Cibula2011 2

Gynecologic Oncology 122 (2011) 264–268

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Gynecologic Oncology j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / y g y n o

New classification system of radical hysterectomy: Emphasis on a three-dimensional anatomic template for parametrial resection☆ D. Cibula a,⁎, N.R. Abu-Rustum b, P. Benedetti-Panici c, C. Köhler d, F. Raspagliesi e, D. Querleu f, g, C.P. Morrow h a

Gynecologic Oncology Centre, Department of Obstetrics and Gynaecology, General University Hospital, First Medical School, Charles University, Prague, Czech Republic Department of Surgery, Gynecology Service, Minimally Invasive Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA Department of Obstetrics and Gynecology, University "Sapienza", Rome, Italy d Department of Gynecology, Campus Mitte, Charité University Medicine, Berlin, Germany e Gynecologic Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy f Department of Gynecologic Oncology, Comprehensive Cancer Center, Institut Claudius Regaud, University of Toulouse, France g McGill University, Montreal, Canada h Keck School of Medicine, University of Southern California, Los Angeles, CA, USA b c

a r t i c l e

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Article history: Received 26 March 2011 Accepted 19 April 2011 Available online 17 May 2011 Keywords: Radical hysterectomy Classification Nerve sparing

a b s t r a c t Objective. The international acceptance of a universal classification system for radical hysterectomy is one of the important challenges in gynecologic oncology. The recently published classification system by Querleu and Morrow is a relevant proposal that has been well received by the professional community. However, it does not include a description of parametrial resection in three dimensions, which mostly determines postoperative morbidity.

Methods. The intention of this follow-up paper was to further develop the classification system based on the four proposed types of radical hysterectomy (A–D) into a three-dimensional model using standard anatomical landmarks for definition of resection margins in longitudinal and transverse dimensions and demonstrate it on pictures.

Results. Resection margins were defined in longitudinal and transverse dimensions for each suggested type of radical hysterectomy on all three parts of the parametria. Besides precise description using stable anatomical landmarks, all resection lines have been shown on intra-operative photographs.

Conclusion. Four types of radical hysteretomy can be precisely defined on a three-dimensional anatomical template, including nerve sparing procedure. Our paper should contribute to better standardization (including nomenclature) of the radical hysterectomy, enhancing harmonization of clinical practice in gynecological oncology. © 2011 Elsevier Inc. All rights reserved.

Introduction The proposed radical hysterectomy classification system of Querleu and Morrow (Q–M classification) [1] has been quoted many times since its publication in 2008. Its fast acceptance by the professional community indicates that the principles of the classification system are properly chosen and the descriptions of the various types of the procedure correspond to surgical execution. The key strong points of the Q–M classification include the following: a) it recognizes the extent of

☆ There were no funds received for this work from any of the following organizations: National Institutes of Health (NIH); Wellcome Trust; Howard Hughes Medical Institute (HHMI); and other(s). ⁎ Corresponding author at: Gynecological Oncology Centre, Department of Obstetrics and Gynecology, First Faculty of Medicine and General University Hospital, Charles University in Prague, Apolinarska 18, Prague 2, Czech Republic. Fax: +420 224967451.

E-mail address: david.cibula@iol.cz (D. Cibula).

0090-8258/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.ygyno.2011.04.029

parametrial resection as the key and sole parameter for differentiation between types of radical hysterectomy; b) besides classification, it also unifies terminology; c) it uses anatomical landmarks to classify parametrial resection; and d) it includes a nerve-sparing modification of radical hysterectomy.

The Q–M classification system, however, does not include a description of parametrial resection in three dimensions, which is a significant topic that requires further clarification, particularly in the most frequent types of the procedure, i.e., types C1 and C2. Clear identification of the resection line in the longitudinal (vertical/deep) plane is the determining factor for late morbidity and long-term quality of life [2–5]; this is due to the different requirements for ureteral dissection and, most importantly, damage to the autonomic pelvic nerves [6]. The lack of standardization of the longitudinal deep resection limits of the parametria in radical hysterectomy is a universal problem that has been mainly unexplored in most educational manuscripts describing parametrectomy.

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The article does not include any discussion on the role of different types of radical hysterectomy in the management of cervical or endometrial cancer. It should be emphasized that the oncological outcome or morbidity can be evaluated and data compared between the institutions only if one classification system is accepted and each type of the procedure is precisely standardized.

The aim of this paper is to extend the proposed classification system by defining parametrial resection margins in both transversal and longitudinal (parametrial deep) dimensions, especially for types C1 and C2 radical hysterectomy, using stable anatomical landmarks.

We describe the required ureteral dissection and resection margins on the three parametrial parts and pictorially demonstrate each type of the procedure.

Terminology We re-introduce in this paper the term “parametrium”, which is broadly accepted and provides a single term applicable to all three anatomical parts: the ventral parametrium (including vesico-uterine and vesico-vaginal ligaments), the lateral parametrium (paracervix), and the dorsal parametrium (including recto-uterine and recto-vaginal ligaments) (Fig. 1).

In line with the Q–M paper, the terms “ventral”, “lateral”, and “dorsal” are used to describe spatial orientation. The term "mesoureter" describes the lateral laminar part of the dorsal parametria, which is stretched dorsally and caudally from the ureter and contains the inferior hypogastric plexus [7].

Two parts of the ventral parametria are recognized in a sagittal plane—cranial (above the ureter) and caudal (below the ureter), divided by the course of the ureter. Due to the tangential route of the ureter through the ventral parametria, a bigger portion of the medial leaf of the ventral parametria is exposed and removed in types B or C1 radical hysterectomies.

Two different spaces are described dorsally—the sacro-uterine space (medial pararectal space) between the rectum and the dorsal parametrium, and the pararectal fossa (pararectal space) between the dorsal parametrium and iliac vessels (Fig. 1).

The deep uterine vein (vaginal vein) is an important landmark in the lateral parametrium (Fig. 2). It is being found during caudal parametrial dissection located about 1–2 cm below the uterine artery and vein.

Fig. 1. Perioperative picture of the ventral, lateral and dorsal parametrium. A—ventral parametrium; B—paravesical space; C—lateral parametrium; D—ureter; E—pararectal fossa (lateral pararectal space); F—dorsal parametrium; G—sacro-uterine space (medial pararectal space); H—rectum; I—cervix.

Fig. 2. Perioperative picture of resection lines on the lateral parametrium. A— paravesical space; B—deep uterine vein (vaginal vein); C—internal iliac vein; D— uterine vein; E—uterine artery; F—pararectal fossa C1, C2—resection lines on the lateral parametrium for types C1 and C2 radical hysterectomy.

Types of radical hysterectomy Type A This type corresponds to the extrafascial hysterectomy, which guarantees full removal of the pericervical tissue up to the attachment of the vaginal fornices.

Ureteral dissection—the ureter does not need to be unroofed.

Parametria—this type does not allow for the resection of the ventral or lateral parametria, it does not include resection of the dorsal parametria. The hypogastric plexus, therefore, remains fully preserved.

Type B This type corresponds to the modified radical hysterectomy.

Identification of autonomic nerves is not required, and the hypogastric plexus remains fully preserved.

Ureteral dissection—the ureter is unroofed and dissected from the cervix (Fig. 3).

Fig. 3. Perioperative picture of horizontal resection lines on the ventral parametrium. A— paravesical space; B—umbilical ligament; C—ureter; B, C1, C2—resection lines on the ventral parametrium for types B, C1 and C2 radical hysterectomy.

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Ventral parametria—as the ureter is only unroofed in its course through the parametria, it allows only for the resection of a small initial part of the medial leaf of the ventral parametria (Figs. 3, 4).

Lateral parametria—as the ureter is unroofed, dissected from the cervix, and displaced laterally, but not dissected from the lateral or ventral parametria, the resection margin is at a medial aspect of the ureteral bed, thus allowing for the horizontal resection of about 1– 1.5 cm of the lateral parametria (Figs. 3,4). The ureteral artery, branching from the uterine artery at its crossing of the ureter, can serve as a helpful landmark, and is usually easily identified and can be spared. Longitudinal (deep parametrial or vertical) resection limit is formed by a tangential plane of the vaginal cuff resection.

Dorsal parametria—type B aims for horizontal resection of 1–2 cm dorsally from the cervix (Fig. 5). The resection line corresponds to the amount of removed lateral parametria. Longitudinally, the removal margin is at the level of the vaginal cuff resection, but it must not be deeper below the course of the ureter due to the branches of the hypogastric plexus.

Type C The Q–M classification system distinguishes between a type C1 procedure, which corresponds to the nerve-sparing modification, and the type C2, which aims for a complete parametrial resection. There are significantly distinct resection margins between the two types, particularly in the longitudinal (deep parametrial or vertical) dimension, which are determined by the course of the main branches of the inferior hypogastric plexus in the C1 type.

Type C1 requires separation of two parts of the dorsal parametria: the medial part, which entails recto-uterine and recto-vaginal ligaments, and the lateral laminar structure, also called mesoureter, which contains the hypogastric plexus. Furthermore, type C1 requires only a partial dissection of the ureter from the ventral parametria, which is usually asymmetric towards more extensive resection of the medial leaf of the cranial (above the ureter) part of the ventral parametria (Figs. 3,4). In the C2 type, the ureter is completely dissected from the ventral parametria up to the urinary bladder wall (Figs. 3,4). Defining the resection limits on the longitudinal (deep parametrial or vertical) plane is crucial for distinguishing between types C1 and C2.

Ureteral dissection—in the C1 type, the ureter is unroofed, dissected from the cervix and from the lateral parametria, but only partially

Fig. 5. Perioperative picture of resection lines on the dorsal parametrium. A—ureter; B— mesoureter; C—space between the recto-uterine ligament and mesoureter (hypogastric plexus); D—branches of the hypogastric plexus (white strips); E—recto-uterine ligament; F—cervix B, C1, C2—resection lines on the dorsal parametrium for types B, C1 and C2 radical hysterectomy.

from the ventral parametria (1–2 cm). The C2 type requires complete dissection of the ureter from the ventral parametria up to the bladder wall.

Lateral parametria Transverse (horizontal) resection margins • C1–C2—the lateral border is identical for both types, formed by the medial aspect of the internal iliac vein and artery (Fig. 2).

Longitudinal (deep parametrial or vertical) resection margins • C1—vaginal vein (deep uterine vein)—the deep parametrial resection margin is formed by the vaginal vein, thus the caudal part of the lateral parametria containing the splanchnic nerves is preserved (Fig. 2).

• C2—pelvic floor (sacral bone)—the resection line continues alongside the medial aspect of the internal iliac vessels and pudendal vessels caudally up to the pelvic floor (Fig. 2). The pararectal and paravesical spaces are completely unified sacrificing the splanchnic nerves in the caudal part. Such deep resection allows for greater mobility of the lateral parametria, facilitating its complete removal.

Ventral parametria Transverse resection margins • C1—partial dissection of the ureter from the ventral parametria allows for resection of 1–2 cm of the ventral parametria (Figs. 3,4).

• C2—urinary bladder wall—complete dissection of the ureter from the ventral parametria is required, which allows for complete removal of the ventral parametria up to the urinary bladder wall; both medial and lateral leafs of the ventral parametria are resected equally (Figs. 3,4).

Longitudinal resection margins

Fig. 4. Perioperative picture of resection lines on the ventral parametrium. A—urinary bladder; B—ureter; C—cervix B, C1, C2—resection lines on the ventral parametrium for types B, C2 and C2 radical hysterectomy.

• C1—resection line is formed by bladder branches of the hypogastric plexus localized below the course of the ureter [8,9] (Fig. 4).

• C2—resection line is formed by the level of the paracolpium and vaginal resection. Both cranial and caudal (below the ureter) parts of the ventral parametria are removed (Fig. 4). Bladder branches of the

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hypogastric plexus are sacrificed; thus, their identification is not required.

Dorsal parametria Transverse resection margins • C1–C2—the dorsal border is identical for both types, formed by the recto-uterine ligament attachment to the rectum (Fig. 5).

Longitudinal resection margins • C1—this type requires sagittal dissection of the hypogastric nerves from recto-uterine and recto-vaginal ligaments (Figs. 5,6). Main branches of the hypogastric plexus must be preserved on the lateral part (mesoureter), while the caudal limit on the recto-uterine and recto-vaginal ligaments is formed by the tangential plane of the vaginal cuff resection.

• C2—this type aims at a complete resection of the dorsal parametria deeply below the rectal attachment, thus branches of the hypogastric plexus are sacrificed (Figs. 5,6).

Type D This type differs from type C2 only in the lateral extent of the lateral parametria resection. Ureteral dissection and resection of both dorsal and ventral parametria is identical to the type C2. Laterally, however, it requires ligation and removal of the internal iliac artery and vein, together with their branches, including the gluteal, internal pudendal, and obturator vessels.

Lateral parametria Transverse resection margin • ligation of the internal iliac artery and vein, their removal together with their branches in the lateral parametria, allows for further lateral extension of the resection. The lateral resection line is formed by the lumbosacral nerve plexus, piriformis muscle, and obturator internal muscle. This type of radical hysterectomy is rarely performed for locally advanced tumors [10].

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Discussion Different terminology and classifications are currently being used to describe the varieties of the radical hysterectomy. An absence of uniformly accepted classification is a major limitation for sharing of results, conducting credible multicenter surgical trials, and setting standards for postgraduate education.

The detailed description and proper understanding of the different types of radical hysterectomy is of utmost importance, as the extent of parametria resection determines late morbidity, especially bladder and rectal dysfunctions [2–4,11]. It is likely that both, damage to autonomic nerves and distinct extent of tissue removal, contribute to the morbidity [12].

The classification of radical hysterectomy should incorporate certain principles. The key and sole parameter for differentiation between types of radical hysterectomy is the extent of parametria resection. The extent of resection should be precisely defined for all three parts of the parametria (ventral, lateral and dorsal) in three dimensions. The type of the procedure may be different on each side of the cervix if tumor growth is asymmetrical. The excision or removal of other organs or structures (urinary bladder, ureter, rectum, and pelvic floor muscle) should not be included in the classification system. Also, the size of the removed vaginal cuff is not a decisive parameter for procedure classification. Although the classification system is proposed for radical hysterectomy, it can also apply to the radical trachelectomy and the radical parametrectomy (a procedure that usually follows inadequate simple hysterectomy).

For the proper execution, teaching, and reproducibility of each surgical procedure, it is crucial to identify stable anatomical landmarks.

It should be understood, however, that only a few such structures are found in the pelvis, including the urinary bladder, rectum, ureter, larger vessels, and nerves. The above landmarks are used in this paper to define the majority of resection margins, thus allowing for the precise standardization of a procedure´s execution.

In conclusion, the aim of this consensus paper has been to refine the parametrial resection for the most common types of radical hysterectomy (types B, C1, and C2), with emphasis on a threedimensional description of the resection limits. We believe that the Q– M classification system is an excellent proposal to be applied in clinical practice. Our extension of the proposal should contribute to better standardization of the different types of the procedure, enhancing reproducibility and harmonization for clinical practice in gynecological oncology.

Conflict of interest statement Authors Cibula D, Abu-Rustum NR, Benedetti-Panici P, Köhler C, Raspagliesi F, Querleu D and Morrow P have no conflicts of interest.

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Fig. 6. Perioperative picture of resection lines on the mesoureter (left side). A—rectouterine ligament; B—space between the recto-uterine ligament and mesoureter (hypogastric plexus); C—branches of the hypogastric plexus; D—mesoureter; E—ureter C1, C2—resection lines for types C1 and C2 radical hysterectomy.

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