Anatomical basis of radical

hysterectomy

Denis Querleu

Institut Bergonié Cancer Center, Bordeaux, France

denis.querleu@mcgill.ca

PART 1 : SURGICAL ANATOMY

• Classical spaces

• Non existing structures

• Less classical spaces

• Autonomic nerves anatomy

The classical spaces

Paravesical

Prevesical

Retrorectal

Pararectal

Latzko 1919

Landmarks of the paravesical fossa(right side)

Umbilical artery

External iliac vessels

Obturator nerve

Hypogastric sheath

Paravesical fossa, caudal part(left side)

Obturator nerveLevator ani fascia

Pubic bone

The wrong plane The right plane

Landmark : superior vesical/umbilical artery

Medial Lateral

Right uterine

artery

Lateral retrovesical

fossa

Paravesical

fossa

Limits of the pararectal fossa

Middle rectal

artery

Uterine

artery

Sacrum

Internal iliac

vessels

Lateral limits of vesicouterine septum(left side)

« Bladder pillar »

Vesicouterine septum

Bladder

Ureter

Uterine vessels

Vesicouterine ligament

Vesicouterine ligament(left side) Vesicouterine ligament

Vesicouterine septum

Origin of the

uterine artery

Ureter

Ascending uterine

vessels

Access to the (right) ureteric tunnel

* 1 h on the left side

Entrance point 11 h *

Lateroumbilical

placement of trocars

Traction on the uterine artery

Ureter

The « cardinal ligament » is

not a ligament (coronal section)

Medial part

Lateral partInternal iliac vessels

Paracervix (Nomina Anatomica)

Uterine artery

Uterine

artery

Ureter

Ureter

The uterosacral ligament

does not exist (axial section)

Bladder

Vagina

Cervix

Medial part

Lateral partInternal iliac vessels

Paracervix

… the « uterosacral ligament » is

actually the hypogastric plexus

Sacral splanchnic

roots

Right inferior hypogastric plexus

Superior hypogastric nerve

R

R

R : rectum

ERR

RRS

RRS : retrorectal spaceR RRS

Left

pelvic sidewall

The uterosacral ligament does not exist

Inferior hypogastric plexus

Paravesical fossa

Ureter

Pararectal fossa« USL» : a peritoneal fold

Sacrouterine space

Other inexisting or misnamed

structures

• « Lateral parametrium » = paracervix

• « Anterior parametrium » = vesical lateral ligament = umbilical and superior vesical arteries

• « Posterior parametrium » = « uterosacral ligament » = nothing but a fibrous condensation close to the torus uterinus

• « Deep vesicouterine ligament » = vesicovaginal ligament

Less classical spaces

• The same spaces, from below

• « New spaces »

– Retrovesical spaces (lateral/medial)

– Sacrouterine space

• The pelvic sidewall layers

– vascular plane

– sacral nerves plane

Pararectal fossa

Vesicouterine septum

Paravesical fossa

Bladder pillar

Vesicouterine

septum

Paravesical fossa

2h

Access to paravesical fossa

3h

Application to prolapse surgery

Application to prolapse surgery

Ureter

Lateral retrovesical fossa (left side)

Lateral to the ureter, medial to the umbilical ligament

(« lateral vesical ligament »)

Paravesical fossa

Pararectal fossa

The « wrong »

plane

Lateral retrovesical

space

Lateral retrovesical fossa (left side)

Lateral to the ureter, medial to the umbilical ligament (« lateral

vesical ligament »)

Paravesical fossa

Paracervix

Pararectal fossa

Left ureter

Left uterine

artery

« Lateral vesical

ligament »

Lateral retrovesical

fossa

Lateral retrovesical fossa (right)

after division of the uterine arteryLateral retrovesical

fossa

« Lateral vesical ligamentRight ureter

Medial retrovesical space (right)

Ureter

Lateral retrovesical

fossa

Medial retrovesical

space

Paracervix

Medial retrovesical space

Medial to the ureter

Left

Right

Okabayashi (sacrouterine) space

« Uterosacral » peritoneal fold

Limits of the sacrouterine space

Uterosacral fold

Inferior hypogastric plexus

Access to the sacrouterine space (1)Division of the posterior leaf of the broad ligament

Right uterosacral fold

Right ureter

« Mesoureter » (autonomic nerves)

Access to the sacrouterine space (2)Reaching the uterosacral fold

Sacrouterine space

Individualization of the (right) paracervix (medial part)

Lateral retrovesical

fossa

Medial retrovesical

space

Sacrouterine space

Ureter

Laterovascular

spaceTransperitoneal laparoscopic

approach, lateral to vessels,

right side

External iliac vein

Obturator nerve

Internal iliac vessels

Technique of resection

of the vascular plane

(Mibayashi 1942)

After resection of the vascular system

Obturator vessels

Pudendal vessels

Gluteal vessels

The sacral plexus plane

The sacral plexus plane(laparoscopic approach, lateral to vessels)

Obturator nerveObturator nerveInternal iliac vessels

The resectable area of the pelvic sidewall

(Höckel 1999)

From

D. Querleu, E Leblanc, P Morice, G Ferron

Chirurgie des cancers gynécologiques

2ème édition, Elsevier-Masson, Paris 2014

Autonomic nerve anatomy

- (1) The « uterosacral ligament» can be

laterally separated from the hypogastric

nerve (« mesoureter »)

Left Yabuki’s sacrouterine space

Right inferior hypogastric plexus

Rectovaginal septumUSL

Retrorectal space

Rectum

Sacrum

Autonomic nerve anatomy

- (2) The nerve plane is prolonged by the

hypogastric plexus, that lies lateral to the rectum

and vagina

Mauroy et al. Raspagliesi et al.

Autonomic nerve anatomy

- (3) The « bladder pillar »

is divided into a

« superficial » (cranial,

anterior) component

containing and a « deep »

(caudal, posterior)

component, the latter

critical for bladder nerve

preservation

Bladder nerves

PART 2 : A « NEW » WAY TO

MANAGE THE PARACERVIX

(« cardinal ligament ») :

PARACERVICAL

LYMPHADENECTOMY

Ureter

Surgical anatomy of the paracervix(transverse section)

Bladder

Vagina

Cervix

Medial partLateral partInternal iliac vessels

Paracervix

Ureter

Surgical anatomy of the paracervix(coronal section)

Vagina

Cervix

Medial part

Lateral partInternal iliac vessels

Paracervix

The concept of paracervical

lymphadenectomy

Right paracervical lymph node

dissection, ventral step

Right paracervical lymph node

dissection, dorsal step

Middle rectal

artery

Right paracervical

dissection.

Lateral step

Left paracervical node dissection

Paracervical lymph node dissection as an

« expander »

of « modified »

rad. hyst.

Removal of medial

paracervix Paracervical lymph node dissection

PART 3 : ANATOMICAL

CLASSIFICATION OF

RADICAL HYSTERECTOMIES

• Tailoring has become a major issue

in cancer surgery (adverse vs

curative effects)

• « Extended » or « radical »

hysterectomies encompass a variety

of different surgeries

• Eponyms are altered with time

Need for a new classification

• Piver/Rutledge/Smith

– Does not take into account Terminologia Anatomica

– Ignores nerve preservation techniques

– Applies to open surgery only

– Mixes lateral, dorsal, and vaginal extent

– Class I is not « radical » ; Class III and IV are not

clearly defined ; Class V is obsolete

– Templates are not clear

Need for a new classification

• Piver/Rutledge/Smith : unclear sketches

Need for standardization of

anatomical nomenclature

• (1) Spatial orientation in the pelvis according to the international anatomical nomenclature

– Medial / lateral

– Caudal / cranial

– Dorsal/ventral

• (2) Adopt a uniform name for the lateral attachments of the cervix and upper vagina : paracervix (Nomina Anatomica)

– Avoiding confusing terms as « cardinal ligament », « Mackenrodt’s ligament », « lateral parametrium »

Design of the new

classification(Querleu-Morrow Lancet Oncol 2008)

• Defines four main categories according to extent of removal of paracervix

• Uses only reliable landmarks

- (1) ureter

- (2) internal iliac vessels

- (3) pelvic wall

• Defines as sub categories

– Nerve preservation techniques

– Paracervical lymphadenectomy

• Takes into account other details, but only as modifiers

123

Four classes according to lateral extent

AC

B

D

C

B

A

B1

B2

D

The four categories

• Class A : minimal resection of paracervix cervix removed in toto

• Class B : resection of the paracervix at the ureter resection of the fibrous component

• Class C : resection of the paracervix at the pelvic sidewall resection of entire paracervix

• Class D : extension of resection to the anatomical structures of the pelvic sidewall exenterative procedures

Class A : the paracervix is transected

medial to the ureter but lateral to the cervix

(half-way)

– Extrafascial hysterectomy in which the position of the

ureters is determined by palpation or direct vision (after

opening the ureteral tunnels) without freeing the ureters

from their beds

– The bladder and rectal pillar are not transected at a

distance from the uterus

• Goal : make sure that the cervix has been removed

in toto by a gynecologic oncologist

Class A

Class A

Right paracervix

Ureter

Uretère

Paracervix

Retrovesical space

Sacrouterine space

Do we need a new

« less radical » type ?

• Tailoring surgery for early cervical cancers, less

than 2 cm, with no LVSI, with negative pelvic nodes (simple hysterectomy may not remove the entire cervix)

• Limiting the extent and consequently adverse

effects of hysterectomies after radiation therapy (ERT is supposed to control microscopic paracervical

disease, ureter at risk if not identified)

Class B : the paracervix is divided at the

ureter

– The ureter is unroofed and rolled laterally permitting transection of the paracervix at the level of the ureteral tunnel

– The neural component of the paracervix is not transected

– The bladder and rectal pillars are resected at a distance from the uterus

– Subcategories : B1 : as described

B2 : with additional lateral paracervical lymph node dissection or liposuction.

Class B

B

Type A versus type B

Class B

sub-types

B1 B2Removal of proximal

paracervixParacervical lymph node dissection

Class C : Resection of the

paracervix at the junction with

hypogastric vessels

- Resection of the rectal pillar at the rectum and

bladder pillar at the bladder

- The ureter is completely mobilized.

Class CUreter

C

Left side

Right side

Posterior branch

of internal iliac artery

Middle rectal artery

Uterine pedicle

Sup. ves. a.

Obt. a.

Ext. iliac

vessels

External iliac

vessels

Retrovesical fossa

Internal iliac a.

… and introducing sub categoriesC1 : Resection of the medial and lateral

components of the bladder pillar, the cranial and

caudal components of the paracervix, and the

rectal pillar with a nerve sparing dissection.

C2 : without NSD

From Raspagliesi et al.

A B

C