Kavallaris2010

Gynecologic Oncology 119 (2010) 198–201

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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 e v i e r. c o m / l o c a t e / y g y n o

Laparoscopic nerve-sparing radical hysterectomy: Description of the technique and patients’ outcome A. Kavallaris ⁎, A. Hornemann, N. Chalvatzas, D. Luedders, K. Diedrich, M.K. Bohlmann Department of Obstetrics and Gynaecology, University of Schleswig-Holstein, Campus Luebeck, 23538 Luebeck, Germany

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Article history: Received 12 May 2010 Available online 10 August 2010 Keywords: Nerve-sparing radical hysterectomy Laparoscopy Inferior hypogastric nerve Inferior hypogastric plexus Splanchnic nerves

a b s t r a c t Objective. The radical hysterectomy type three can be accompanied by postoperative morbidity, such as dysfunction of the lower urinary tract with loss of bladder or rectum sensation. We describe the technique of laparoscopic nerve-sparing radical hysterectomy and patient's outcome.

Methods. Thirty-two patients underwent laparoscopic nerve-sparing radical hysterectomy with pelvic lymphadenectomy. Both the hypogastric and the splanchnic nerves were identified bilaterally during pelvic lymphadenectomy.

Results. The median age of the patients was 52 years, and the average operating time was 221 min. There were no intraoperative or postoperative complications considering the nerve-spring radical hysterectomy.

Postoperatively, in all patients spontaneous voiding was possible on the third postoperative day with a median residual urine volume of b 50 ml.

Conclusions. Laparoscopic identification (neurolysis) of the inferior hypogastric nerve and inferior hypogastric plexus is a feasible procedure for trained laparoscopic surgeons who have a good knowledge not only of the retroperitoneal anatomy but also of the pelvic neuro-anatomy as this qualification could prohibit long-term bladder and voiding dysfunction during nerve-sparing radical hysterectomy. © 2010 Elsevier Inc. All rights reserved.

Introduction The classical surgical management of early-stage cervical carcinoma includes the extirpation of the uterus, along with radical resection of the parametrial tissues and upper vagina, together with complete bilateral pelvic lymphadenectomy.

This surgical approach, known as radical hysterectomy, was first described and systematically performed by Ernst Wertheim [1] more than 100 years ago, and was then modified by Okabayashi in 1921 [2] and re-popularized by Meigs [3] in the 1950s and by Piver [4] in the 1970s. The Wertheim–Meigs operation type III is the treatment of choice for FIGO stages Ib–IIa cervical cancer. Efficacy and oncologic safety of radical hysterectomy are accompanied by a substantial rate of long-term postoperative complications involving the pelvic autonomic nerve system. It is well known that radical hysterectomy type III can be complicated by postoperative morbidity, such as dysfunction of the lower urinary tract with loss of bladder or rectum sensation [5–8]. The pelvic autonomic nerves are the pathway for the neurogenic control of rectal, bladder and sexual arousal (lubrication and swelling of the vagina). The inferior hypogastric nerves carry the sensitive fibers and the sympathetic fibers responsible for the ⁎ Corresponding author. Department of Obstetrics and Gynaecology, University of Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23538 Luebeck, Germany.

Fax: + 49 451 500 2430.

E-mail address: andreas.kavallaris@uk-sh.de (A. Kavallaris).

0090-8258/$ – see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.ygyno.2010.07.020

relaxation of the bladder detrusor muscle and contraction of the urethral sphincter.

The steps of classical radical hysterectomy at which autonomic nerves may be injured are as follows: → hypogastric (sympathetic) nerves during the resection of the uterosacral ligament at the posterior pelvic wall [4], → pelvic splanchnic (parasympathetic) nerves during the dissection of lymph nodes medial to the internal iliac vein and around the deep uterine vein and during the division of the deep uterine vein in the cardinal ligament [9], → vesical branches of the pelvic plexus during the resection of the vesico-uterine ligament [10], → Inferior hypogastric plexus during the resection of the uterosacral and rectovaginal ligaments [11], → superior hypogastric plexus during pre-sacral and periaortic lymph node dissection [12].

In order to maintain bladder function, those nerve networks should be preserved intact as much as possible unless these attempts sacrifice the therapeutic role of surgery.

Although the anatomy of the pelvic autonomic nerves is not fully described, and these structures are rarely visualized in operating rooms during surgery, we believe that laparoscopy may allow better visualization of the retroperitoneal structures and better identification of important nerve structures of the pelvic autonomic nerves. It is

A. Kavallaris et al. / Gynecologic Oncology 119 (2010) 198–201

especially due to the enlargement achieved by modern video-optical systems with digital zoom function and carbon dioxide pressure.

In this preliminary report, we describe the laparoscopic nervesparing radical hysterectomy and patient's outcome, which was developed by our institute based on anatomic considerations.

Patients and methods Between 10/2008 and 02/2010, 32 patients referred to our specialized gynecological oncological unit were operated for early cervical cancer. All 32 patients underwent laparoscopic nerve-sparing radical hysterectomy with pelvic lymphadenectomy. All surgical procedures were documented on DICOM Record System (image and video documentation Endobase, Olympus).

Data on patient age, body mass index, operating time, hospital stay, previous surgical history, amount of blood loss, and recovery of bladder and bowel function following surgery, time to resume voiding function, intraoperative and early postoperative complications were prospectively recorded in a computerized database. At the time of the initial gynecological evaluation, a careful detailed history had been obtained and in particular the bladder and bowel function had been evaluated.

All patients underwent pelvic and kidney ultrasonography, haemogram, liver, and kidney blood tests before operation. Patients were admitted 1 day prior to surgery with the bowel being prepared 24 h before surgery. During surgery, each patient received single-shot prophylactic antibiotics (cefuroxim 1.5 g i.v. and metronidazol 500 mg i.v.). Antithrombotic prophylaxis was started on the day of surgery and continued until the patient's discharge. The intraabdominal drainage was removed when the amount of fluid was b100 ml in 24 h.

Surgical procedure The surgical procedure of the laparoscopic nerve-sparing radical hysterectomy with pelvic lymphadenectomy was performed under general anesthesia in a Trendelenburg position, with the five-port laparoscopy performed after the pneumoperitoneum has been created with a Veress needle. One 10 mm port was inserted through the umbilicus for camera introduction and a 5 mm port inserted suprapubically. Two 5 mm ports were inserted lateral to the visualized inferior epigastric vessels and a fourth 5 mm port was inserted subcostal (Palmer's point). The whole abdominal cavity, including peritoneum, liver, gall bladder, stomach, appendix and bowels was inspected for pathologies. After bringing the patient in a head-down position, bowels were moved out of the pelvis and the inner genital organs were inspected.

The identification of the inferior hypogastric and the splanchnic nerves was always performed after pelvic lymphadenectomy and the frozen section of these lymphnodes showed no metastasis.

We used a different approach of the nerves identification as the majority of the authors [2,5,6,11–21] who described their technique of the nerve-sparing procedure. The laparoscopic procedure of nerve identification started with the identification of the ureter at its crossing with the common iliac artery. We then started with the preparation towards the promontory until the lateral part of the plexus hypogastric superior was visualized. The superior hypogastric plexus is a triangularly shaped net of sympathetic fibers that lies in pre-sacral space at the level of promontory, covered by peritoneal sheet and the anterior layer of the visceral pelvic fascia. It gives origin to the right and left inferior hypogastric nerves, descending for 8–10 cm along the lateral sides of mesorectum, into the bilayered visceral pelvic fascia, following the ureteral course in a dorsal and caudal direction. After the identification of the inferior hypogastric nerve we started with the preparation of the nerve towards the uterine artery with simultaneous removal the inferior hypogastric

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nerve away from the uterosacral ligament (Fig. 1). The inferior hypogastric nerve appears approximately 2–3 cm dorsally of the ureter in the lateral part of the uterosacral ligament when entering the lateral parametrium. At this point we have to mention that there is a different approach depending on the pelvic wall side as the identification of the nerval structures on the right side is – according to our experience – easier than on the left site. This difference is due to anatomic structures to be overcome on the left pelvic wall such as the rectosigmoid, and the physiological adhesions of the bowel.

Furthermore, the left ureter has a different – deeper and more medial – course than the right ureter. The pelvic splanchnic nerves run from the S2–S4 roots of the sacral plexus and join in the inferior hypogastric plexus (Fig. 2) with the inferior hypogastric nerves at the lateral part of the uterosacral ligaments, laterally to the rectum at the level and dorsal of the cardinal ligament. The inferior hypogastric plexus forms a “triangularly shaped plexus, placed in a sagittal plane” [14]. After identification of the inferior hypogastric nerve and the splanchnic nerves we then performed the radical resection of the uterosacral and cardinal ligaments.

At the end of the procedure, no suprapubic catheter is required.

The transurethral catheter is removed the morning of the third postoperative day. When the patient voided spontaneously the effect of surgery on bladder function was examined. When the amount of residual urine was consistently b50 ml in two consecutive ultrasound measurements the procedure was considered successful.

Results The median age of the patients was 52 years (range 33–64), with a history of previous laparoscopic operations in 16 patients in additional 4 patients (12.5%) with a previous laparotomy for benign pathologies. Table 1 shows the TNM classification of the cervical cancers. The median body mass index (BMI) was 23.5 kg/m2 (range 17.26–28.04 kg/m2). The average operating time was 221 min (range, 145–285). Median length of hospital stay was 9 days (range 7–14).

There were no intraoperative or postoperative complications considering the nerve-spring radical hysterectomy. The operative and postoperative complications considering the lymphadenectomy are shown in Table 2. The approximate blood loss was 250 ml (range 120–300 ml). The inferior hypogastric plexus and the inferior hypogastric nerve were completely identified intraoperatively and preserved in all 32 patients.

Postoperatively, in all patients spontaneous voiding was possible on the third postoperative day. Overall the residual urine volume was b50 ml in all patients in two ultrasound measurements.

Fig. 1. Preparation of the inferior hypogastric nerve towards the uterine artery with simultaneous removal of the nerve away from the uterosacral ligament (right side).

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A. Kavallaris et al. / Gynecologic Oncology 119 (2010) 198–201 Table 2 Intraoperative and postoperative complications.

Fig. 2. The inferior hypogastric plexus forms a “triangularly shaped plexus, placed in a sagittal plane,” and the pelvic splanchnic nerves run from the S2–S4 roots of the sacral plexus and join in the inferior hypogastric nerves building the inferior hypogastric plexus (right side).

Discussion Radical hysterectomy Piver type III is considered the standard surgical treatment for FIGO stages Ib–IIa cervical cancer worldwide.

Bladder dysfunction or urination difficulty in patients, who have undergone radical hysterectomy, causes deterioration in the patients’ quality of life due to physical and mental stress. The rate of postvoiding residual volume after non nerve-sparing radical hysterectomy ranges from 15 to 20% [5,8–10,15,17,18]. This can be explained by intraoperative lesions of the inferior hypogastric nerve and inferior hypogastric plexus nerves due their location at the proximal portion for the uterosacral ligament.

Radical hysterectomy is associated with a risk of autonomic nerve damage and consequent bladder and bowel dysfunction [8–10,15–23].

The sympathetic and parasympathetic nervous systems play an integrated part in the successful completion of urine voiding. To minimize damage to the bladder and bowel functioning, the importance of carefully identification and preserving the autonomic nerve has recently been stressed in the performance of radical hysterectomies.

Many gynecologic oncologists have become knowledgeable about the anatomy of pelvic autonomic nerve without sacrificing the radicality of the radical hysterectomy procedure.

A lot of studies are published with description of their technique of nerve-sparing surgery and patients’ outcome [2,5,10–14,16,19–22].

However, there is only one study [13] demonstrating the laparoscopic identification and preservation of the pelvic autonomic nerve during radical hysterectomy. The principle of this study [13] is based on primary identification of the anatomic pathway of the splanchnic pelvic nerves before transection of the parametria and, consequently, of a part of the inferior hypogastric plexus. Functional identification of

Table 1 TNM classification.

Number of patients

Tumor

Grade

Lymphatic-vessel infiltration

Vascular infiltration

2 5 3 11 3 5 3

pTIb1 pTIb1 pTIb1 pTIb2 pTIb2 pTIIa pTIIa

1 2 3 2 3 2 3

0 0 0 1 0 1 1

0 0 0 0 0 0 1

Intraoperative complications

Pts.

Injury of genitofemoral nerve (right side) Injury of obturator vein (right side) Post-operative complications Lymphocele (7 days postoperatively) Urinary tract infection Secondary haemorrhage (explorative laparoscopy necessary) Wound infection (incision site)

1 1 1 1 1 1

the different sacral roots is performed using the Laparaoscopic NeuroNavigation (LANN technique). However, in the study of Possover et al.

[23] radical hysterectomy was performed vaginally.

The present study confirmed our hypothesis that by taking advantage of the optic properties of laparoscopy, identification and preservation of pelvic autonomic nerves is feasible, especially by visualizing the pelvic splanchnic nerves and to perform total laparoscopic nerve-sparing radical hysterectomy.

Comparison of the technique and the patient's outcomes such as urinary function of our patients to the other studies of nerve-sparing radical hysterectomy is difficult because the technique, the extent of radical hysterectomy and the evaluation of the urinary function of each study are different. There is also a different approach of radical hysterectomy between Western publications [5,6,11,13,16,22,23] and Japanese studies [2,9,10,12,19–21] as for the procedure of radical hysterectomy, the resection landmarks of the parametrium differ between both approaches. In Western countries, the lines of resection of the radical hysterectomy are defined according to the classification of Piver, Rutledge, and Smith [4] and in Japan are defined according to Okabayashi [24]. The original Okabayashi type III radical hysterectomy was more radical than the Piver type III radical version and usually the pelvic nerve plane is sacrificed. As stated by Okabayashi himself, the preservation of nerve function was considered to be one of the future challenges [24].

Damage of only the inferior hypogastric nerve may result in changes in the feeling of bladder filling, whereas damage of the inferior hypogastric plexus leads to bladder dysfunction with urinary retention. The identification of the inferior hypogastric nerve and plexus was feasible in our study and performed in acceptable operative time.

Bladder fullness was the first function to return quickly after nerve-sparing surgery followed by self-reported satisfaction of micturition. This suggests that the sympathetic function is better preserved than the parasympathetic function.

In comparison, the enlargement of the laparoscopic view using modern video-optical systems with digital zoom function helps to better visualize the nerves especially of the single fibers of the inferior hypogastric plexus. Optimal access to the relevant pelvic area and in the depth of the peritoneum is guaranteed. These requirements are fulfilled by laparoscopy with suitable instruments, microsurgical techniques, and the magnification effect. Optimal access to the relevant pelvic area and in the depth of the peritoneum is guaranteed.

However, we believe that some experience is needed to visualize the nerves, but the knowledge of their presence is the most important factor for their preservation.

In conclusion, this is the first report that describes a precise total laparoscopic nerve-sparing radical hysterectomy and patient's outcome. Laparoscopic identification (neurolysis) of the inferior hypogastric nerve and inferior hypogastric plexus is a feasible procedure for trained laparoscopic surgeons who have a good knowledge not only of the retroperitoneal anatomy but also of the pelvic neuro-anatomy as this qualification could prohibit long-term bladder and voiding dysfunction during nerve-sparing radical hysterectomy.

A. Kavallaris et al. / Gynecologic Oncology 119 (2010) 198–201 Conflict of interest statement The authors declare that there are no conflicts of interest.

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