Myths and facts about nerve- sparing radical hysterectomy Tomoyasu Kato Division of Gynecology, National Cancer Center Hospital, Tokyo, Japan Function of female autonomic nerves Anatomical Sympathetic Parasympathetic structure Bladder Stimulate the urethral sphincter Relax the urethral sphincter Inhibit the detrusor Stimulate the detrusor Rectum and auns Inhibit expulsion of feces Expulsion of feces Stimulate internal sphincter of anus Genital tract Inhihibit uterine contraction and Vaginal lubrication vasodilation Genital swelling 2010.7.31 1st ASGO International Workshop 2 Neural Control of the Lower Urinary Tract • The lower urinary tract is innervated by 3 sets of peripheral nerves involving the parasympathetic, sympathetic, and somatic nervous systems: • Pelvic parasympathetic nerves arise at the sacral level of the spinal cord, excite the bladder, and relax the urethra. • Lumbar sympathetic nerves inhibit the HGN bladder body and excite the bladder base and urethra. • Pudendal nerves excite the external PSN urethral sphincter. • These nerves contain afferent sensory as well as efferent motor axons. 2010.7.31 1st ASGO International Workshop 3 Pudendal N. autonomic nerves in Pelvis HGN HGN PP U U B B R R 2010.7.31 1st ASGO International Workshop 4 Autonomic nerves related to voiding function right pelvis by fresh cadaver study UB UT Rectum HGN PSN 2010.7.31 1st ASGO International Workshop 5 Autonomic nerves related to voiding function • Hypogastric nerves • sympathetic • Pelvic splanchnic nerves • parasympathetic • Pelvic plexus • bladder branches HGN PSN PP 2010.7.31 1st ASGO International Workshop 6 Level of nerve preservation 1. Non-touch preservation 2. Exposure preservation 3. Partial preservation 4. Dissection 2010.7.31 1st ASGO International Workshop 7 Bladder function recovery bladder PVR<50m Method HGN PSN P Plexus braches L Simple Hx ◎ ◎ ◎ ◎ ＜5POD class II RH ◎ ◎ ◎ ○ 7-16POD class III RH × ◎(S2,3,4) △ △ CIC: 10% Nerve-sparing ARH (Tokyo) ○ ◎(S2,3,4) ○ △ 18POD Extended NS ARH (total) ○ × (S2)○(S3,4) ○ △ 18POD NS ARH (partial) × × (S2)○(S3,4) △ △ 24POD ◎ non-touch preservation ○ exposure preservation △ partial preservation dissectio 2010.7.31 1st ASGO International Workshop 8 × n 1. The hypogastric nerves 2010.7.31 1st ASGO International Workshop 9 Left hypogastric nerves UR 2010.7.31 1st ASGO International Workshop 10 HGN UA UR Ureterohypogastri c fascia ARF retroperitoneun This tissue plane is UR corresponded to the anterior renal fascia, which includes the HGN and the pelvic HGN plexus (PP). 2010.7.31 1st ASGO International Workshop 11 wrong correct Anterior layer of the vesicouterine ligament 2010.7.31 1st ASGO International Workshop 12 2. the pelvic splanchnic nerves 2010.7.31 1st ASGO International Workshop 13 stump of uterine A PSN(S3) 2010.7.31 1st ASGO International Workshop 14 Middle rectal artery PSN(S3) 2010.7.31 1st ASGO International Workshop 15 3. The pelvic plexus 2010.7.31 1st ASGO International Workshop 16 Partial preservation of the pelvic plexus in case of deep myomertiral or parametrial invasion Stump of the cardinal Uterus ligament N. hypogastric 2010.7.31 1st ASGO International Workshop 17 Mobilization of the visceral stump of the cardinal ligament Hypogastric nerves For total preservation of the pelvic plexus, this stump should be mobilized ventrally above the hypogastric nerves before dissection of the uterosacral and rectovaginal ligaments. 2010.7.31 1st ASGO International Workshop 18 Different dissection line of pelvic plexus total partial HGN PP PSN 2010.7.31 1st ASGO International Workshop 19 4. bladder branches 2010.7.31 1st ASGO International Workshop 20 Lateral aspect R UT UR UB Bladder branches ventral to bladder body 2010.7.31 1st ASGO International Workshop dorsal to bladder 21base UR: ureter Ventral branches were sacrificed during the dissection of the vesicouterine ligament left UR UT CL UT 2010.7.31 x201st ASGO International Workshop 22 Preservation of dorsal branches to the bladder St.of the CL Clamping of the right rectovaginal ligament uterus pV Right angular forceps 1 Branches to the bladder Yellow arrow: Branches to the bladder 2010.7.31 1st ASGO International Workshop movie 2010.7.31 1st ASGO International Workshop 24 Factors of injury to autonomic nerves • Drying along the surgical margin • Hypoxia in venous bleeding • Pressure from surgical retractors • Extension stress or excess traction with taping • Direct injury with electrical scaples • Thermal injury by power sauce such as ligasure and harmonic scaples 2010.7.31 1st ASGO International Workshop 25 Conclusion • Both an understanding of the precise neuroanatomy and a gentle handling of the autonomic nerves are important to obtain a good balance between oncologic outcome and QOL after nerve-sparing radical hysterectomy. 2010.7.31 1st ASGO International Workshop 26 Thank you for your attention 2010.7.31 1st ASGO International Workshop 27.