Problem: postoperative dysfunctions
In recent years, nerve-sparing radical hysterectomy for cervical cancer has proven successful in reducing postoperative bladder, colorectal and sexual dysfunction. At our institution, we perform this procedure using a magnified laparoscopic view to better identify fibers and surgical landmarks; this improves dissection of the pars vasculosa from the pars nervosa of the parametrium.
Typically, the medial pararectal space (Okabayashi’s space) is developed between the mesoureter and the rectouterine ligament by opening up a space between the posterior leaf of the broad ligament (medial) and the ureter (lateral). In contrast, the lateral pararectal space (Latzko’s space) is developed between the mesoureter and pelvic wall by opening up the space between the internal iliac artery (lateral) and the ureter (medial).
Our solution
In our procedure, blunt opening of the medial and lateral pararectal spaces at the level of the rectal wings allows preservation of the mesoureter, as well as identification of the middle rectal artery and the origin of the parasympathetic pelvic splanchnic nerves at the sacral roots. The posterior parametrial planes can then be safely dissected, and the cardinal ligament can be completely transected while sparing the fibers distributed within the rectovaginal ligament ( Figures 1 and 2 ). Subsequent visualization of the inferior hypogastric plexus at its origin permits preservation of the visceral afferent and efferent fibers that are directed to the uterus, the vagina, and the bladder.
