Skip to main content

Pelvic Neuroanatomy

Pelvic neuroanatomy determines functional outcome in reconstructive pelvic surgery. The cavernous nerves are the basis of nerve-sparing prostatectomy. The pelvic plexus in the cardinal and uterosacral ligaments is associated with bladder, bowel and sexual function after radical hysterectomy. The superior hypogastric plexus lies at risk during sacrocolpopexy, and the pudendal nerve traverses Alcock's canal in every perineal operation. Somatic nerve injuries present as flank, groin, medial-thigh or labial pain.

See also The Perineum for pudendal-branch territory; The Presacral Space for the superior hypogastric plexus geometry; The Cervix and The Uterus for nerve-sparing radical hysterectomy; The Penis, The Prostate, The Bladder for organ-specific innervation.

Organizing Framework — Three Parallel Systems​

The pelvic viscera receive three systems acting in concert:

SystemOriginOutput
SympatheticT10–L2Storage, continence, vasoconstriction, ejaculation (emission)
ParasympatheticS2–S4Voiding, defecation, erection / clitoral engorgement
SomaticS2–S4 (pudendal), a direct sacral nerve to levator ani described in 12 female cadavers[10], and the lumbosacral plexus (iliohypogastric, ilioinguinal, genitofemoral, femoral, obturator, sciatic)Voluntary sphincter and pelvic-floor control[10]; perineal and genital sensation; lower-limb motor/sensory

Autonomic fibers converge on the inferior hypogastric (pelvic) plexus on each side of the rectum, upper vagina and prostate, the terminal relay station for bladder, rectum, vagina, prostate, and erectile innervation. Somatic fibers travel independently via named nerves.

Sympathetic Pathway​

Thoracolumbar origin and abdominal traversal​

  1. Preganglionic cell bodies: T10–L2 intermediolateral gray column.
  2. Exit via ventral roots, then white rami communicantes, then the sympathetic trunk.
  3. Lumbar splanchnic nerves leave the lumbar sympathetic trunk and contribute, directly or through preaortic plexuses, to the superior hypogastric plexus and hypogastric nerves. The greater, lesser and least thoracic splanchnic nerves primarily serve abdominal prevertebral plexuses and are not the direct pelvic route (anatomy chapter).

Superior hypogastric plexus ("presacral nerve")​

  • Forms near the aortic bifurcation; descends across the sacral promontory in a connective-tissue sheet just below peritoneum.
  • In 17 female cadavers, the plexus lay a median 21.3 mm (range 9–40 mm) below the aortic bifurcation in 14 specimens (82.4%) and a median 25.3 mm above it in the rest.[Ripperda 2017] It lay left of midline in 58.8%, with median length 39.5 mm and width 9 mm, a flat band rather than a cord.[Ripperda 2017]
  • Predominantly sympathetic. Immunohistochemistry in four cadavers showed sympathetic and most likely postganglionic parasympathetic fibers; afferent fibers also travel in it.
  • Splits into paired hypogastric nerves.
  • Transmits visceral afferents for midline pelvic pain; it is the target of superior hypogastric plexus block and presacral neurectomy for refractory dysmenorrhea or endometriosis.

Hypogastric nerves​

  • Paired; descend from the superior hypogastric plexus across the pelvic inlet.
  • Run within the parietal pelvic fascia posterolaterally along the pelvic sidewall.
  • In the same cadaver series they lay a median 23 mm (range 5–32 mm) below the promontory, and the nearest nerve branch lay a median 0–0.5 mm from the midportion of the uterosacral ligament.[Ripperda 2017] This proximity makes them vulnerable during uterosacral suspension, radical hysterectomy and ventral rectopexy.
  • Merge with pelvic splanchnic nerves to form the inferior hypogastric plexus.

Sacral sympathetic trunk​

Continues the sympathetic trunk into the pelvis medial to the anterior sacral foramina. Sacral splanchnic branches contributed to the inferior hypogastric plexus in 16 of 34 hemipelvises (47%) where the trunk was identified[Ripperda 2017], and in 2 of 6 cadavers in another dissection series.

See The Presacral Space for further sacrocolpopexy-relevant relationships and the callout on preserving the superior hypogastric plexus.

Parasympathetic Pathway​

Sacral origin​

  • Preganglionic fibers arise from the sacral parasympathetic nucleus in the intermediate gray of S2–S4.[2]
  • Exit as pelvic splanchnic nerves (nervi erigentes) from the ventral rami of S2–S4.
  • Merge directly into the inferior hypogastric plexus from behind, joining the hypogastric nerves (sympathetic) and sacral splanchnic contributions.

Clinical significance​

  • Parasympathetic drive supports voiding (detrusor contraction), defecation (rectal motility), and erection or clitoral engorgement (cavernosal NO release). During the rectoanal inhibitory reflex, enteric inhibitory nerves primarily mediate internal anal sphincter relaxation.[9]
  • Injury to the pelvic splanchnic nerves or inferior hypogastric plexus may contribute to impaired bladder emptying or sensation, bowel dysfunction and sexual dysfunction. The phenotype depends on injury extent and on the pathways that remain.
  • Suprasacral spinal lesions spare the sacral reflex arc and typically produce a hyperreflexic bladder. Sacral and cauda-equina lesions interrupt the arc and typically produce an underactive or acontractile bladder. Urodynamics defines the individual phenotype.

The Inferior Hypogastric (Pelvic) Plexus — Where It All Converges​

A dense fan-like plexus beside the rectum, with branches toward the upper vagina or prostate. In female cadavers it formed 1–3 cm lateral to the rectum and upper third of the vagina.[Ripperda 2017] It lies in the cardinal and uterosacral ligaments (female) or the lateral prostatic pedicle (male). Its relationship to the pelvic fascia varies between individuals.

Inputs​

  • Hypogastric nerve (sympathetic from T10–L2)
  • Pelvic splanchnic nerves (parasympathetic from S2–S4)
  • Sacral splanchnic nerves (sympathetic from sacral trunk, in 16 of 34 hemipelvises [47%] where the trunk was identified)[Ripperda 2017]
  • Sensory afferents

Outputs (branches)​

  • Bladder branches. One to three discrete branches pass deep to the ureter toward the bladder base.
  • Uterine branches. Follow the ascending uterine artery superficial to the ureter, which distinguishes them from the bladder branches during dissection.
  • Rectal branches. Reach the lateral rectal wall; an S4 branch attached directly to it in 53% of specimens.[Ripperda 2017]
  • Vaginal branches. Pass to the upper vagina.
  • Cavernous nerves. Pass to the corpora cavernosa (M) or clitoral body (F); see below.

Why nerve-sparing surgery turns on the inferior hypogastric plexus​

  • Radical hysterectomy. Nerve-sparing dissection aims to preserve the hypogastric, pelvic-splanchnic and bladder branches, including the dorsolateral parasympathetic part of the cardinal ligament, when oncologically feasible. A Cochrane review compares nerve-sparing with standard radical hysterectomy for early cervical cancer.
  • Radical prostatectomy. Cavernous fibers commonly course posterolateral to the prostate at about 5 and 7 o'clock, but their distribution is variable. Nerve preservation is balanced against cancer control.
  • Total mesorectal excision. Dissection along the mesorectal plane aims to spare the hypogastric nerves and plexus, though injury still occurs.

Cavernous Nerves — Male Cadaveric Dorsal and Lateral Contributions​

Cavernous fibers arise from the inferior hypogastric plexus and contribute to erectile responses, and neighboring urethral innervation contributes to continence. A male cadaveric microdissection (three formalin-embalmed and 16 Thiel-embalmed hemipelves) described two origins for the nerve supply to the proximal urethra and corpora:

  1. Dorsal route. Follows the seminal-vesicle and ejaculatory-duct axis toward the male proximal urethra and prostate base.
  2. Lateral route. Follows the inferior vesical artery toward posterolateral periprostatic neurovascular tissue.

See The Penis, The Prostate and The Vulva.

The two routes were connected in about one third of samples, and the authors concluded that saving both the dorsal and lateral roots is important to maintain erectile and continence function. Seminal-vesicle-tip sparing could avoid injury to fibers along the dorsal route when oncologically appropriate. The cadaveric study did not compare operations or measure postoperative potency or continence.

Somatic Lumbosacral Plexus — What Reconstructive Surgery Touches​

From the lumbar plexus (L1–L4)​

NerveRootsTerritoryOperative risk
IliohypogastricT12–L1Anterior abdominal wall / monsPfannenstiel incision entrapment, trocar injury
IlioinguinalL1Inguinal region, anterior scrotum / labia majoraInguinal herniorrhaphy neuralgia; laparoscopic trocar injury
GenitofemoralL1–L2Genital branch: cremaster (M), anterior scrotum / labia majora. Femoral branch: skin over femoral triangleRetroperitoneal dissection, psoas abscess drainage
Lateral femoral cutaneousL2–L3Lateral thigh skinLithotomy-positioning neuropathy ("meralgia paresthetica"); retractor injury
FemoralL2–L4Anterior thigh, quadriceps, medial leg (saphenous)Deep retractor injury (Bookwalter / Balfour); lithotomy; psoas dissection
ObturatorL2–L4Medial thigh, adductorsObturator-canal / obturator-LND injury; TOT sling

From the sacral plexus (L4–S4)​

NerveRootsTerritoryOperative risk
SciaticL4–S3Posterior thigh; most of leg and foot below knee, except the medial leg supplied by the saphenous nerve[3]Lithotomy, prone positioning, retroperitoneal SSLF mispositioning
Posterior femoral cutaneousS1–S3Posterior thigh + perineal branch to lateral perineumSSLF-region dissection; lateral ischial-tuberosity and superficial perineal dissection[11]
Superior glutealL4–S1Gluteus medius/minimusTransgluteal approaches
Inferior glutealL5–S2Gluteus maximusTransgluteal, deep pelvic work
PudendalS2–S4; sphincter motor neurons in Onuf's nucleus[4]Perineal and dorsal genital branches (see below); the inferior rectal nerve may arise separately[5]SSLF adjacent; Alcock's-canal entrapment; pudendal-nerve block landmark. Separate nerves to levator ani and coccygeus may cross the medial SSLF suture zone.[8]

The pudendal nerve (S2–S4)​

  • Exits pelvis through the greater sciatic foramen below piriformis.
  • Wraps around the ischial spine and sacrospinous ligament.
  • Re-enters through the lesser sciatic foramen into Alcock's (pudendal) canal on the medial surface of the obturator internus.
  • Distal nerves include the following; the inferior rectal nerve is not invariably a pudendal branch. In a 43-cadaver dissection, its origin was assessable in 37, and it arose separately from S3–S4 in 33/37 (89.2%).[5]
    • Inferior rectal nerve. Perianal sensation; in the cited cadaveric series, its motor branches supplied the subcutaneous external anal sphincter, while perineal and levator ani nerves supplied the superficial and deep portions.[5]
    • Perineal nerve. Deep: bulbospongiosus, ischiocavernosus, transverse perinei and external urethral sphincter (via Onuf's nucleus); superficial: posterior scrotal or labial sensation.
    • Dorsal nerve of the penis or clitoris. Dominant sensory input to the glans; runs periosteal on the inferior pubic ramus.

Onuf's nucleus (sacral ventral horn) contains motor neurons supplying the striated external urethral and external anal sphincters. Relative preservation has been reported in ALS, which is consistent with the continence typically retained until late disease.

See The Perineum for the full pudendal-branch territory and The Vulva for the clitoral-NVB callout.

Enteric Nervous System​

The intrinsic nervous system of the gut regulates the rectum and anal canal through two plexuses:

  • Auerbach's (myenteric) plexus. Lies between circular and longitudinal muscle; coordinates motility.
  • Meissner's (submucosal) plexus. Lies in the submucosa; coordinates secretion and local reflexes.

Ganglion cells in the anal canal are mostly restricted to the zone above the dentate line. Distal intestinal aganglionosis in Hirschsprung disease causes functional obstruction and commonly abolishes the rectoanal inhibitory reflex (RAIR); an absent RAIR is not specific to that disorder.[9]

Reference Zones for Reconstructive Surgery​

The cardinal ligament geometry​

  • The cardinal ligament is a visceral perivascular or perineural mesentery carrying uterine vessels, ureter (at its base), pelvic plexus fibers, and fatty connective tissue.
  • Piver–Rutledge–Smith and Querleu–Morrow describe resection extent, but the 2017 Querleu–Morrow type C subcategories also specify autonomic nerve preservation: C1 preserves the inferior hypogastric plexus and bladder branches; C2 divides the plexus and sacrifices its bladder branches.[7]

The 5-7 o'clock prostatic pedicle​

  • The prostatic pedicle and NVB run posterolaterally at 5 and 7 o'clock along the capsule.
  • Intrafascial dissection, between the capsule and prostatic fascia, preserves the most nerve tissue. Interfascial and extrafascial dissection sacrifice progressively more. Neither the clock position nor the plane name guarantees functional recovery or oncologic suitability.

The 2 and 10 o'clock dorsal penile / clitoral neurovascular geometry​

  • Dorsal penile / clitoral nerves course in the dorsal neurovascular tissues toward the glans; branching and communicating fibers vary.
  • The dorsal penile nerve block is classically placed at the 10 and 2 o'clock positions; branching and communicating fibers vary, so a nerve-free 12 o'clock line is not assured.

S1 foramen proximity in sacrocolpopexy​

  • A cadaveric study placed the medial-superior S1 foramen at a median 26 mm caudal (range 22–37) and 19 mm lateral (range 13–23) to its defined promontory and midline landmarks. The authors advise anticipating the first sacral nerve about 2.5 cm below the promontory midpoint and 2 cm to the right of midline. Fixation below the promontory risks S1 radiculopathy.
  • Sacral fixation depends on direct identification of nearby nerves, vessels and the disc.

Alcock's canal and pudendal entrapment​

  • The original Nantes criteria for suspected pudendal nerve entrapment require pain in pudendal territory, worse when sitting, not waking the patient at night, no objective sensory loss, and relief with a correctly performed diagnostic pudendal block. The criteria are clinical, and imaging abnormalities that explain the symptoms exclude the diagnosis. AUA 2025 notes that these criteria lack clinical validation and do not cover every possible entrapment site.[1]
  • Decompression has been described for selected refractory cases after a diagnostic pudendal block. AUA 2025's ungraded discussion advises against open release because of scarring and re-entrapment risk and describes limited laparoscopic and robotic evidence.[1] Guideline differences are discussed under Pudendal neuralgia.

Clinical Correlations for the Reconstructive Surgeon​

  • Nerve-sparing radical prostatectomy. A 19-hemipelvis cadaveric microdissection mapped lateral and dorsal neural routes relevant to preservation when oncologically appropriate; it did not test whether saving both improves postoperative potency or continence. No single fascial plane guarantees potency or continence.
  • Nerve-sparing radical hysterectomy. The aim is to preserve pelvic autonomic branches while meeting oncologic margins.
  • Nerve-preserving sacrocolpopexy. A six-cadaver study described a longitudinal peritoneal incision along the right common iliac artery and above the promontory. This approach exposes the anterior longitudinal ligament while protecting the superior hypogastric plexus and the presacral area below the promontory.
  • Ureteric-injury prevention at hysterectomy and USLS. The ureter crosses beneath the uterine artery near the cervix, with variable spacing. Identify the ureter before clamping or placing deep sutures.
  • Post-hysterectomy bladder dysfunction. Autonomic nerve injury is one contributor, especially after radical surgery, and other causes are evaluated.
  • Post-APR / exenteration sexual dysfunction. Pelvic autonomic nerve injury may contribute, alongside vascular, hormonal and psychosocial factors.
  • Pudendal nerve block. The needle is directed medial to the ischial spine through the sacrospinous ligament, transvaginally or transperineally, with the spine palpated as the landmark.
  • Obturator-nerve injury during TOT, paravaginal repair or obturator LND produces medial-thigh sensory loss and adductor weakness. A recognized sharp transection can be repaired by end-to-end epineurial coaptation at the time of injury; a case report of laparoscopic repair after transection during obturator lymphadenectomy for radical prostatectomy documented functional recovery, though outcome after nerve repair varies with the specific injury and repair expertise available.[Spaliviero 2004]
  • Lithotomy-position neuropathy. Common peroneal, femoral and lateral femoral cutaneous nerves may be injured by stirrup pressure, deep retractors or hip positioning. Padding and periodic positioning checks are used to prevent it.
  • Lateral femoral cutaneous nerve during lateral dissection. The nerve crosses the iliacus lateral to psoas; energy devices used to divide lateral peritoneal attachments during adhesiolysis or retroperitoneal exposure in this plane can transect it, a mechanism distinct from lithotomy positioning.[Baggish 2021]
  • Superior hypogastric plexus block / presacral neurectomy. These are selected procedures for central midline pelvic pain such as dysmenorrhea or central endometriosis, and they do not address lateral or vulvar pain.
  • Ganglion impar block. The ganglion impar lies near the sacrococcygeal junction and is not the inferior hypogastric or pelvic plexus; a ganglion impar block is used in selected perineal or coccygeal pain.
  • Sacral neuromodulation (SNM). Usually accesses a sacral foramen, often S3, and is an option for selected refractory OAB, non-obstructive urinary retention and fecal incontinence (AUA OAB guidance; AUA retention statement; ASCRS fecal-incontinence guidance). Its mechanism is incompletely resolved, and chronic pelvic pain is not a routine indication.
  • Neurogenic bladder phenotypes by lesion level. Suprapontine lesions typically produce overactivity with preserved coordination, suprasacral spinal lesions add detrusor-sphincter dyssynergia, and sacral or cauda-equina lesions typically produce an underactive or acontractile bladder, depending on injury extent.[6] Actual behavior needs urodynamic evaluation.

Videos​

Dissection of the Dorsal Nerve of the Clitoris
Llado-Farrulla M, et al. Urology Video Journal 2023 (CC BY-NC-ND 4.0)
Open source videoRead the article

References​

- Ripperda CM, Jackson LA, Phelan JN, Carrick KS, Corton MM. "Anatomic Relationships of the Pelvic Autonomic Nervous System in Female Cadavers: Clinical Applications to Pelvic Surgery." Am J Obstet Gynecol. 2017;216(4):388.e1–388.e7. doi:10.1016/j.ajog.2016.12.002 - Baggish MS. Basic Pelvic Anatomy. In: Baggish MS, Karram MM, eds. Atlas of Pelvic Anatomy and Gynecologic Surgery. 5th ed. Elsevier; 2021:5–58. - Spaliviero M, Steinberg AP, Kaouk JH, et al. "Laparoscopic Injury and Repair of Obturator Nerve During Radical Prostatectomy." Urology. 2004;64(5):1030. doi:10.1016/j.urology.2004.06.046

  • Kraima AC, van Schaik J, Susan S, et al. "New Insights in the Neuroanatomy of the Human Adult Superior Hypogastric Plexus and Hypogastric Nerves." Auton Neurosci. 2015;189:60–67. doi:10.1016/j.autneu.2015.02.001
  • Röthlisberger R, Aurore V, Boemke S, et al. "The Anatomy of the Male Inferior Hypogastric Plexus: What Should We Know for Nerve Sparing Surgery." Clin Anat. 2018;31(6):788–796. doi:10.1002/ca.23079
  • Shiozawa T, Huebner M, Hirt B, Wallwiener D, Reisenauer C. "Nerve-Preserving Sacrocolpopexy: Anatomical Study and Surgical Approach." Eur J Obstet Gynecol Reprod Biol. 2010;152(1):103–107. doi:10.1016/j.ejogrb.2010.05.009
  • Kietpeerakool C, Aue-Aungkul A, Galaal K, Ngamjarus C, Lumbiganon P. "Nerve-Sparing Radical Hysterectomy Compared to Standard Radical Hysterectomy for Women With Early Stage Cervical Cancer (Stage Ia2 to IIa)." Cochrane Database Syst Rev. 2019;2:CD012828. doi:10.1002/14651858.CD012828.pub2
  • Wecht JM, Krassioukov AV, Alexander M, et al. "International Standards to Document Autonomic Function Following SCI (ISAFSCI): Second Edition." Top Spinal Cord Inj Rehabil. 2021;27(2):23–49. doi:10.46292/sci2702-23
  • Baader B, Herrmann M. "Topography of the Pelvic Autonomic Nervous System and Its Potential Impact on Surgical Intervention in the Pelvis." Clin Anat. 2003;16(2):119–130. doi:10.1002/ca.10105
  • Yan Y, Inal B, Kapavarapu P, Alber K, Rao SSC. "Novel Concepts on the Functional Neuroanatomy of the Anorectum." Am J Gastroenterol. 2024;120(7):1478–1487. doi:10.14309/ajg.0000000000003221
  • Eid S, Iwanaga J, Chapman JR, et al. "Superior Hypogastric Plexus and Its Surgical Implications During Spine Surgery." World Neurosurg. 2018;120:163–167. doi:10.1016/j.wneu.2018.08.170
  • Florian-Rodriguez ME, Hamner JJ, Corton MM. "First Sacral Nerve and Anterior Longitudinal Ligament Anatomy: Clinical Applications During Sacrocolpopexy." Am J Obstet Gynecol. 2017;217(5):607.e1–607.e4. doi:10.1016/j.ajog.2017.07.008
  • Labat J-J, Riant T, Robert R, et al. "Diagnostic Criteria for Pudendal Neuralgia by Pudendal Nerve Entrapment (Nantes Criteria)." Neurourol Urodyn. 2008;27(4):306–310. doi:10.1002/nau.20505
  • American Urological Association/Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction. "The AUA/SUFU Guideline on the Diagnosis and Treatment of Idiopathic Overactive Bladder." 2024. Guideline PDF
  • American Urological Association. "Non-Neurogenic Chronic Urinary Retention: Consensus Definition, Management Strategies, and Future Opportunities." AUA statement
  • Bordeianou LG, et al. "The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Fecal Incontinence." Dis Colon Rectum. 2023;66(5):647–661. ASCRS guideline

1. American Urological Association. Diagnosis and Management of Male Chronic Pelvic Pain (Chronic Prostatitis/Chronic Pelvic Pain Syndrome and Chronic Scrotal Content Pain): AUA Guideline (2025). Approved March 2025. Full 2025 guideline Future Directions, p44.

2. Brown HK, Nolan MF. "Ultrastructure and quantitative synaptology of the sacral parasympathetic nucleus." J Neurocytol. 1979;8(2):167–179. doi:10.1007/BF01175559

3. Rodziewicz TL, Stevens JB, Ajib FA, Tunnell DJ. "Sciatic Nerve Block." In: StatPearls. StatPearls Publishing; updated June 5, 2023. NCBI Bookshelf

4. Thor KB, de Groat WC. "Neural Control of the Female Urethral and Anal Rhabdosphincters and Pelvic Floor Muscles." Am J Physiol Regul Integr Comp Physiol. 2010;299(2):R416–R438. doi:10.1152/ajpregu.00111.2010

5. Plochocki JH, Rodriguez-Sosa JR, Adrian B, et al. "A Functional and Clinical Reinterpretation of Human Perineal Neuromuscular Anatomy: Application to Sexual Function and Continence." Clin Anat. 2016;29(8):1053–1058. doi:10.1002/ca.22774

6. Unger CA, Tunitsky-Bitton E, Muffly T, Barber MD. "Neuroanatomy, Neurophysiology, and Dysfunction of the Female Lower Urinary Tract: A Review." Female Pelvic Med Reconstr Surg. 2014;20(2):65–75. doi:10.1097/SPV.0000000000000058

7. Querleu D, Cibula D, Abu-Rustum NR. "2017 update on the Querleu-Morrow classification of radical hysterectomy." Ann Surg Oncol. 2017;24(11):3406–3412. doi:10.1245/s10434-017-6031-z

8. Giraudet G, Ruffolo AF, Lallemant M, Cosson M. "The anatomy of the sacrospinous ligament: how to avoid complications related to the sacrospinous fixation procedure for treatment of pelvic organ prolapse." Int Urogynecol J. 2023;34(9):2329–2332. doi:10.1007/s00192-023-05496-3

9. Huizinga JD, Liu L, Barbier A, Chen JH. "Distal colon motor coordination: The role of the coloanal reflex and the rectoanal inhibitory reflex in sampling, flatulence, and defecation." Front Med (Lausanne). 2021;8:720558. doi:10.3389/fmed.2021.720558

10. Barber MD, Bremer RE, Thor KB, Dolber PC, Kuehl TJ, Coates KW. "Innervation of the female levator ani muscles." Am J Obstet Gynecol. 2002;187(1):64–71. doi:10.1067/mob.2002.124844

11. Jiamjunyasiri A, Tsutsumi M, Muro S, Akita K. "Origin, course, and distribution of the posterior femoral cutaneous nerve and the spatial relationship among its branches." Anat Sci Int. 2023;98(4):540–547. doi:10.1007/s12565-023-00721-x