathways involved in continence and sexual function. The presented illustrations offer an operative roadmap that supports surgical planning, enhances intraoperative orientation, and promotes the preservation of neurovascular integrity. This visual anatomical reference aims to improve both surgical safety and functional outcomes in advanced gynecological procedures.