Nerve-sparing radical hysterectomy: steps to standardize surgical technique

Abstract

AimThe primary objective of this review was to study and analyze techniques of nerve-sparing radical hysterectomy so as to be able to characterize and elucidate intricate steps for the dissection of each component of the pelvic autonomic nerve plexuses during nerve-sparing radical hysterectomy.MethodsThis review was based on a five-step study design that included searching for relevant publications, selecting publications by applying inclusion and exclusion criteria, quality assessment of the identified studies, data extraction, and data synthesis.ResultsThere are numerous differences in the published literature concerning nerve-sparing radical hysterectomy including variations in techniques and surgical approaches. Techniques that claim to be nerve-sparing by staying above the dissection level of the hypogastric nerves do not highlight the pelvic splanchnic nerve, do not take into account the intra-operative patient position, nor the fact that the bladder branches leave the inferior hypogastric plexus in a ventrocranial direction, and the fact that inferior hypogastric plexus will be drawn cranially with the vaginal walls (if this is not recognized and isolated earlier) above the level of hypogastric nerves by drawing the uterus cranially during the operation.ConclusionsThe optimal nerve-sparing radical hysterectomy technique has to be radical (type C1) and must describe surgical steps to highlight all three components of the pelvic autonomic nervous system (hypogastric nerves, pelvic splanchnic nerves, and the bladder branches of the inferior hypogastric plexus). Recognizing the pelvic splanchnic nerves in the caudal parametrium and the isolation of the bladder branches of the inferior hypogastic plexus requires meticulous preparation of the caudal part of the ventral parametrium.

Nerve-sparing radical hysterectomy—Muallem technique with explanation of parametrium and paracolpium anatomy

“…4 5 This will be explained in that the radical resection (type C) sacrifices the ventral part of the inferior hypogastric Educational video lecture plexus, the bladder branches, and probably the pelvic splanchnic nerves (leading to type C2) without prior direct visualization and dissection of the bladder branches and inferior hypogastric plexus. 6 This gives rise to two problems: First, the current understanding of radical hysterectomy is more centered on the uterus, especially the uterine cervix and little or nothing being discussed concerning the significance of the resection of the vaginal cuff (that generally runs up to one-third or half of the vagina) and the paracolpium as an essential part of radical hysterectomy. 1 7 8 (Figure 1) Second, there is an obvious disparity of opinion concerning the technique of nerve-sparing radical hysterectomy despite agreement on the need to highlight all the anatomical autonomic nerve structures and sparing these nerves also.…”

“…1 7 8 (Figure 1) Second, there is an obvious disparity of opinion concerning the technique of nerve-sparing radical hysterectomy despite agreement on the need to highlight all the anatomical autonomic nerve structures and sparing these nerves also. 6 In our experience, understanding the precise three-dimensional anatomy of paracolpium and its close anatomical relationship to the components of the pelvic autonomic nervous system is the key in performing the nerve-sparing radical hysterectomy. Therefore, our technique concentrates on describing the entire three-dimensional anatomy of paracolpium and the essential role of vaginal vessels in the anatomy of radical hysterectomy.…”

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

“…In 2017, Querleu et al [ 9 ] took up an initiative to standardize the anatomic nomenclature and redefine the technical descriptions of various radical hysterectomy procedures. Nevertheless, specific published literature [ 5 , 10 , 11 ] reveal that there is still a need for a comprehensive and precise anatomy of radical hysterectomy with extensive knowledge of the pelvic spaces, blood supplies, autonomic nerve system and connective pillars to enable the surgical procedure to be carried out accurately with the right balance as regards radicality, prognosis and quality of life.…”

Nerve Sparing Radical Hysterectomy: Short-Term Oncologic, Surgical, and Functional Outcomes

“…In our previous paper, we emphasized upon restricting the term nerve-sparing radical hysterectomy only to surgical techniques that include a clear description of the surgical steps required to dissect and spare all components of the pelvic autonomic nervous system (hypogastric nerves, pelvic splanchnic nerves, and the bladder branches of the inferior hypogastric plexus) [8]. Fujii et al described in 2007 the precise anatomy of the vesicouterine ligament for radical hysterectomy and showed for the first time the meticulous separation of the blood vessels and connective tissues to preserve the pelvic splanchnic nerve, the hypogastric nerve, and the bladder branch of the inferior hypogastric plexus under magnification [15].…”

“…Some investigators, who claimed that nerve-sparing radical hysterectomy has to be restricted only to small tumors in early-stage cervical cancers [4][5][6][7], ignored that the fact that technique was designed to deal with vesicovaginal ligament (ventral paracolpium) with sparing the bladder branches of inferior hypogastric plexus. Resecting of ventral paracolpium (vesicovaginal ligament) is necessary only in more advanced tumors [8].…”