Robotic Nerve-Sparing Radical Hysterectomy
Javier F. Magrina
Paul M. Magtibay
GENERAL PRINCIPLES
Definition
Robotic nerve-sparing radical hysterectomy is viewed by an increasing proportion of gynecologic oncologists as a preferable surgical technique to the conventional radical hysterectomy for the surgical treatment of patients with early cervical cancer. The pelvic autonomic nerves are spared on the lateral aspects of the (1) uterosacral ligaments, (2) dorsal vesicouterine ligaments, and (3) vagina. The pelvic splanchnic nerves are spared on the dorsal portion of the lateral parametrium. Primary indications are for patients with stage IB1 (tumor size 2 to 4 cm without lymph-vascular space invasion (LVSI), <2 cm with LVSI), and/or stage IIA with vaginal involvement of the sizes indicated above.
Cervical lesions must be biopsied to be differentiated from other cervical conditions. Office biopsy or loop excision will provide the needed histologic diagnosis.
IMAGING AND OTHER DIAGNOSTICS
MRI seems to be the most accurate imaging technique to determine the size and extension of cervical cancer. PET scan is useful to determine regional and distant metastases, such as metastatic nodal and visceral disease.
DIFFERENTIAL DIAGNOSIS
Some benign conditions such as a cervical fibroid and Wegener granulomatosis may suggest cervical cancer, although tissue examination will clearly provide the correct diagnosis.
PREOPERATIVE PLANNING
Pathologic examination of a biopsy or loop excision is a must before proceeding to treatment. Some histologic types of cervical cancer are preferably treated by chemo-irradiation. Imaging studies are sometimes necessary to determine the size and extent (local, regional, and distant) of the cancerous lesion. Pelvic examination in the office or, if in doubt, under anesthesia is a basic requirement. Involvement of the vagina and extent into the lateral parametria and/or uterosacral ligaments must be ruled out to consider surgical treatment. If there is doubt of bladder or rectal involvement, as may be the case in barrel-shaped lesions, cystoscopy and proctoscopy examinations are helpful to determine mucosal involvement.
Nonoperative Management
Patients with nodal or visceral involvement, infiltration of the parametria, uterosacral ligaments, bladder or rectum, and size >4 cm are preferably treated with chemo-irradiation. A pretreatment extraperitoneal aortic nodal dissection can be performed to determine whether the field of irradiation must include the aortic area.
SURGICAL MANAGEMENT
Robotic nerve-sparing radical hysterectomy (type C1) is indicated for patients with cervical cancer 2 to 4 cm in size or ≤2 cm with lymphatic invasion, including vaginal involvement but not surpassing the indicated size. The technique follows the same surgical steps as the conventional technique1 but sparing the pelvic autonomic nerves to the bladder. Because the technique is not difficult with the use of robotic technology and image magnification, and it provides similar perioperative and survival outcomes as the conventional technique,2 it should be preferable in the hands of trained surgeons. The nerve-sparing technique can also be applied to surgical candidates for radical parametrectomy.3
Positioning
Arms are tucked at each side (Fig. 22.1). Arms and legs are loosely padded with foam pads. With the patient on the table and prior to draping, there is an opportunity to place the operating table in the Trendelenburg position to determine if the patient slides or not, and adjusted as needed. It is then returned to the normal position and the patient is prepped and draped.
Approach
Radical nerve-sparing radical hysterectomy can be performed by laparotomy or minimally invasive surgery, laparoscopy, or robotics. The magnification obtained with an endoscopic camera greatly facilitates identification and preservation of the pelvic autonomic nerves. When performed by laparotomy, magnifying loops are necessary for the same reason.
 Figure 22.1. The patient in a semi-lithotomy position with arms tucked at each side and padded for protection. Legs will also be padded to prevent pressure injury. |
PROCEDURES AND TECHNIQUES
Procedures and Techniques
Entry and trocar placement
Following introduction of the laparoscope under direct visualization (either using a transumbilical open technique or entry using a transparent trocar introduced under laparoscopic guidance), the upper abdomen is explored in the supine position. The patient is then placed in the Trendelenburg position to a degree enough to displace the sigmoid and small bowel out of the pelvis and allow a safe pelvic operation.
Two robotic trocars (8 mm each) are introduced 10 cm to the right and left of the umbilical optical trocar and at the same level of the umbilicus. An assistant trocar (10 mm) is placed midway and 3 cm cranial to the umbilical and left trocar in all patients. Another robotic trocar, designated as the right robotic arm, is introduced 5 cm lateral and 3 cm cranial to the umbilical trocar (Tech Fig. 22.1). The robotic column is side-docked to the patient’s right leg (Tech Fig. 22.2 and Video 22.1 
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