and Kentaro Sekiyama2
Department of Gynecology and Obstetrics, Kyoto University, Kyoto, Japan
Department of Obstetrics and Gynecology, Kitano Hospital, Kita-ku, Osaka, Japan
KeywordsOkabayashi’s radical hysterectomyWertheim’s radical hysterectomyBladder dysfunctionColorectal dysfunctionInferior hypogastric plexus (cross shape)Hypogastric nervePelvic splanchnic nerveBladder branchNerve-sparing radical hysterectomyT-shaped inferior hypogastric plexus
7.1 Severe Bladder Dysfunction/Colorectal Motility Disorders Are Common Complications of Radical Hysterectomy (Figure 7.1)
Since Wertheim introduced radical hysterectomy in 1911 , his method became the standard procedure for the surgical treatment of cervical cancer in Western Countries. However, in Japan, Takayama and Okabayashi at Kyoto Imperial University thought that Wertheim’s method is not radical enough for invasive cervical cancers. They pursued to create a “better” surgery and Okabayashi established an anatomy oriented method to accomplish more radical surgery than that of Wertheim’s method in 1921 . However, postoperatively both methods have often been associated with severe bladder dysfunction and colorectal motility disorders that adversely impacted the patient’s quality of life.
7.1.1 Nerve Supply to the Uterus, Rectum, and Urinary Bladder (Figure 7.2)
The uterus, vagina, urinary bladder, and rectum are innervated by a motor and sensory autonomic nerve supply (sympathetic and parasympathetic origin). The sympathetic fibers come from T10-L2 to form the inferior hypogastric nerve. The parasympathetic fibers come from S2, 3 and 4 at the pelvic wall to form the pelvic splanchnic nerve. These fibers merge and construct the inferior hypogastric plexus that has branches to the uterus and to the urinary bladder [3–6].
7.1.2 Locations of Nerve Damages During Radical Hysterectomy (Figure 7.3)
During radical hysterectomy, such as Wertheim’s method and Okabayashi’s method, surgical procedures to the uterosacral ligament and the rectovaginal ligament can lead to injury of the hypogastric nerve [7, 8]. The surgical procedures to the paracolpium (vaginal blood vessels) can give rise to damage to the bladder branch of the inferior hypogastric plexus [7, 8]. During Okabayashi’s method, the treatment to the deep uterine vein in the cardinal ligament can injure the pelvic splanchnic nerve. In contrast, Wertheim’s method usually does not divide the deep uterine vein (cardinal ligament). Therefore, it appears unlikely to injure the pelvic splanchnic nerve. However, instead of dividing the cardinal ligament, Wertheim’s method divides the paracervical tissues including the parametrial tissues and the paracolpium. During the division of the paracervical tissues, Wertheim’s method increases the possibility of injury to the bladder branch from the inferior hypogastric plexus.
7.1.3 Efforts on Nerve-Sparing Radical Hysterectomy (Figure 7.4)
Japanese doctor Takashi Kobayashi at Tokyo University is a pioneer of the nerve-sparing radical hysterectomy. Modifying Okabayashi’s radical hysterectomy Kobayashi tried to preserve nerve functions during radical hysterectomy. In 1961, Kobayashi  described the concept for the improvement of postoperative bladder function by preserving the pelvic splanchnic nerve by the separation of the vascular part (the deep uterine vein) from the dorsal hard bundle (the pelvic splanchnic nerve) during the division of the cardinal ligament. Sakamoto [10, 11] and Kuwabara  succeeded in these concepts. Then, in 1983, Fujiwara  at Kitano Hospital described the importance of the preservation of the hypogastric nerve with the pelvic splanchnic nerve and the bladder branch by the division of only the uterine branch from the inferior hypogastric plexus. Since then, many Japanese as well as Western countries’ doctors started to undertake a nerve-sparing radical hysterectomy and published many papers on nerve-sparing radical hysterectomy [14–25]. Nevertheless, almost all published papers on nerve-sparing radical hysterectomy could not clearly show the surgical anatomy of the inferior hypogastric plexus with the bladder branch and the uterine branch. Publications using Wertheim or Piver Type III surgery show mainly the process of isolation of the inferior hypogastric nerve, and there is usually no clear description on the pelvic splanchnic nerve or the bladder branch from the inferior hypogastric plexus [14–20]. The reason is clear because Wertheim and Piver Type III surgeries neither reveal nor isolate the deep uterine vein beneath which the pelvic splanchnic nerve resides. Moreover, although these surgeries divide the anterior (ventral) leaf of the vesicouterine ligament, the concept of separation and division of the posterior (dorsal) leaf of the vesicouterine ligament, beneath which the bladder branch resides, is lacking. In contrast, Japanese doctors usually perform Okabayashi’s radical hysterectomy . Okabayashi’s radical hysterectomy separates and divides the posterior (dorsal leaf of the vesicouterine ligament. Therefore, the publications from Japan have described both inferior hypogastric nerve and pelvic splanchnic nerve, and provided more information on the inferior hypogastric plexus [21–25]. In 2007, Fujii et al.  published a clear description of the surgical anatomy of the cross-shaped inferior hypogastric plexus (Figures 7.4, 7.5, and 7.6) and reported how to divide the uterine branch alone from the plexus. If the uterine branch is solely divided, the urinary bladder function is preserved following surgery. This publication stimulated and generated great interest in many doctors as a result of which nerve-sparing radical hysterectomy became very popular [27–29].