Abstract
Radical hysterectomy represents the treatment of choice for FIGO stage IA2–IIA cervical cancer. It is associated with several serious complications such as urinary and anorectal dysfunction due to surgical trauma to the autonomous nervous system. In order to determine those surgical steps involving the risk of nerve injury during both classical and nerve-sparing radical hysterectomy, we investigated the relationships between pelvic fascial, vascular and nervous structures in a large series of embalmed and fresh female cadavers. We showed that the extent of potential denervation after classical radical hysterectomy is directly correlated with the radicality of the operation. The surgical steps that carry a high risk of nerve injury are the resection of the uterosacral and vesicouterine ligaments and of the paracervix. A nerve-sparing approach to radical hysterectomy for cervical cancer is feasible if specific resection limits, such as the deep uterine vein, are carefully identified and respected. However, a nerve-sparing surgical effort should be balanced with the oncological priorities of removal of disease and all its potential routes of local spread.
Résumé
L'hystérectomie radicale est le traitement de choix pour les cancers du col utérin de stade IA2–IIA de la Fédération Internationale de Gynécologie Obstétrique (FIGO). Cette intervention comporte plusieurs séquelles graves, telles que les dysfonctions urinaires ou ano-rectales, par traumatisme chirurgical des nerfs végétatifs pelviens. Pour mettre en évidence les temps chirurgicaux impliquant un risque de lésion nerveuse lors d'une hystérectomie radicale classique et avec préservation nerveuse, nous avons recherché les rapports entre le fascia pelvien, les structures vasculaires et nerveuses sur une large série de sujets anatomiques féminins embaumés et non embaumés. Nous avons montré que l'étendue de la dénervation potentielle après hystérectomie radicale classique était directement en rapport avec le caractère radical de l'intervention. Les temps chirurgicaux à haut risque pour des lésions nerveuses sont la résection des ligaments utéro-sacraux, des ligaments vésico-utérins et du paracervix. L'hystérectomie radicale avec préservation nerveuse est possible si des limites de résection spécifiques telle que la veine utérine profonde sont soigneusement identifiées et respectées. Cependant une chirurgie de préservation nerveuse doit être mise en balance avec les priorités carcinologiques d'exérèse du cancer et de toutes ses voies potentielles de dissémination locale.
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The authors are grateful to Mr. A.G. Bigioni for the illustrations and to Mme. Y. Tiburzi for technical help.
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Ercoli, A., Delmas, V., Gadonneix, P. et al. Classical and nerve-sparing radical hysterectomy: an evaluation of the risk of injury to the autonomous pelvic nerves. Surg Radiol Anat 25, 200–206 (2003). https://doi.org/10.1007/s00276-003-0137-7
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DOI: https://doi.org/10.1007/s00276-003-0137-7