Nerve-Sparing Radical Hysterectomy



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.



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 image).

    Only gold members can continue reading. Log In or Register to continue

May 7, 2019 | Posted by in GYNECOLOGY | Comments Off on Nerve-Sparing Radical Hysterectomy
Premium Wordpress Themes by UFO Themes