Surgical treatment of cancer in any organ requires removal of the primary tumor and areas of potential spread. Cancer of the cervix spreads first by direct extension and second by lymph node metastasis. Direct extension is into the cervix, then to the parametria, and then to the pelvic sidewall. The radical hysterectomy and lymph node dissection performed by Meigs fulfilled these requirements. The high rate of bladder dysfunction and ureter injuries led surgeons to modify the radicality of the operation to avoid the autonomic nerves. Piver and Rutledge published five classes of extended hysterectomy in 1974 to address this modification of the Meigs radical hysterectomy. This classification became inadequate after the widespread adoption of nerve-sparing techniques. In 2007, an international conference in Kyoto organized by Shingo Fujii and Paul Morrow produced the Kyoto classification that is in wide use today. The two classification systems are shown in the tables (see Tables 17.1 and 17.2). The Piver class 2 and the Kyoto type B are similar, but the Kyoto classification includes both type B1 and type B2 to indicate when the parauterine fatty nodal tissue is removed from the ureter to the obturator space. The most significant difference is in the Piver class 3 and Kyoto type C. The Piver class 3 removes the entire cardinal ligament including the autonomic nerves, and the Kyoto type C is divided into C1 which removes just the paracervical tissue cranial to the autonomic nerves, and the type C2 removes the entire paracervix including the autonomic nerves. This book will use the Kyoto classification and the nerve-sparing radical hysterectomy (NSRH) will be type C1.