Liposuction-assisted nerve-sparing extended radical hysterectomy: Oncologic rationale, surgical anatomy, and feasibility study,☆☆,,★★

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Abstract

OBJECTIVE: Our purpose was to improve the therapeutic index of radical hysterectomy by extending the resection of parametrial tissue without further impairing pelvic autonomic nerve functions. STUDY DESIGN: We studied the topographic anatomy of the parametrial tissue with high-resolution magnetic resonance imaging and by dissection of fresh human cadavers. We then performed a clinical feasibility study of the liposuction-assisted nerve-sparing extended radical hysterectomy. RESULTS: Magnetic resonance imaging demonstrated that the perispinous adipose tissue is retained after type III radical hysterectomy and is a frequent site of tumor recurrence. The perispinous adipose tissue contains the pelvic plexus, the pelvic splanchnic nerves, small blood vessels, and lymphatic tissue. We developed the liposuction-assisted nerve-sparing extended radical hysterectomy and applied it to seven consecutive patients with cervical or vaginal cancer. No intraoperative or postoperative complications occurred. Postoperative magnetic resonance imaging assured us that perispinous adipose tissue was cleared in all cases. A metastatic lymph node was found in the perispinous adipose tissue removed by liposuction from one patient. Suprapubic cystostomies could be removed after a median period of 12 days. CONCLUSION: The nerve-sparing removal of perispinous adipose tissue by liposuction is a feasible addition to wide en bloc parametrectomy in anatomically defined planes. (Am J Obstet Gynecol 1998;178:971-6.)

Section snippets

MRI

Scans were performed on a Siemens Expert 1.0 T Magnetom (Siemens, Erlangen, Germany). A T2-weighted turbo spin echo sequence was used in transverse and sagittal orientation. A T1-weighted spin echo sequence was used in transverse orientation and repeated after administration of contrast agent. Additionally a turbo spin echo sequence with fat suppression was used in coronal orientation. This sequence was optionally repeated in a sagittal orientation. The total time of data acquisition was about

MRI studies

The sectional anatomy of the parametrial tissues was studied with pelvic MRI series of patients without gynecologic pathology. Sections 5 mm thick around the ischial spine clearly demonstrated a bilateral triangular zone of adipose tissue between the mesorectum (lower border), uterovaginal venous plexus (upper border), and obturator internus, coccygeus, iliococcygeus muscle (lateral border), designated perispinous adipose tissue (Fig. 1, A).

. T2-weighted axial MRI scans of the female pelvis

Comment

According to the concepts of surgical oncology, radical treatment involves the wide en bloc resection of the tumor-bearing organ along with its primary lymphatic drainage compartment. The relevance of this principle has been recently reappraised with total mesorectal excision techniques for the surgical treatment of rectal cancer.9, 10 For the operative therapy of cervical cancer, radical hysterectomy adheres to the same oncologic principle, resection of the uterus en bloc with the parametria.

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    From the Departments of Obstetrics and Gynecology,a Anatomy,b and Radiology,c University of Mainz.

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    Supported by a grant from Else Kröner-Fresenius-Stiftung to M.H.

    Reprint requests: Michael Höckel, MD, PhD, University of Mainz Medical School, Langenbeckstraße 1, 55101 Mainz, Germany

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