Magnifying lenses assisted nerve-sparing radical hysterectomy and prevention of nerve plexus trauma

Abstract

The objectives of the study were to present a new approach for nerve-sparing radical hysterectomy (NSRH) with the assistance of magnifying lenses and to describe the differences in autonomic nerve plexus trauma between NSRH type III and conventional radical hysterectomy (RH) types II and III with the aid of immunohistochemistry. Eighteen women with FIGO stage IB(1)-IB(2) cervical cancer underwent loupes-assisted NSRH (n = 8), RH type II (n = 6), and RH type III (n = 4). Biopsies were taken intraoperatively from uterosacral ligament (USL) and cardinal ligament (CL), as well as from anterior vaginal wall (AVW) and posterior vaginal wall (PVW). Immunohistochemistry was approached with the use of S-100 protein, a general nerve marker. The percentage area of immunoreactivity (PAI) was used as an objective quantitative measure of nerve fibers within the ligaments. The PAI was greater in RH-III biopsies from both USL and CL (P < 0.001) when compared with RH-II and NSRH biopsies. For AVW and PVW, PAI differences were not statistically significant (AVW, P = 0.119; PVW, P = 0.067). Uterine-supporting ligaments represent a major pathway for autonomic nerves to the pelvic organs. As significantly more autonomic nerves are transected during the division of the uterine-supporting ligaments in RH type III, a more careful approach in the dissection of the ligaments through nerve-preserving techniques seems to be necessary in order to prevent iatrogenic intraoperative injury of the pelvic plexus and reduce or prevent postoperative complications.

Preservation of Autonomic Nerves in Laparoscopic Total Radical Hysterectomy

“…14 Reported cases in literature have used magnifying lensesassisted NSRH for prevention of nerve plexus trauma. 15 Fujii et al have also used magnification (2.5 times) to clarify the anatomy necessary for the nerve-sparing Okabayashi RH. 16 They meticulously separated the blood vessels and connective tissues to preserve the PSN, the hypogastric nerve, and the bladder branch of the IHP under magnification (2.5Â) during the Okabayashi RH performed in 24 patients (FIGO stage IB, n ¼ 22, and stage IIA, n ¼ 2) with cervical carcinoma.…”

“…16,17 Thus, magnification greatly aids dissection of nerves. [15][16][17] The uterine vein is an important landmark in a nerve-sparing procedure. In our technique, we have identified the nerves, preserving the hypogastric nerves, PSN, and the autonomic branches to the bladder using laparoscopic magnification and access, for precise nerve dissection.…”

Anatomical basis of female pelvic cavity for nerve sparing radical hysterectomy

“…To preserve the HN, it is usually suggested to cut the USL at the medial wall of the Okabayashi space, though it has been reported to be too difficult to separate the nerve fibers within the ligament tissue [17]. Therefore, it was suggested by Kato et al [12] that the ureter mesentery should be spared together with the HN to simplify the surgical process and avoid injury to the nerve, a suggestion with which we agree.…”

A Modified Nerve-Sparing Panhysterectomy for Benign Uterine Diseases: Techniques and Evaluation of Postoperative Pelvic Dysfunctions

“…Previous studies showed that NSRH could improve postoperative pelvic visceral dysfunctions by preserving the nerves in patients with cervical cancer, compared to conventional radical hysterectomy [9,10,11]. However, the study of the preservation of pelvic autonomic nerves in panhysterectomy for benign uterine diseases remains rare.…”