An improved nerve-sparing radical hysterectomy technique for cervical cancer using the paravesico-vaginal space as a new surgical landmark

Yuqin Zhang, Tingyan Shi, Sheng Yin, Sining Ma, Di Shi, Jun Guan, Libing Xiang, Yang Liu, Yulan Ren, Deyan Tan, Rongyu Zang, Yuqin Zhang, Tingyan Shi, Sheng Yin, Sining Ma, Di Shi, Jun Guan, Libing Xiang, Yang Liu, Yulan Ren, Deyan Tan, Rongyu Zang

Abstract

Bladder dysfunction remains a major postoperative challenge for early stage cervical cancer patients. The present prospective phase 2 trial in patients with stage IB1 and IIA1 cervical cancer follows up on our previous, unpublished work describing a new surgical landmark, the paravesico-vaginal space. We describe a novel nerve-sparing radical hysterectomy (NSRH) approach to treat early stage cervical cancer without compromising local control rate or survival. Between September 2015 and August 2016, 49 patients were enrolled to receive NSRH. The bladder catheter was routinely removed on postoperative day 4. The primary endpoints were rate of postvoid residual urine volume (PVR) ≤ 50 ml and proportion of patients with successful catheter removal (ClinicalTrials.gov Identifier: NCT02562729). Anatomically, from ventral to dorsal, the terminal ureter, deep uterine vein, and cardinal ligament were the three markers of the paravesico-vaginal space. The median operative time was 100 min, and the median blood loss was 200 ml. Thirty-four patients (69.4%) had successful catheter removal on postoperative day 4, and 17 patients (34.7%) had a PVR ≤ 50 ml. Our results suggest that by accessing the paravesico-vaginal space landmark, the bladder branch of the inferior hypogastric plexus can be completely preserved, contributing to greater NSRH efficiency without compromising outcomes for patients with early stage cervical cancer.

Keywords: cervical cancer; deep uterine vein; nerve-sparing radical hysterectomy; paravesico-vaginal space; terminal ureter.

Conflict of interest statement

CONFLICTS OF INTEREST The authors declare no conflicts of interest.

Figures

Figure 1. Anatomic relationship between the paravesico-vaginal…
Figure 1. Anatomic relationship between the paravesico-vaginal space and the deep uterine vein
(A) right, anatomical view of fresh cadavers; (B) right, ventral and cranial operative view (level one); (C) left lateral, ventral, and cranial operative view (level two); (D) left, operative view of the pear-shaped paravesico-vaginal space and the cardinal ligament (level three). Abbreviations: IHP, inferior hypogastric plexus; R, right; L, left.

References

    1. Wertheim E. A discussion on the diagnosis and treatment of cancer of the uterus. Brit Med J. 1905;2:689–704.
    1. Wertheim E. The extended abdominal operation for carcinoma uteri (based on 500 operative cases) Am J Obstet Dis Women Child. 1912;66:169–232.
    1. Okabayashi H. Radical abdominal hysterectomy for cancer of the cervix uteri. Surg Gynecol Obstet. 1921;33:335–41.
    1. Meigs JV. Carcinoma of the cervix—the Wertheim operation. Surg Gynecol Obstet. 1944;78:195–98.
    1. Piver MS, Rutledge F, Smith JP. Five classes of extended hysterectomy for women with cervical cancer. Obstet Gynecol. 1974;44:265–72.
    1. Yabuki Y, Asamoto A, Hoshiba T, Nishimoto H, Kitamura S. Dissection of the cardinal ligament in radical hysterectomy for cervical cancer with emphasis on the lateral ligament. Am J obstet Gynecol. 1991;164:7–14.
    1. Yabuki Y, Asamoto A, Hoshiba T, Nishimoto H, Nishikawa Y, Nakajima T. Radical Hysterectomy: An Anatomic Evaluation of Parametrial Dissection. Gynecol Oncol. 2000;77:155–63.
    1. Forney JP. The effect of radical hysterectomy on bladder physiology. Am J Obstet Gynecol. 1980;138:374–82.
    1. Asmussen M, Heintz APM, Criffiths CT, Trimbos JB. Urodynamics after radical surgery for carcinoma of uterine cervix. Surgery in Gynecol Oncol. 1984;16:143–164.
    1. Wit EM, Horenblas S. Urological complications after treatment of cervical cancer. Nat Rev Urol. 2014;11:110–7.
    1. Kobayashi T. Abdominal radical hysterectomy with pelvic lymphadenectomy for cancer of the cervix. Tokyo: Nanzando. 1961:178–87.
    1. Kato T, Murakami G, Yabuki Y. A new perspective on nerve-sparing radical hysterectomy: nerve topography and over-preservation of the cardinal ligament. Jpn J Clin Oncol. 2003;33:589–91.
    1. Rob L, Halaska M, Robova H. Nerve-sparing and individually tailored surgery for cervical cancer. Lancet Oncol. 2010;11:292–301.
    1. Kim HS, Kim TH, Suh DH, Kim SY, Kim MA, Jeong CW, Hong KS, Song YS. Success Factors of Laparoscopic Nerve-sparing Radical Hysterectomy for Preserving Bladder Function in Patients with Cervical Cancer: A Protocol-Based Prospective Cohort Study. Ann Surg Oncol. 2015;22:1987–1995.
    1. Zang RY. Modalities of pelvic autonomic nerve-sparing surgery in pelvic malignancies. [Article in Chinese] China Oncol. 2006;16:907–10.
    1. Zang RY, Chen X, Tang J, Yang HJ. Preliminary study of pelvic autonomic nerve-sparing sub-radical/radical hysterectomy on preserving postsurgical bladder function in patients with cervix and endometrioid cancer. [Article in Chinese] Prog Obstet Gynecol. 2006;15:773–5.
    1. Fujii S, Takakura K, Matsumura N, Higuchi T, Yura S, Mandai M, Baba T, Yoshioka S. Anatomic identification and functional outcomes of the nerve sparing Okabayashi radical hysterectomy. Gynecol Oncol. 2007;107:4–13.
    1. Fujii S. Anatomic identification of nerve-sparing radical hysterectomy: a step-by-step procedure. Gynecol Oncol. 2008;111:S33–41.
    1. Querleu D, Morrow CP. Classification of radical hysterectomy. Lancet Oncol. 2008;9:297–303.
    1. Charoenkwan K. A simplified technique for nerve-sparing type III radical hysterectomy: by reorganizing their surgical sequence, surgeons could more easily identify key nerves. Am J Obstet Gynecol. 2010;203:1–6.
    1. Obesity: preventing and managing the global epidemic Report of a WHO consultation. World Health Organ Techn Rep Ser. 2000;894:i–xii. 1–253.
    1. Liang Z, Chen Y, Xu H, Li Y, Wang D. Laparoscopic nerve-sparing radical hysterectomy with fascia space dissection technique for cervical cancer: description of technique and outcomes. Gynecol Oncol. 2010;119:202–7.
    1. Kavallaris A, Hornemann A, Chalvatzas N, Luedders D, Diedrich K, Bohlmann MK. Laparoscopic nerve-sparing radical hysterectomy: description of the technique and patients' outcome. Gynecol Oncol. 2010;119:198–201.
    1. Raspagliesi F, Ditto A, Fontanelli R, Solima E, Hanozet F, Zanaboni F, Kusamura S. Nerve-sparing radical hysterectomy: a surgical technique for preserving the autonomic hypogastric nerve. Gynecol Oncol. 2004;93:307–14.
    1. Kato K, Suzuka K, Osaki T, Tanaka N. Unilateral or bilateral nerve-sparing radical hysterectomy: a surgical technique to preserve the pelvic autonomic nerves while increasing radicality. Int J Gynecol Cancer. 2007;17:1172–8.
    1. Charoenkwan K, Srisomboon J, Suprasert P, Tantipalakorn C, Kietpeerakool C. Nerve-sparing class III radical hysterectomy: a modified technique to spare the pelvic autonomic nerves without compromising radicality. Int J Gynecol Cancer. 2006;16:1705–12.

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