Nerve-Sparing Radical Hysterectomy
Kenneth D. Hatch
GENERAL PRINCIPLES
Both the Meigs and Okabayashi radical hysterectomies removed the entire attachment of the cardinal ligament to the pelvic sidewall. This included the autonomic nerves leading to loss of normal bladder function.
Definition
Nerve-sparing radical hysterectomy (NSRH) refers to the operative techniques that avoid transection of the sympathetic and parasympathetic nerves that innervate the bladder. There are two techniques currently being used for nerve-sparing operations.
The first technique is direct identification and dissection of the autonomic nerves. This was first published by Kobayashi (1961) and Sakamoto (1970) in Japanese (they will not be cited in the key references). They described a ventral blood vessel portion and a dorsal nerve portion of the cardinal ligament and proposed the operation to preserve the nerves. Fujiwara (1984) then identified a bladder branch of the splanchnic nerve during dissection of the bladder base (also published in Japanese). Yabuki published the first English language description in 1991. Shingo Fujii has published the most complete description and illustration of the nerve dissection (Figs. 18.1, 18.2, 18.3, 18.4 and 18.5).
Trimbos from the Netherlands studied the operation in Japan and introduced it to Europe (2001). He noted that the pelvis of the Western women had more deposits of fat in the deeper areas of the pelvis than in Japanese women. For example, after cutting the vascular part of the parametrium in Japanese women, the underlying nerve fibers were easily seen; whereas in Western women, the nerves were covered by a fatty layer that had to be removed before the nerves could be seen.
Figure 18.1. Relationship of the autonomic nerves to the uterus, bladder, and major blood vessels. (From Fujii S, Takakura K, Matsumura N, et al. Anatomic identification and functional outcomes of the nerve sparing Okabayashi radical hysterectomy. Gynecol Oncol. 2007;107[1]:4-13.)
Höckel then published the results of an operation based on the developmentally defined surgical anatomy called the total mesometrial resection (TMMR). This technique preserves the inferior hypogastric plexus in the pelvis and the superior hypogastric plexus over the aorta and then splits the mesoureter away from the uterosacral and rectovaginal ligaments. The mesoureter contains the hypogastric nerve. He does not dissect the nerve independently. He then retracts the ureter and mesoureter laterally when dividing the paracolpos, thus avoiding the nerve to the bladder.
These two different techniques of NSRH will be shown in the videos.
Anatomic Considerations
Bladder function is dependent on intact sympathetic and parasympathetic innervation. The sympathetic nerves originate from T11-L2 and form a superior hypogastric plexus over the bifurcation of the aorta. The paired hypogastric nerves descend into the pelvis approximately 2 cm dorsal to the ureter (see Tech Fig. 18.1). They connect with the parasympathetic splanchnic nerves originating from S2-S4. This forms the inferior hypogastric plexus. From the hypogastric plexus, the splanchnic nerves travel dorsal to the deep uterine vein toward the uterus with a uterine branch and a bladder branch (see Fig. 18.1).
If the hypogastric nerve is not dissected away from the uterosacral ligament, it will be transected when the surgeon divides the uterosacral or rectovaginal ligament.
Figure 18.2. The vascular portion of the cardinal ligament (paracervix) before division of the uterine artery and vein.
Figure 18.3. Operative photo (A) and diagram (B) of the deep uterine vein. (From Fujii S, Takakura K, Matsumura N, et al. Anatomic identification and functional outcomes of the nerve sparing Okabayashi radical hysterectomy. Gynecol Oncol. 2007;107[1]:4-13.)
Figure 18.4. Photograph (A) and diagram (B) of the dissection of the deep uterine vein. (From Fujii S, Takakura K, Matsumura N, et al. Anatomic identification and functional outcomes of the nerve sparing Okabayashi radical hysterectomy. Gynecol Oncol. 2007;107[1]:4-13.)
If the bladder branch of the splanchnic nerve is not retracted laterally with the ureter when the paracolpium is divided, it may be damaged.
Both sympathetic and parasympathetic nerves will be divided when the surgeon transects the nerves at the pelvic sidewall as is done with a type C2 radical hysterectomy.
The sympathetic nerves from the hypogastric nerve are responsible for storage of urine and the parasympathetic with voiding (sympathetic—store, parasympathetic—pee). Disruption of the sympathetic nerves will result in parasympathetic dominance and a high-pressure, low-volume bladder. If both sympathetic and parasympathetic nerves are damaged in a C2 radical hysterectomy, there will be high pressure and low volume for a few days and then an atonic bladder with complete loss of sensation.
The nerve-sparing operation starts by preserving the superior hypogastric plexus over the bifurcation of the aorta when a paraaortic node dissection is performed. The hypogastric nerve in the root of the rectosigmoid mesentery is dissected down to the cardinal ligament. The deep uterine vein is transected and pulled medially with the specimen. This allows for transection of the uterine branches of the nerves. The remainder of the splanchnic nerve can be pushed laterally with the ureter (see Tech Figs. 18.1, 18.2, 18.3, 18.4, 18.5, 18.6and 18.7). These operative photos demonstrate the entire course of the hypogastric nerve from the superior hypogastric plexus to the inferior hypogastric plexus. The video will show dissection of the hypogastric nerve when a paraaortic node dissection is not performed (see Video 18.1
).
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