Nerve-sparing radical hysterectomy for cervical carcinoma
Introduction
Carcinoma of the cervix is the second most common cancer among women and is one of the leading causes of cancer-related deaths in females, both in developed and developing countries. Approximately 493,000 cases, with a total of 274,000 deaths, occur annually. Almost 85% of the cases occur in undeveloped countries, accounting for 15% of all cancers in women. In well-developed countries, it accounts for 3.6% of new cancers, with an incidence of 14 cases per 100,000 women. It is estimated that 9710 new cases of invasive cervical cancer and approximately 3700 cervical cancer-related deaths will occur in the US in 2006 [1], [2], [3], [4], [5].
The classical surgical management of early-stage cervical carcinoma includes the extirpation of the uterus and cervix, along with radical resection of the parametrial tissues and upper vagina, together with complete bilateral pelvic lymphadenectomy. This surgical approach, known as radical hysterectomy (RH), was first described and systematically performed by Wertheim [6] more than 100 years ago, and was then modified by Okabayashi in 1921 [29] and re-popularized by Meigs [7] in the 1950’s. This operation yields 5-year survival rates of 75–90%. The surgical principles of this operation have undergone only minor modification throughout the years and it remains the basis for the surgical approach utilized by gynecologic oncologists today [6], [7], [8]. On the other hand, it is well known that radiotherapy (RT) irreversibly destroys reproductive capacity and negatively affects the ability to have sexual intercourse in young women. Therefore, despite the comparable efficacy rate of RT and RH, RH is the preferred treatment option for the treatment of early-stage cervical carcinoma in young women because of the possibility of preserving the ovaries and vaginal integrity.
With the concept of the improvement of quality of life in the field of surgical oncology, recent studies have questioned the efficacy and safety of RH due to a high rate of long-term postoperative complications involving the pelvic autonomic nerve system. As is known, the female pelvic organs, including the bladder, urethra, rectum, and vagina, are closely related to quality of life. Normal functioning of these pelvic organs depends on autonomic nerves, which arise from the thoracal and sacral nerve plexus. These autonomic nerves have important functions for sexual arousal, orgasm, urinary functions, and anorectal mobility. Although these autonomic nerves of the pelvic organs and their origins are well described in anatomy textbooks, these structures are rarely visualized in operating rooms during surgery and, unfortunately, basic anatomic landmarks are not commonly used by surgical oncologists until the recent publications of Fujii et al. [29], [34], [49].
Although RH is an effective approach for the management of early-stage cervical carcinoma, some recent studies demonstrated that it frequently causes bladder dysfunction, anorectal mobility disorders, and sexual dissatisfaction in cervical cancer survivors. These complications are believed to be the result of surgical trauma involving the sympathetic and parasympathetic branches of the autonomous innervation of the pelvic organs [9], [10], [11], [12]. Injuries to the autonomic pelvic nerves can be encountered during the different phases of RH, as described below:
- •
Superior hypogastric plexus during pre-sacral and periaortic lymph node dissection.
- •
Hypogastric nerves during the resection of the uterosacral ligaments.
- •
Pelvic splanchnic nerve during the division of the deep uterine vein in the cardinal ligament.
- •
Inferior hypogastric plexus during division of the uterosacral and rectovaginal ligaments.
- •
Bladder branch from the inferior hypogastric plexus during resection of the vesicovaginal ligaments and the paracolpium (Fig. 1, Fig. 2).
Therefore, some investigators have focused on preserving the pelvic nerves to prevent surgery-related nerve damage in order to prevent pelvic organ dysfunction and to obtain a better quality of life in cervical cancer survivors. It has been suggested that there might be two main approaches for reducing postoperative surgery-related pelvic nerve damage in patients that undergo RH for cervical carcinoma:
- 1.
Less radical surgery by reducing the extent of the resected parametrial tissues.
- 2.
Preserving the nerves without reducing the radicality of surgery.
The benefits of less radical surgery for cervical carcinoma, in terms of postoperative long-term pelvic organ dysfunction, have been demonstrated by Landoni et al. in a randomized prospective study. They demonstrated the similar oncological outcomes with type II RH and type III RH, with a lower incidence of long-term pelvic organ dysfunction. The reason for the decrease in long-term pelvic complications with a less radical approach is related to the protection of the pelvic nerves [21]. On the other hand, some investigators have proposed that preserving the pelvic autonomic nerves with nerve-sparing surgical techniques may reduce the incidence of long-term complications following RH, without reducing the radicality of the operation. However, there is no randomized study on this subject to compare to those on less radical surgery [12], [14].
Herein, some technical details and oncological outcomes of nerve-sparing RH are summarized together with a brief overview of pelvic organ dysfunction following RH and a historical perspective.
Section snippets
Search strategy and selection criteria
Data for this review were identified by searches of PubMed, and references from relevant articles using the search terms “nerve sparing hysterectomy” and “Okabayashi radical hysterectomy”, “cervical carcinoma”, “bladder dysfunction”, “anorectal dysfunction”, and “sexual dysfunction”. Abstracts and reports from meetings were included only when they related directly to previously published work.
Bladder dysfunctions
The close proximity of the bladder to the uterus and cervix inevitably results in the disruption of its anatomic support, autonomic innervation, and blood supply during RH, and these surgical traumas may cause irreversible functional changes to the urinary tract [13]. A systematic review of the literature reported that even simple hysterectomy is related to increased risk of urinary tract dysfunction. The authors found that the risk of developing urinary incontinence after hysterectomy was
History of nerve-sparing radical hysterectomy
Historically, the pioneer of nerve-sparing pelvic surgery concept was the Japanese gynecologist, Okabayashi. In the 1921, he described the principles of his systemic RH technique (in English) in order to improve the outcomes of RH by Wertheim method while working at Kyoto Imperial University [50]. In 1944, he already proclaimed that preservation of the pelvic nerves would become an important part of the RH for the optimization of the RH outcomes (in Japanese) [51]. Subsequently, Kobayashi
Technical details and oncological outcomes of nerve-sparing hysterectomy
In Japan, Hidekazu Okabayashi modified Wertheim method in 1921 [29], [50]. Okabayashi’s surgical technique was characterized by the extensive resection of the parametriums and the separation of the posterior leaf of the vesicouterine ligament. This essential step enabled the bladder to be separated from the ureter, completely away from the lateral side of the cervix and vagina [50], [51]. His surgical technique was widely performed in Japan; however, it did not become a popular approach in the
Reviewer
Prof. Shingo Fujii, Postgraduate School of Medicine, Department of Gynecology and Obstetrics, Kyoto University, Sakyoku, Kyoto, Japan.
Acknowledgements
I would like to thank the Turkish Scientific Research Council & Turkish-German Gynecology Association (TUBITAK-TAJD), European Society of Surgical Oncology (ESSO), European School of Oncology (ESO), and FIGO/IGCS Gynecologic Oncology Fellowship, which designated me (Polat Dursun) as a Clinical Gynecologic Oncology Fellow. I am also very appreciative of their financial and motivational support. Additionally, I would like to thank my hosts (Professor Dr. A. Schneider, Professor Dr. M. Höckel, and
Polat Dursun is an Obstetrics and Gynecology specialist in the Department of Obstetrics and Gynecology at Baskent University School of Medicine in Ankara, Turkey. He received his M.D. in 2000 at the Cukurova University and then joined the Hacettepe University School of Medicine in Ankara to complete his training at the Department of Obstetrics and Gynecology. After completion of the his training in 2005, he visited the some pioneers of gynecologic oncologic surgery in Germany and France in
References (57)
- et al.
Radical vaginal trachelectomy (Dargent’s operation): a critical review of the literature
Eur J Surg Oncol
(2007) - et al.
Nerve sparing radical hysterectomy: latest developments and historical perspective
Crit Rev Oncol Hematol
(2003) - et al.
Vesical dysfunctions after radical hysterectomy for cervical cancer: a critical review
Crit Rev Oncol Hematol
(2003) - et al.
Class II versus class III radical hysterectomy in stage IB-IIA cervical cancer: a prospective randomized study
Gynecol Oncol
(2001) - et al.
Association between the mesenchymal compartment of uterovaginal organogenesis and local tumour spread in stage IB–IIB cervical carcinoma: a prospective study
Lancet Oncol
(2005) - et al.
Hysterectomy and urinary incontinence: a systematic review
Lancet
(2000) - et al.
Urinary tract dysfunction after radical hysterectomy for cervical cancer
Gynecol Oncol
(2002) - et al.
Anorectal dysfunction after surgical treatment for cervical cancer
J Am Coll Surg
(2002) - et al.
Manometric characterisation of rectal dysfunction following radical hysterectomy
Gynecol Oncol
(1991) - et al.
An improved radical hysterectomy with fewer urological complications and with no loss of therapeutic results for cervical cancer
Ballieres Clin Obstet Gynecol
(1988)
Liposuction-assisted nerve-sparing extended radical hysterectomy: oncologic rationale, surgical anatomy, and feasibility study
Am J Obstet Gynecol
Identification and preservation of the motoric innervation of the bladder in radical hysterectomy type III
Gynecol Oncol
Tsukasa Baba precise anatomy of the vesico-uterine ligament for radical hysterectomy
Gynecol Oncol
Dissection of the cardinal ligament in radical hysterectomy for cervical cancer with emphasis on the lateral ligament
Am J Obstet Gynecol
A new proposal for radical hysterectomy
Gynecol Oncol
Radical hysterectomy: an anatomic evaluation of parametrial dissection
Gynecol Oncol
Nerve-sparing radical hysterectomy: a surgical technique for preserving the autonomic hypogastric nerve
Gynecol Oncol
Type II versus Type III nerve-sparing radical hysterectomy: comparison of lower urinary tract dysfunctions
Gynecol Oncol
The LANN technique to reduce postoperative functional morbidity in laparoscopic radical pelvic surgery
J Am Coll Surg
Anatomic identification and functional outcomes of the nerve sparing Okabayashi radical hysterectomy
Gynecol Oncol
Bladder dysfunction after radical abdominal hysterectomy
Am J Obstet Gynecol
Lower urinary tract dysfunction after radical hysterectomy for carcinoma of cervix
Urology
Global cancer statistics, 2002
CA Cancer J Clin
Advances in the surgical management of invasive cervical cancer
Curr Opin Obstet Gynecol
Cancer facts and figures 2006
The extended abdominal operation for carcinoma uteri (based on 500 operative cases)
Am J Obstet Dis Women Child
Radical hysterectomy with bilateral pelvic lymph node dissections. A report of 100 patients operated on five or more years ago
Am J Obstet Gynecol
Cited by (35)
Invasive cervical cancer
2023, DiSaia and Creasman Clinical Gynecologic OncologyThe Pelvic Splanchnic Nerves
2020, Surgical Anatomy of the Sacral Plexus and its BranchesInvasive cervical cancer
2018, Clinical Gynecologic OncologyPosterior pelvic exenteration and retrograde total hysterectomy in patients with locally advanced ovarian cancer: Clinical and functional outcome
2016, Taiwanese Journal of Obstetrics and GynecologyAnatomical consideration for the technique of nerve-sparing during radical hysterectomy for cervical cancer
2016, Gynecologie Obstetrique et FertiliteBladder function after modified posterior exenteration for primary gynecological cancer
2013, Gynecologic OncologyCitation Excerpt :In gynecological tumors involving the outer layer of the rectosigmoid treated with modified posterior exenteration, the surgeon would be often required to make the excision on a more radical plane than that in TME. In the gynecological literature, the incidence of postoperative bladder dysfunction has been reported to occur in 70–85% of patients in whom conventional radical hysterectomy was performed [12]. Therefore the importance of preservation of the autonomic nerve function has recently been stressed in radical hysterectomy studies [7–12].
Polat Dursun is an Obstetrics and Gynecology specialist in the Department of Obstetrics and Gynecology at Baskent University School of Medicine in Ankara, Turkey. He received his M.D. in 2000 at the Cukurova University and then joined the Hacettepe University School of Medicine in Ankara to complete his training at the Department of Obstetrics and Gynecology. After completion of the his training in 2005, he visited the some pioneers of gynecologic oncologic surgery in Germany and France in order to learn the principles of the new surgical operations for the management of gynecologic cancers. During this 1-year period, he had learned the principles of laparoscopic oncologic operations, nerve-sparing hysterectomy, radical vaginal surgery, radical vaginal trachelectomy and vulvo-vaginal flap techniques. During his visits, he was awarded by Turkish Scientific Research Council & Turkish-German Gynecology Association (TUBITAK-TAJD), European Society of Surgical Oncology (ESSO), European School of Oncology (ESO), and FIGO/IGCS Gynecologic Oncology Fellowship, and European Association of Cancer Research. His main focus is on surgical management of gynecologic malignancies. Now, he is working with Prof. Dr. Ali Ayhan the best-known gynecologist and oncologist of Turkey.