Laparoscopic Nerve-Sparing
Radical Hysterectomy
Prof.Dr.Metin Çapar
Karatay University Faculty of Medicine
OBS&GYNECOLOGY Konya /TURKEY
Superior hypogastric plexus(SHP)
 It begins at the aortal bifurcation and
continues through the presacral area to the
pelvis.
 It contains mostly sympathetic nerves from
T12-L2 segments of the spinal cord),
 It also contains some fibres from L1-2
splanchnic nerves.
 It caudally and laterally leads to the right and
left hypogastric nerves.
• hypogastric nerve is a term for the transition between
the superior hypogastric plexus and the inferior
hypogastric plexus. The hypogastric nerve enters the
sympathetic chain at T10-L2.
Inferior hypogastric(IHP)
The inferior hypogastric plexus(IHP) is a
condensation of nerve elements, fibres,
and ganglia. It is composed of sympathetic
fibres from hypogastric nerve and
parasympathetic nerves from pelvic
splanchnic nerve
Anatomy of pelvic organ innervation
• The inferior hypogastric plexus is a paired structure, with each
situated on the side of the rectum in the male, and at the sides of the
rectum and vagina in the female.
• The Uterovaginal plexus is a division of the inferior hypogastric plexus. In older
texts, it is referred to as two structures, the "vaginal plexus" and "uterine
plexus".
• The Vaginal Plexus arises from the lower part of the pelvic plexus. It is distributed
to the walls of the vagina, to the erectile tissue of the vestibule, and to the
clitoris. The nerves composing this plexus contain, like the vesical, a large
proportion of spinal nerve fibers.
• The Uterine Plexus accompanies the uterine artery to the side of the uterus,
between the layers of the broad ligament; it communicates with the ovarian
plexus.
• The uterine supporting ligaments contain autonomic nerves
and ganglia, as extensions of the inferior hypogastric plexus.
The USLs have a greater nerve density than the CLs. Because
RH disrupts more nerve tissue than a simple hysterectomy,
these data provide further evidence for the neurogenic
etiology of pelvic morbidity after RH.
Cancer. 2000 Aug 15;89 (4):834-41 10951347 Cit:50
Pelvic nerve plexus trauma at radical hysterectomy and simple hysterectomy: the nerve content of the uterine supporting ligaments.
S A Butler-Manuel, L D Buttery, R P A'Hern, J M Polak, D P Barton
• Radical hysterectomy with pelvic lymphadenectomy is considered to
be the cornerstone in the treatment of early-stage cervical cancer.
Although survival in early-stage cervical cancer is up to 95%, long-term
morbidity with regard to bladder, bowel, and sexual function is
considerable. Damage to the pelvic autonomic nerves may be the
cause of these long-term complications following radical
hysterectomy.
• Some authors have presented surgical techniques to preserve the
autonomic nerves (ie, the hypogastric nerves and the splanchnic
nerves) without compromising radicality. Safety, efficacy, and the
surgical techniques of nerve-sparing radical hysterectomy are
presented, and data confirm that whenever the decision is made to
perform a radical hysterectomy, nerve-sparing techniques should be
considered.
Int J Gynecol Cancer. 2010 Oct ;20 (11 Suppl 2):S39-41 20975361
Nerve sparing in radical surgery for early-stage cervical cancer: yes we should!
Cornelis D de Kroon, Katja N Gaarenstroom, Mariette I E van Poelgeest, Alexander A Peters, J Baptist Trimbos
Deep uterine vein(DUV)
It collect blood from uterine and
bladder and connect to internal iliac
vein, Just beyond the PSN
Uterin branch
Pelvic splanic nerve
Pelvic splanic nerve
IHP
Pararectal space
IHP and parametrium
IHP and parametrium is in the middle of
the three space
Paravaginal space
The paravaginal space is locate in the
angle formed by bladder branch and
uterine branch of nerve. This space
also locate between bladder and
vagina.
• The exact incidence of lower urinary tract dysfunction is not known
• its pathogenesis is not completely understood. Advances in urodynamic
assessment and widespread availability of a standardized technique have
facilitated its exploration prior to and subsequent to the surgical management of
patients with gynecologic pelvic cancer.
Aoun F1, Peltier A1, van Velthoven R1.
Adv Urol. 2014;2014:303958. doi: 10.1155/2014/303958. Epub 2014 Nov 23
Paravesical space
Paravaginal space
ureter
Pararectal space
[Feasibility of unilateral or bilateral nerve-sparing radical hysterectomy in patients with cervical cancer and
evaluation of the post-surgery recovery of the bladder and rectal function].
[Article in Chinese]
There were no significant differences between nerve-sparing radical hysterectomy (NSRH) and radical
hysterectomy (RH) groups in
1-operation time [NSRH: (224.5 ± 40.0) min, RH: (176.4 ± 30.0 min)],
2- blood loss [NSRH: (464.3 ± 144.0) ml, RH: (374.2 ± 138.7) ml],
3-postoperative hospital stay days [NSRH: (8.4 ± 2.0) d, RH: (9.2 ± 1.8) d, and
4-residual urine volume [NSRH: (64.8 ± 16.9) ml, RH: (70.6 ± 16.0) ml].
There were also no significant differences between UNSRH and BNSRH groups in
1-operation time [UNSRH: (208.5 ± 28.5) min, BNSRH: (233.3 ± 43.1) min],
2-blood loss [UNSRH: (440.0 ± 104.9) ml, BNSRH: (477.8 ± 162.90) ml],
3-postoperative hospital stay days [UNSRH: 9.1 ± 1.8) d, BNSRH: (8.7 ± 2.1 d], and
4-the residual urine volume [UNSRH: (68.3 ± 12.5) ml, BNSRH: (62.8 ± 20.0) ml].
There was a significant difference in the time of the Foley catheter removal between NSRH [(12.4 ± 5.2) d] and
RH [(22.4 ± 9.7) d] groups.
There was a significant difference in the time of the Foley catheter removal between UNSRH [(18.2 ± 3.6) d]
and BNSRH [(9.1 ± 2.0) d] groups.
During the postoperative 3 weeks follow-up, the patients in the NSRH group had a higher rate of satisfaction at
urination and defecation (100%, 75%) than the RH group (54.5%, 24.2%).
CONCLUSION:
UNSRH and BNSRH are safe and feasible techniques for early stage cervical
cancer, and may significantly improve the recovery of bladder
and
rectal function.
Zhu T1, Yu AJ, Shou HF, Chen X, Zhu JQ, Yang ZY, Zhang P, Gao YL.
Author information
Zhonghua Zhong Liu Za Zhi. 2011 Jan;33(1):53-7.
UNSRH and BNSRH are safe and
feasible techniques for early stage
cervical cancer, and may
significantly improve the recovery of
bladder and rectal function.
Sexual Function Impaired Less With Nervesparing Surgery in Cervical Cancer
Nerve-sparing (NS) laparoscopic radical hysterectomy (LRH) impairs sexual function less than conventional LRH
incervical cancer patients, according to a
study published in the Journal of Sexual Medicine.
Giorgio Bogani, MD, from the University of Insubria in Varese, Italy, and colleagues evaluated sexually active
cervical cancer patients undergoing Type C (class III) LRH (2004 to 2013). The authors sought to determine the
impact of NS procedures on preoperative versus postoperative sexual function.
Specific postoperative domain scores showed that
desire,
arousal,
orgasm and
pain scores were similar between groups (P>0.05), while patients undergoing
NS-LRH experienced higher
lubrication (3.4 vs. 1.7; P=0.02) and
satisfaction (4.6 vs. 2.8; P=0.004) scores,
compared to patients undergoing conventional LRH.
Survival outcomes were similar between the groups.
"The NS approach impairs sexual function less, minimizing the effects of radical surgery," the researchers wrote.
Reference
1.Bogani G et al. J Sex Med. 2014;doi:10.1111/jsm.12702.
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