Liposuction-assisted nerve-sparing extended radical hysterectomy: Oncologic rationale, surgical anatomy, and feasibility study

doi:10.1016/S0002-9378(98)70533-2

American Journal of Obstetrics and Gynecology

Volume 178, Issue 5, May 1998, Pages 971-976

https://doi.org/10.1016/S0002-9378(98)70533-2 Get rights and content

Abstract

OBJECTIVE: Our purpose was to improve the therapeutic index of radical hysterectomy by extending the resection of parametrial tissue without further impairing pelvic autonomic nerve functions. STUDY DESIGN: We studied the topographic anatomy of the parametrial tissue with high-resolution magnetic resonance imaging and by dissection of fresh human cadavers. We then performed a clinical feasibility study of the liposuction-assisted nerve-sparing extended radical hysterectomy. RESULTS: Magnetic resonance imaging demonstrated that the perispinous adipose tissue is retained after type III radical hysterectomy and is a frequent site of tumor recurrence. The perispinous adipose tissue contains the pelvic plexus, the pelvic splanchnic nerves, small blood vessels, and lymphatic tissue. We developed the liposuction-assisted nerve-sparing extended radical hysterectomy and applied it to seven consecutive patients with cervical or vaginal cancer. No intraoperative or postoperative complications occurred. Postoperative magnetic resonance imaging assured us that perispinous adipose tissue was cleared in all cases. A metastatic lymph node was found in the perispinous adipose tissue removed by liposuction from one patient. Suprapubic cystostomies could be removed after a median period of 12 days. CONCLUSION: The nerve-sparing removal of perispinous adipose tissue by liposuction is a feasible addition to wide en bloc parametrectomy in anatomically defined planes. (Am J Obstet Gynecol 1998;178:971-6.)

Section snippets

MRI

Scans were performed on a Siemens Expert 1.0 T Magnetom (Siemens, Erlangen, Germany). A T₂-weighted turbo spin echo sequence was used in transverse and sagittal orientation. A T₁-weighted spin echo sequence was used in transverse orientation and repeated after administration of contrast agent. Additionally a turbo spin echo sequence with fat suppression was used in coronal orientation. This sequence was optionally repeated in a sagittal orientation. The total time of data acquisition was about

MRI studies

The sectional anatomy of the parametrial tissues was studied with pelvic MRI series of patients without gynecologic pathology. Sections 5 mm thick around the ischial spine clearly demonstrated a bilateral triangular zone of adipose tissue between the mesorectum (lower border), uterovaginal venous plexus (upper border), and obturator internus, coccygeus, iliococcygeus muscle (lateral border), designated perispinous adipose tissue (Fig. 1, A).

. T₂-weighted axial MRI scans of the female pelvis

Comment

According to the concepts of surgical oncology, radical treatment involves the wide en bloc resection of the tumor-bearing organ along with its primary lymphatic drainage compartment. The relevance of this principle has been recently reappraised with total mesorectal excision techniques for the surgical treatment of rectal cancer.9, 10 For the operative therapy of cervical cancer, radical hysterectomy adheres to the same oncologic principle, resection of the uterus en bloc with the parametria.

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2020, Gynecologic Oncology Reports
The resulting characteristics of 20th century radical hysterectomy demonstrated that, in the quest for a radical cure, its surgical procedure became extended. The consequences of this were increased difficulty in the procedure with risk of massive hemorrhage and vesical and anorectal dysfunction. Moreover, the cardinal and transverse cervical ligaments, which were individually recognized during the 19th century, became regarded as synonymous during the middle of the 20th century. Because of this, traditional surgical procedures such as Wertheim and Latzko’s were not precisely followed, further delaying the advent of a new idea(s) for radical hysterectomy. The desired goal for 21st radical hysterectomy should be an anatomy and operative procedure that clarify and rectify these aforementioned negative surgical outcomes. In 1998, International Federation of Associations of Anatomists (IFAA) introduced clinical terminology in Terminologia Anatomica. With the IFAA’s decision in mind, the author focused, out of the many theories and surgical procedures for cancer of the uterine cervix, on three noteworthy proposals. From these proposals, the possibility for a new idea(s) on theories and surgical procedures was explored through the fusion of anatomy and clinical practice. The idea for a new procedure(s) required a morphological distinction between description in textbooks and intraoperative findings, that is: a) a traditional anatomy that was based on gross/systemic anatomy; and b) an anatomy in which part of an artifact resulting from applying an artificial maneuver to a living body could be regarded as surgical anatomy. The author has tentatively called the former descriptive anatomy and the latter practical anatomy. The development of this practical anatomy led to the idea for and practical application of a less-extirpating and nerve-sparing operation, which improved patient’s outcome. Radical hysterectomy of the 21st century should be conducted following this new anatomy that is concentrated around practical anatomy and independent from descriptive anatomy.
Standardized terminology of apical structures in the female pelvis based on a structured medical literature review
2020, American Journal of Obstetrics and Gynecology
Citation Excerpt :
Through group consensus, we have provided definitions, and propose their adoption as standard terms: “Vesicouterine ligament” was used in 26 citations from 10 countries (Netherlands, Japan, Spain, Belgium, Germany, Serbia, Austria, France, United States, China) from 1975 through 2014.16,19,37,38,40,41,42,43,45,47,52,54,55,57,69,74,77,83,84,85–87,89,103,104 This structure would be considered a connective tissue ventral extension of the cardinal ligament [A09.1.03.031] that attaches to the bladder [A08.3.01.001] and carries blood vessels, nerves, and the distal ureter [A08.2.01.001] (Figure 2).
The objectives of this study were to review the published literature and selected textbooks, to compare existing usage to that in Terminologia Anatomica, and to compile standardized anatomic nomenclature for the apical structures of the female pelvis. MEDLINE was searched from inception until May 30, 2017, based on 33 search terms generated by group consensus. Resulting abstracts were screened by 11 reviewers to identify pertinent studies reporting on apical female pelvic anatomy. Following additional focused screening for rarer terms and selective representative random sampling of the literature for common terms, accepted full-text manuscripts and relevant textbook chapters were extracted for anatomic terms related to apical structures. From an initial total of 55,448 abstracts, 193 eligible studies were identified for extraction, to which 14 chapters from 9 textbooks were added. In all, 293 separate structural terms were identified, of which 184 had Terminologia Anatomica−accepted terms. Inclusion of several widely used regional terms (vaginal apex, adnexa, cervico-vaginal junction, uretero-vesical junction, and apical segment), structural terms (vesicouterine ligament, paracolpium, mesoteres, mesoureter, ovarian venous plexus, and artery to the round ligament) and spaces (vesicocervical, vesicovaginal, presacral, and pararectal) not included in Terminologia Anatomica is proposed. Furthermore, 2 controversial terms (lower uterine segment and supravaginal septum) were identified that require additional research to support or refute continued use in medical communication. This study confirms and identifies inconsistencies and gaps in the nomenclature of apical structures of the female pelvis. Standardized terminology should be used when describing apical female pelvic structures to facilitate communication and to promote consistency among multiple academic, clinical, and surgical disciplines.
Current concepts and practical techniques of nerve-sparing laparoscopic radical hysterectomy
2016, European Journal of Obstetrics and Gynecology and Reproductive Biology
Citation Excerpt :
The concept of autonomic nerve-sparing radical hysterectomy (NSRH) was first proposed by Kobayahsi [3] in the 1960s and Sakamoto and Takizawa [4] in the 1980s and named the “Tokyo method”. Subsequent studies have suggested its feasibility and efficacy, proposing various technical issues to preserve pelvic nerves [16–24]. However, the complexity of pelvic anatomy, including vessels and autonomic nerves around the uterus and bladder and the insufficient visual representation of pelvic space in the field of abdominal surgery, has been a barrier to better understanding of nerve-sparing techniques.
Laparoscopic radical hysterectomy has been widely performed for patients with early-stage cervical cancer. The operative techniques for nerve-sparing to avoid bladder dysfunction have been established during the past three decades in abdominal radical hysterectomy, but how these techniques can be applied to laparoscopic surgery has not been fully discussed. Prolonged operation time or decreased radicality due to less accessibility via a limited number of trocars may be a disadvantage of the laparoscopic approach, but the magnified visual field in laparoscopy may enable fine manipulation, especially for preserving autonomic nerve tracts. The present review article introduces the practical techniques for sparing bladder branches of pelvic nerves in laparoscopic radical hysterectomy based on understanding of the pelvic anatomy, clearly focusing on the differences from the techniques in abdominal hysterectomy.
Nerve-sparing radical hysterectomy versus conventional radical hysterectomy in early-stage cervical cancer. A systematic review and meta-analysis of survival and quality of life
2016, Maturitas
Survival after radical hysterectomy (RH) for early-stage cervical cancer is good. Hence quality of life (QOL) after treatment is an important issue. Nerve-sparing radical hysterectomy (NSRH) improves QOL by selectively sparing innervation of bladder, bowel and vagina, reducing therapy-induced morbidity. However, the oncological outcome and the functional outcome after NSRH are subjects of debate. We aim to present the best possible evidence available regarding both QOL and survival after NSRH in early-stage cervical cancer.
Systematic review and meta-analysis on studies comparing NSRH and RH.
Forty-one studies were included, and 27 were used for the meta-analysis. There was no difference in 2-, 3- and 5-year overall survival: the risk ratios (RRs) were respectively 1.02 (95% CI 0.99–1.05, n = 879), 1.01 (95% CI 0.95–1.08, n = 1324) and 1.03 (95% CI 0.99–1.08, n = 638). No difference was found in 2-, 3- and 5-year disease-free survival: RR 1.01 (95% CI 0.95–1.05, n = 1175), 0.99 (95% CI 0.94–1.03, n = 1130) and 1.00 (95% CI 0.95–1.06, n = 933) respectively. Post-operative time to micturition was significantly shorter in the NSRH group: standardized mean difference (SMD) −0.84 (CI 95% −1.07 to −0.60).
NSRH can be considered safe and effective for early-stage cervical cancer since short- and long-term survival do not differ from those of conventional RH, while bladder function after NSRH is significantly less impaired.
Short and long-term urodynamic and quality of life assessment after nerve sparing radical hysterectomy: A prospective pilot study
2016, European Journal of Obstetrics and Gynecology and Reproductive Biology
The aim of this study was to compare pre- and postoperative bladder function and quality of life (QoL) in women diagnosed with gynecologic malignancy and treated with nerve sparing radical hysterectomy (NSRH).
Before and after NSRH for uterine malignancy, bladder function was prospectively assessed in a small cohort of 12 women (39–72 years) suffering from uterine malignancy using urodynamic studies and a validated self-administered condition specific QoL questionnaire. Urodynamic studies were performed one day before (U0) as well as one week (U1) and 22 months (U2) after surgery. The questionnaire was applied at U0 and U2.
Cystometry showed detrusor contractions leading to overactive bladder incontinence in six out of nine women at short-term, which persisted in three women at long-term follow-up leading to a significant impaired QoL. Voiding function and bladder sensation remained uncompromised after surgery.
NSRH preserves voiding function and bladder sensation. However, short and long-term urodynamic detrusor overactivity and urge incontinence was observed in a significant number of women although symptoms improved over time. These data are important for counselling women and for the design of larger studies to assess the benefits of NSRH versus conventional radical hysterectomy (RH).
Anatomical consideration for the technique of nerve-sparing during radical hysterectomy for cervical cancer
2016, Gynecologie Obstetrique et Fertilite
L’hystérectomie radicale est le traitement de référence des cancers du col utérin aux stades précoces IA2 à IIA1 mais s’accompagne d’une morbidité non négligeable sur le plan urinaire, digestif et sexuel liée à une lésion des fibres nerveuses à destinée viscérale. L’innervation pelvienne est constituée de fibres sympathiques (plexus hypogastrique supérieur [PHS], nerfs hypogastriques [NH], nerfs sacrés splanchniques [NSS]) et parasympathiques (nerfs splanchniques pelviens [NSP]) qui se rejoignent au niveau du plexus hypogastrique inférieur (PHI). Nous décrivons les repères anatomiques permettant d’identifier les nerfs au cours de l’hystérectomie radicale pour cancer du col utérin. Le PHS peut être lésé pendant le curage lombo-aortique et sa préservation impose un abord sur le bord droit de l’aorte et une dissection minutieuse du promontoire. Les lésions des NH surviennent au cours de la résection des ligaments utéro-sacrés et/ou du fascia rectovaginal et, après division du ligament utéro-sacré, seule la partie médiale fibreuse devrait être réséquée. La dissection et la résection du paracervix sont à risque de lésions des NSP et le PHI et leurs préservations nécessitent, d’une part, une attention particulière aux repères anatomiques tels que l’artère rectale moyenne, la veine utérine profonde et l’uretère, et d’autre part, une section sélective des fibres utérines nerveuses. Les branches vésicales peuvent être préservées par une dissection minutieuse du feuillet postérieur du ligament vésico-utérin. Dans la majorité des cas, la préservation nerveuse lors d’une hystérectomie radicale pour cancer du col utérin peut être réalisée sans pour autant compromettre la radicalité de la chirurgie sur le plan carcinologique.
Radical hysterectomy (RH) is an effective treatment for early-stage cervical cancer IA2 to IIA1 but RH is often associated with several significant complications such as urinary, anorectal and sexual dysfunction due to pelvic nerve injuries. Pelvic autonomic nerves including the superior hypogastric plexus (SHP), hypogastric nerves (HN), pelvic splanchnic nerves (PSN), sacral splanchnic nerves (SSN), inferior hypogastric plexus (IHP) and efferent branches of the IHP. We aimed to precise the neuroanatomy of the female pelvis in order to provide key-points of surgical anatomy to improve NSRH for cervical cancer. The SHP could be injured during periaortic lymph node dissection and its preservation necessitates an approach on the right side of the aorta and a blunt dissection of the promontory before lomboaortic lymphadenectomy. Injuries to HN can occur during the resection of USL at the posterior pelvic wall and of rectovaginal ligaments and to preserve HN only the medial fibrous part of the uterosacral ligament should be resected. The middle rectal artery, the deep uterine vein and the ureter should be identified to preserve PSN and IHP during resection of paracervix. Vesical branches can be preserved by blunt dissection of the posterior layer of the vesicouterine ligament after identifying the inferior vesical vein. In most of cases, NSRH for cervical cancer can be performed. Anatomical landmarks as middle rectal artery, deep uterine vein, inferior vesical vein and ureter and the respect of nervous part of uterine ligament and of parametrium provide to surgeon a safe preservation of pelvic innervation without compromising oncological outcomes.

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^☆: From the Departments of Obstetrics and Gynecology,^a Anatomy,^b and Radiology,^c University of Mainz.

^☆☆: Supported by a grant from Else Kröner-Fresenius-Stiftung to M.H.

^★: Reprint requests: Michael Höckel, MD, PhD, University of Mainz Medical School, Langenbeckstraße 1, 55101 Mainz, Germany

^★★: 6/1/87330

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Liposuction-assisted nerve-sparing extended radical hysterectomy: Oncologic rationale, surgical anatomy, and feasibility study☆,☆☆,★,★★

Abstract

Section snippets

MRI

MRI studies

Comment

Baillieres Clin Obstet Gynaecol

Am J Obstet Gynecol

Baillieres Clin Obstet Gynaecol

Am J Obstet Gynecol

Gynecol Oncol

Eur J Obstet Gynecol Reprod Biol

Gynecol Oncol

The extended abdominal operation for carcinoma uteri (based on 500 operative cases)

Am J Obstet Dis Women Child

Radical abdominal hysterectomy for cancer of the cervix uteri

Surg Gynecol Obstet

Carcinoma of the cervix: the Wertheim operation

Surg Gynecol Obstet

Results of surgical treatment of 1028 cervical cancers studied with volumetry

Cancer