Nerve-Sparing Surgery in Cervical Carcinoma

Transcription

1 Nerve-Sparing Surgery in Cervical Carcinoma 106 Shingo Fujii, MD, PhD Introduction The 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 developed as Wertheim method (1911) in Western countries and Okabayashi method (1921) in Japan and in East Asia (1). Both types of RH had been often associated with severe bladder dysfunction and colorectal motility disorders such as a loss of sensation of bladder fullness and micturition, and disability to void urine, or severe constipation (1). These complications are believed to be the result of surgical trauma involving the sympathetic and parasympathetic branches of the pelvic nerves. Injuries to these nerves can be encountered during different phases of RH. The uterus, vagina, urinary bladder and rectum are innervated by a motor and sensory autonomic nerve supply, both of sympathetic and parasympathetic origin. The sympathetic fibers come from T11-L2 which form the superior hypogastric plexus. The parasympathetic fibers come from S2, 3 and 4 at the pelvic wall as the pelvic splanchnic nerve. These fibers merge and form the inferior hypogastric plexus which branch to innervate the uterus and the urinary bladder. It has been reported that during RH the hypogastric nerve is often sacrificed when a) the surgeon divides the uterosacral ligament and rectovaginal ligament, b) the pelvic splanchnic nerve when the surgeon divides the deep uterine vein in the cardinal ligament, and c) the bladder branch of the inferior hypogastric plexus when the surgeon ligates and divides the paracolpium (2). Therefore, some investigators propose to perform less radical surgery that can reduce the injuries to these nerves than the classical RH. However, in order to minimize these dysfunctions Japanese doctors have started to preserve pelvic nerves innervating to the urinary bladder and the rectum during RH around the period of 1950 (1). The concept of nerve-sparing RH is very simple. Theoretically if we can reveal the inferior hypogastric plexus and can isolate the uterine branch from the inferior hypogastric plexus, we can divide only the uterine branch from the inferior hypogastric plexus. By this procedure, we can preserve the hypogastric nerve, the pelvic splanchnic nerve and the bladder branch from the inferior hypogastric plexus (2). However, until recently, nobody showed the exact anatomy of the cross-shaped inferior hypogastric plexus that is constructed by hypogastric nerve, pelvic splanchnic nerve, uterine branch, and bladder branch (1). Using Okabayashi s method, by the separation of the posterior leaf of the vesicouterine ligament, we are now able to reveal the crossshaped inferior hypogastric plexus. Moreover, we can divide only the uterine branch from the inferior hypogastric plexus. Consequently, the outcomes of the urinary function after the division of an only uterine branch from the inferior hypogastric plexus are satisfactory (2). However, it looks difficult to reveal the inferior hypogastric plexus during surgeries if surgeon may approach using Wertheim s method that usually does not separate the posterior leaf of the vesicouterine ligament independently. Therefore, on nerve-sparing surgery there are many reported studies using different surgical methods. This implies that it is difficult to compare the reported urinary functions and surgical outcomes performed under different surgical extent of RH and nerve-sparing processes (2). This chapter describes the anatomy of the vesicouterine and the cross-shaped inferior hypogastric plexus (2,3), as well as the surgical steps how to reveal and how to cut an isolated uterine branch from the plexus (2,3). Oncological Safety As described the nerve-sparing RH separates and preserves medially one tissue layer (containing pelvic nerve plane) more than that of the classical RH (Figure 1) (2, 3). This is a concern on oncological safety compared to the classical RH. Up to the present moment reported oncological outcomes of nerve-sparing RH are not significantly different from those of classical RH (1). However, the indication of nerve-sparing RH is not recommended to the patients with FIGO IIB stage disease, because location of the inferior hypogastric plexus is very close to the foci of IIB lesion (2). In this case, some doctors recommend nerve-sparing RH to the side that is not invaded by cervical cancer. The result of unilateral nerve sparing RH is also satisfactory for the preservation of bladder function (1). However, it is necessary to perform a randomized study comparing the effectiveness, complications, and oncological outcomes of classical RH with nerve-sparing RH. In order to perform a randomized study, Dursun et al (1) described that the surgical steps of this concept should be clearly identified and disseminated to gynecologic oncologists to ensure reproducible results. The uniform reporting of precise surgical 635

2 636 u Nerve-Sparing Surgery in Cervical Carcinoma Figure 1. Cutting lines of classical and nerve sparing RH. steps is required for reproducible results and to compare the data between the studies. Anatomy Necessary for Nerve-Sparing RH The anatomy of the inferior hypogastric plexus encompassing the hypogastric nerve, the pelvic splanchnic nerve and the bladder branch/the uterine branch from this plexus is complicated and is not easy to appreciate during the surgery of RH. In order to detect the structure of the inferior hypogastric plexus, it is essential to have the knowledge of the anatomy of the parametrium (deep uterine vein) in order to preserve the pelvic splanchnic nerve (2,3). Moreover, the anatomy of the vesico-uterine ligament, particularly the posterior leaf of the vesico-uterine ligament (4) is very important. As well as it is necessary to have surgical skill to separate carefully these tissues in order to reveal the structure of the inferior hypogastric plexus. The anatomical structures of the vesico-uterine ligament (anterior/posterior) that we have revealed are shown in Figure 2A. In the anterior leaf of the vesico-uterine ligament (Figure 2B), we can appreciate 1) uterine artery, 2) superficial uterine vein, 3) ureter branch of the uterine artery, 4) superior vesical vein (draining into the superficial uterine vein, and 5) cervicovesical vessels. And we can separate and divide these blood vessels in the connective tissue of the anterior leaf (Figure 3AB, 4A). After these procedures, we can shift the ureter laterally (Figure 4B). In this situation, we can appreciate the posterior leaf of the vesicouterine ligament as shown in Figure Figure 2A,B. Vesicouterie ligaments (A) and blood vessels (1-5) in the anterior leaf of the vesicouterine ligament (B). Figure 3A,B. Step by step separation and division of the blood vessels in the connective tissue of the anterior leaf.

3 Nerve-Sparing Surgery in Cervical Carcinoma u 637 Figure 6A,B. Inferior hypogastric plexus (A) and isolation of uterine branch (B). Figure 4A,B. Cut ends of the vessels in the anterior leaf of the vesicouterine ligament (1-5) (A) and shifting the ureter laterally (B). 5A. In the posterior leaf of the vesicouterine ligament, we usually appreciate two major vesical veins that start from the urinary bladder and drain into the deep uterine vein (Figure 5B). Division of these veins reveals the inferior hypogastric plexus (Figure 6A). And we can isolate and divide only the uterine branch from the inferior hypogastric plexus (Figure 6B). Then we can separate and divide the paracolpium (vaginal blood vessels) preserving T-shaped nerve plane (Figure 7A). Confirming the length of the vaginal cuff, we can remove the uterus (Figure 7B). Wertheim method separates the anterior leaf of the vesicouterine ligament, but not intentionally separates the posterior leaf of the vesico-uterine ligament. In contrast, Okabayashi method identifies the deep uterine vein in the parametrium (2,3) and intentionally separates the posterior leaf of the Figure 5A,B. Posterior leaf of the vesico-uterine ligament (A) and two vesical veins (B). Figure 7A,B. Division of paracolpium preserving T-shaped nerve plane (A) and removal of ureters (B).

4 638 u Nerve-Sparing Surgery in Cervical Carcinoma Figure 8. Division of the uterine artery and isolation of deep uterine vein. Figure 11A,B. Confirmation of inferior hypogastric plexus and isolation of the uterine branch. Figure 9A,B. Separation of deep uterine vein from pelvic nerves (A) and isolation of hypogastric nerve (B). Figure 12A,B. Separation of blood vessels in the posterior leaf of vesico-uterine ligament. vesicouterine ligament (2,3,4). Therefore, it is easier for us to identify the inferior hypogastric plexus during the surgery of Okabayashi method. Step 7: Operative Procedure Only the operative steps that are necessary to identify the anatomy of the pelvic nerves are described. Step 1: Step 2: Step 3: Step 4: Step 5: Step 6: Isolation and separation of the deep uterine vein (Figure 8) from the pelvic splanchnic nerve (Figure 9A) Isolation and separation of the hypogastric nerve (Figure 9B) Separation of the connective tissue between the rectum and the vagina Division of the uterosacral ligament Separation of the cut end of the deep uterine vein from the pelvic splanchnic nerve Separation of blood vessels in the anterior leaf of the vesico-uterine ligament (Figure 10A,B). Figure 10A,B. Separation of blood vessels in the anterior leaf of the vesico-uterine ligament. Step 8: Separation of blood vessels in the posterior leaf of the vesico-uterine ligament (Figure 11AB) Identification of the bladder branch from the inferior hypogastric plexus (Figure 12A) 1. How to identify the bladder branch from the inferior hypogastric plexus: After removal of the fatty tissues residing between the dorsal portion of the urinary bladder and the rectal sidewall, if we trace the splanchnic nerve toward the inferior hypogastric plexus, we can appreciate definite nerve bundles running from the plexus to the bladder beneath the inferior vesical vein. The bladder branch from the inferior hypogastric plexus is running parallel with the blood vessels of the paracolpium. Step 9: Separation and division of the uterine branch from the inferior hypogastric plexus 1. Identification of the pelvic nerve plane: (Figure 12A) If we trace the hypogastric nerve toward the posterior-lateral wall of the uterus, we can appreciate the inferior hypogastric plexus formed by the hypogastric nerve, the splanchnic nerve, the bladder branch and the uterine branch from the inferior hypogastric plexus (Cross-shaped). These nerves reside in the same connective tissue plane that we call the pelvic nerve plane. 2. Isolation and division of the uterine branch from the inferior hypogastric plexus: (Figure 12B, 13A) On the same level of the hypogastric nerve, the bladder branch from the inferior hypogastric plexus can be separated from the blood vessels of the paracolpium. Then Pean s forceps is insinuated from the v-shaped depression created between

5 Nerve-Sparing Surgery in Cervical Carcinoma u Figure 13A,B. Division of uterine branch from the inferior hypogastric plexus, T-shaped nerve plane and rectovaginal ligament. the bladder branch and the blood vessels of the paracolpium into the connective tissue between the pelvic nerve plane and the cervix/upper vagina at the level a little bit ventral side of the hypogastric nerve and a little bit dorsal side of the cut end of the deep uterine vein. The uterine side of the pelvic nerve plane including the uterine branch from the inferior hypogastric plexus is clamped, divided, and ligated. When we cut the uterine branch of the pelvic nerves, there is a feeling resembling a stretched string breaking with a snap. 3. T-shaped nerve plane: (Figure 13A) After the division of the uterine branch, the hypogastric nerve, the pelvic splanchnic nerve and the bladder branch of the inferior hypogastric plexus forms the T-shaped nerve plane. Step 10: Division of the rectovaginal ligament 1. Isolation of the rectovaginal ligament: (Figure 13B) By pushing the rectum up, the rectovaginal ligament rises to the surface between the pelvic nerve plane and the rectum. 2. Division of the rectovaginal ligament: (Figure 14A) Only the rectovaginal ligament is divided using bipolar scissors toward the upper vagina excluding the T-shaped nerve plane). Step 11: Separation and division of the paracolpium 1. Division of the rectovaginal ligament separates the blood vessels of the paracolpium from the T-shaped nerve plane: (Figure 14B) If we divide the remaining rectovaginal ligament close to the upper vagina, the bladder branch from the inferior hypogastric plexus forming T-shaped nerve plane is gradually separated from the blood vessels of the paracolpium. Figure 15A,B. Division of blood vessels of paracolpium and preservation of T-shaped nerve plane. 2. Division of the blood vessels of the paracolpium: (Figure 15A) The separation can extend caudally to obtain vaginal length deemed appropriate by the level of cervical disease. At the designated level, the blood vessels of the paracolpium are clamped, cut and ligated. 3. Preservation of the T-shaped nerve plane: (Figure 15B) The T-shaped nerve plane formed by the hypogastric nerve, the pelvic splanchnic nerve and the bladder branch of the inferior hypogastric nerve is completely preserved. Step 12: Extirpation of the uterus Conclusion If the surgeon can perform separation of the posterior leaf of the vesicouterine ligament, and could trace the cross-shaped inferior hypogastric plexus, we can successfully divide only the uterine branch from the inferior hypogastric plexus. As aresult, patients can void urine completely with the sensation of bladder fullness and the sense of satisfaction at the time of micturition. References Figure 14A,B. Division of rectovaginal ligament which seperates blood vessels of the parametrium from the T-shaped nerve plane. 639 Dursun P, Ayhan A, Kuscu E. Nerve-sparing radical hysterectomy for cervical carcinoma. Crit Rev Oncol Hematol Jun;70(3): 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. 107 (2007), Fujii S. Anatomic identification of nerve-sparing radical hysterectomy: A step-by-step procedure. Gynecol Oncol 2008;111: S33-S41. Fujii S, Takakura K, Matsumura N, Higuchi T, Yura S, Mandai M, Baba T. Precise anatomy of the vesico-uterine ligament for radical hysterectomy. Gynecol Oncol. 2006; 104: