Anatomical Highlights During Nerve-Sparing Radical Hysterectomy: A Step-by-Step Educational Video

For patients with early-stage low-risk uterine cervical cancer ≤ 2 cm, simple hysterectomy is recommended, and this can now be considered the new standard of care.¹ However, for patients with cervical cancer > 2 cm with "non-SHAPE" criteria, radical hysterectomy is still recommended as the standard primary treatment.². Nerve-sparing radical hysterectomy requires deep knowledge of pelvic neurovascular anatomy. Lack of proper anatomical knowledge and adequate surgical skills are associated with not only the risk of hypogastric nerve injury but also unnecessary bleeding during surgery, which may lead to unintentionally less radical surgery.

We performed nerve-sparing radical hysterectomy (Querleu-Morrow classification: type C1³) using the following eight steps (Video). In Japan, total laparoscopic radical hysterectomy is performed under the public health insurance system. Step 1: Development of the lateral pararectal space and the paravesical space. Step 2: Isolation of the ureter and separation of the hypogastric nerve. Step 3: Development of the rectovaginal space. Step 4: Dissection of the anterior leaf of the vesicouterine ligament. Step 5: Development of the paravaginal space and dissection of the posterior leaf of the vesicouterine ligament Fig. 1). Step 6: Separation of the cut end of the deep uterine vein from the pelvic splanchnic nerve (Fig. 2). Step 7: Transection of the uterine branch from the inferior hypogastric plexus and ligation of the paracolpium. Step 8: Vaginal cuff creation and transection of the vaginal wall.

Surgeons should recognize the importance of developing a retroperitoneal avascular space based on precise anatomical landmarks, and each surgical step must be reproducible. Fig. 1 Anatomical relationships between the posterior leaf of the vesicouterine ligament and the paravaginal space (Left side). (A) and (B) The surgical forceps can easily penetrate the paravesical space. This space is known as the "paravaginal space." (C) After development of the paravaginal space, the posterior leaf of the vesicouterine ligament can be dissected. Fig. 2 Anatomical relationships between deep uterine vein, hypogastric nerve and bladder branch (right side). (A) The bladder branch from the inferior hypogastric plexus can be identified when the cut end of the deep uterine vein is cranially retracted. (B) Dot line: dissection line.