Nerve-sparing radical hysterectomy was developed in an attempt to minimize complications, including bladder, colorectal, and sexual dysfunction which are associated with disruption of the pelvic autonomic nerves during resection of the parametrium. In this article, the author proposes a simple, effective technique for identification and preservation of the pelvic nerves during type III radical hysterectomy. The essential technical considerations include the sequential approach to parametrial resection, starting from the posterior part, the direct visualization of the main nerve trunks at all sites during parametrial resection, and the avoidance of direct manipulation and unnecessary dissection of the nerves. Operative outcomes of 22 patients with cervical or uterine cancer who underwent type III radical hysterectomy from August 2008 to March 2010 were reviewed. Comparing with the earlier method performed at the author’s institution, the present technique was associated with an increased proportion of patients who had a postvoid residual urine volume (PVR) under 50 mL at postoperative day 7 (55% vs 27%) and a shorter median duration before this PVR was reached (7 days vs 9 days). The systematic approach proposed in this article would make the nerve-sparing technique for radical hysterectomy more straightforward and applicable to various settings. A thorough understanding of anatomy and adequate surgical skills are always vital components of successful nerve-sparing radical hysterectomy.
Problem: enduring dysfunction
Type III radical hysterectomy and pelvic lymphadenectomy, an effective treatment for early-stage cervical cancer, has a 5-year survival rate approaching 70-90%. However, the procedure is frequently associated with significant lasting morbidities, including bladder, colorectal, and sexual dysfunction. Bladder dysfunction, which results from disruption of the pelvic autonomic nerves during resection of the parametrium, is most common, with a prevalence perhaps as high as 80%.
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In an attempt to minimize complications, nerve-sparing radical hysterectomy was developed; the first such surgery occurred in Japan. The procedure has since been widely accepted in other parts of the world. Although an improvement, previously described techniques for nerve-sparing procedures had their own drawbacks: they often required sophisticated surgical dissection; they were not always easily reproducible; and they achieved diverse outcomes on postoperative bladder function. We propose a simple, effective technique for identification and preservation of the pelvic autonomic nerves during type III radical hysterectomy.
Our solution
Since our institution adopted a nerve-sparing technique for radical hysterectomy in 2005, we have continuously improved our method so that it might be more widely accepted. This article reviews the modified surgical technique that was employed in 22 patients with cervical or uterine cancer who underwent type III radical hysterectomy from August 2008 through March 2010, along with the patients’ operative outcomes. The study, performed at the Division of Gynecologic Oncology, Chiang Mai University, Thailand, was approved by our research ethics committee of our faculty of medicine.
Conventional bilateral pelvic lymphadenectomy was followed by a Piver-Rutledge type III radical hysterectomy. We began at the posterior parametrium, where our main objective was to find and protect the hypogastric nerve and the inferior hypogastric plexus. The hypogastric nerve is the proximal (sympathetic) part of the pelvic autonomic nervous system that originates from the superior hypogastric plexus; the inferior hypogastric plexus, a fan-shaped structure located immediately lateral to the uterosacral ligament and rectovaginal septum, is formed by the hypogastric nerve and splanchnic (parasympathetic) nerves.
First, the loose tissue connecting the ureter and the posterior leaf of the broad ligament was sharply dissected down until it was possible to enter Okabayashi pararectal space at the point where the yellow fatty tissue at the bottom was seen ( Figure 1 , A). This space provides a landmark for easy identification of the hypogastric nerve, which courses through the mesoureter, approximately 2 cm beneath the ureter ( Figure 1 , B). The nerve plane was then followed downward in the anterocaudal direction approaching the inferior hypogastric plexus.
To prevent unnecessary trauma to the nerves from excessive manipulation, we did not attempt to completely dissect and isolate the nerves from adjacent structures at this stage. Instead, the intact mesoureter, which contains the nerves, and the surrounding tissues were gently pushed and retracted away from the line of posterior parametrial resection. This was accomplished by inserting 2 small spatula or paravesical/pararectal retractors into Okabayashi pararectal space. Each instrument was retracted simultaneously in the opposite direction: one medially, the other laterally. To further separate the inferior hypogastric plexus from the posterior parametrium, the neuroligamentous space was developed between the nerve plexus and the uterosacral ligament/rectovaginal septum complex by using small-tip right-angle clamps ( Figure 1 , C). Then, the ligamentous complex was clamped close to its posterior attachment ( Figure 2 ).
The next stage of surgery focused on resection of the vascular portion of the lateral parametrium. At this point, the inferior hypogastric plexus was directly visualized to avoid injury. After posterior parametrial resection, the uterus was significantly more mobile. It was held upward and away from the nerve, which runs anterocaudally. The lateral parametrium was then identified as a soft tissue strand between the paravesical and Latzko pararectal spaces. We retracted the inferior hypogastric plexus medially, separating it from the lateral parametrium by Latzko pararectal space ( Figure 3 , A). The vascular part of the lateral parametrium, including the uterine artery and deep uterine veins, was then resected close to the pelvic sidewall ( Figure 3 , B). Usually, this was managed with a single slice. The resected parametrium was subsequently freed from the underlying tissue and brought over to the medial side of the ureter ( Figure 3 , C).
In the last phase of surgery, we concentrated on resecting the vesicouterine ligament and avoiding injury to the main vesical branch of the inferior hypogastric plexus. Again, this step was performed under direct visualization. Generally, the vesical branch was identified by following the course of the inferior hypogastric plexus caudally while holding the uterus and the attached parametrial tissue upward. Because the posterior and lateral parametria had already been sufficiently resected, it was possible to lift the uterus even further away from the path of the pelvic nerves. We then entered the ureteric tunnel and transected the superficial layer of the vesicouterine ligament ( Figure 4 , A). The ureter and the vesical branch were retracted downward and laterally, and the deep layer of the vesicouterine ligament was finally resected at a position that was anteromedial to the nerve ( Figure 4 , B). The remainder of the procedure was concluded in conventional fashion. Figure 5 displays the preserved pelvic nerve at the end of the operation. The supplementary video clip presents important steps of the procedure.
Clinical characteristics and operative outcomes of each patient have been compiled in Table 1 . Patients’ average age was 46.8 years (range, 25–68 years). Five patients (22.7%) had previously undergone abdominal surgery–specifically, 2 nephrectomies, 2 appendectomies, and 1 cesarean section. For the 20 patients with cervical cancer, tumor stage was IA2 in 1 patient (5%), IB1 in 14 patients (70%), IB2 in 2 patients (10%), and IIA in 3 patients (15%). Squamous cell carcinoma was identified in 13 patients (65%), adenocarcinoma in 3 patients (15%), adenosquamous carcinoma in 3 patients (15%), and neuroendocrine carcinoma in 1 patient (5%). For the 2 patients who had endometrial cancer with gross cervical involvement, histology detected endometrioid carcinoma. Among women with gross cervical tumors, the mean tumor diameter was 3.7 cm (range, 1.5–8.5 cm). Fifteen patients (68.2%) had infiltrative tumors, 1 (4.5%) had an exophytic tumor, and 6 (27.3%) had microscopic tumors.
