A Concise Paradigm on Radical Hysterectomy: The Comprehensive Anatomy of Parametrium, Paracolpium and the Pelvic Autonomic Nerve System and Its Surgical Implication

Abstract

<jats:p>The current understanding of radical hysterectomy is more centered on the uterus and little is discussed regarding the resection of the vaginal cuff and the paracolpium as an essential part of this procedure. The anatomic dissections of two fresh and 17 formalin-fixed female pelvis cadavers were utilized to understand and decipher the anatomy of the pelvic autonomic nerve system (PANS) and its connections to the surrounding anatomical structures, especially the paracolpium. The study mandates the recognition of the three-dimensional (3D) anatomic template of the parametrium and paracolpium and provides herewith an enhanced scope during a nerve-sparing radical hysterectomy procedure by precise description of the paracolpium and its close anatomical relationships to the components of the PANS. This enables the medical fraternity to distinguish between direct infiltration of the paracolpium, where the nerve sparing technique is no longer possible, and the affected lymph node in the paracolpium, where nerve sparing is still an option. This study gives rise to a tailored surgical option that allows for abandoning the resection of the paracolpium by FIGO stage IB1, where less than 2 cm vaginal vault resection is demanded.</jats:p>

Nerve-Sparing Systematic Lymph Node Dissection in Gynaecological Oncology: An Innovative Neuro-Anatomical and Surgical Protocol for Enhanced Functional Outcomes

“…The superior hypogastric plexus, often called the presacral nerve, terminates by dividing into right and left hypogastric nerves and consists primarily of sympathetic and visceral afferent fibers [ 12 ]. These fibers merge with the pelvic splanchnic nerves (parasympathetic) in the deep extraperitoneal spaces at the lateral sidewall of the vagina and rectum, to form the inferior hypogastric plexus bilaterally from which nerve fibers spread out to the pelvic organs [ 7 , 13 , 14 , 15 ]. The aortic plexus receives sympathetic supply from the lumbar sympathetic trunk and suprarenal pre-aortic plexuses via lumbar splanchnic nerves and intermesenteric nerves, respectively [ 16 ].…”

“…The present study also contends that a poor anatomical understanding of the sympathetic nerves within the boundaries of an infra-renal bilateral template has limited the promulgation of a precise nerve-sparing surgery during such systematic lymph node dissections. Since we already described the precise anatomy of pelvic autonomic nervous system (inferior hypogastric plexus) in our previous studies [ 7 , 8 , 9 ], the principal goal of the present study was to provide the first ever-comprehensive exposition of the anatomy of the female aortic plexus and superior hypogastric plexus and their variations, to elucidate and improve the surgical outcomes of a systematic nerve-sparing lymph node dissection.…”

A New Anatomic and Staging-Oriented Classification of Radical Hysterectomy

“…This new classification of radical hysterectomy depends on the Cibula 3-dimentional concept of parametrium [11], Muallem 3-dimentional concept of paracolpium and his comprehensive description of the anatomy of parametrium, paracolpium and the pelvic autonomic nerve system [10], and the international anatomic nomenclature (Terminologia Anatomica) [12,13].…”

“…Advocating this type of resection, because it can reduce the risk of ureteral injuries even when it is not radical enough to assess the microscopic parametrial invasion, is really difficult. Minimizing the risk of injuring the ureter, pelvic autonomic nerve system or the bladder and/or the ureter blood supply has to still one of the most important aspects of radical hysterectomy, but it has to depend on the precise understanding of anatomy in this area presented from Fujii et al [9] and Muallem et al [10]. This work aims to suggest a new anatomic and staging-oriented classification of radical hysterectomy taking into account the increased need of tailoring the surgery according to the tumor size, localization and infiltration in the vagina.…”

Ultrasound of the Uterosacral Ligament, Parametrium, and Paracervix: Disagreement in Terminology between Imaging Anatomy and Modern Gynecologic Surgery

“…From a surgical point of view, parametrium and paracervix, which is the upper part of the paracolpium (see above), contain structures that require different surgical approaches [ 31 ]. Namely, the parametrium contains the ureter and vessels that are usually isolated in advanced surgery (radical hysterectomy and deep infiltrating endometriosis) while the paracervix contains vessels (usually sacrificed whenever required) and nerves that should be, if possible, preserved in modern nerve-sparing radical surgery.…”