Nerve-sparing Radical Hysterectomy Research Articles

Long-Term and Short-Interval Assessment of Self-Reported Urinary and Sexual Functions after Nerve-Sparing Radical Hysterectomy: A Prospective Cohort Study.

Long-Term and Short-Interval Assessment of Self-Reported Urinary and Sexual Functions after Nerve-Sparing Radical Hysterectomy: A Prospective Cohort Study.

Improved bladder function in radical hysterectomy without worsening oncologic outcome: resection of the posterior layer of the vesicouterine ligament with the procedure limited to the vesical veins.

The classic Okabayashi nerve-sparing radical hysterectomy involves complete resection of the posterior leaf of the vesicouterine ligament, whereas in the simplified nerve-sparing radical hysterectomy, only the vesical veins and some connective tissue of the posterior layer of the vesicouterine ligament are resected. This study aimed to compare bladder function and cervical carcinoma relapse-free survival between these two techniques. We conducted a retrospective, historical control study. All female patients aged >20 years who were diagnosed with cervical cancer stage IB1-IIB and underwent radical hysterectomy with pelvic lymphadenectomy between 2009 and 2022 were enrolled. Patients who had a history of other cancers and those who were treated with non-surgical approaches or non-radical hysterectomy were excluded. The primary outcome was relapse-free survival during the follow-up period. A total of 114 patients who underwent curative-intent radical hysterectomy were included in this study. The median follow-up duration was 60 months. No significant difference was observed in relapse-free survival between the two surgical procedures. The simplified nerve-sparing radical hysterectomy was superior in terms of both motor and sensory bladder function outcomes. Resection of the posterior layer of the vesicouterine ligament, with the procedure limited to the vesical veins, is an effective and safe method for radical hysterectomy. It may be more useful for preserving the bladder function, without leading to unfavorable oncologic outcomes.

Surgical Anatomy and Dissection of the Hypogastric Plexus in Nerve-Sparing Radical Hysterectomy.

Radical hysterectomy is a central surgical procedure in gynecological oncology. A nerve-sparing approach is essential to minimize complications from iatrogenic injury to the pelvic nerves, resulting in postoperative urinary, anorectal, and sexual dysfunction. The hypogastric plexus (HP), a complex network of sympathetic and parasympathetic nerves, plays a critical role in pelvic autonomic innervation. This article offers a comprehensive overview of the surgical anatomy of the HP and provides a step-by-step description of HP dissection, with a particular emphasis on preserving the bladder nerve branches of the inferior HP. A thorough understanding and mastery of the anatomical and surgical nuances of HP dissection are crucial for optimizing outcomes in nerve-sparing gynecologic-oncological procedures.

Survival associated with extent of radical hysterectomy in early-stage cervical cancer: a subanalysis of the Surveillance in Cervical CANcer (SCCAN) collaborative study

International guidelines recommend tailoring the radicality of hysterectomy according to the known preoperative tumor characteristics in patients with early-stage cervical cancer. This study aimed to assess whether increased radicality had an effect on 5-year disease-free survival in patients with early-stage cervical cancer undergoing radical hysterectomy. The secondary aims were 5-year overall survival and pattern of recurrence. This was an international, multicenter, retrospective study from the Surveillance in Cervical CANcer (SCCAN) collaborative cohort. Patients with the International Federation of Gynecology and Obstetrics 2009 stage IB1 and IIA1 who underwent open type B/C1/C2 radical hysterectomy according to Querleu-Morrow classification between January 2007 and December 2016, who did not undergo neoadjuvant chemotherapy and who had negative lymph nodes and free surgical margins at final histology, were included. Descriptive statistics and survival analyses were performed. Patients were stratified according to pathologic tumor diameter. Propensity score match analysis was performed to balance baseline characteristics in patients undergoing nerve-sparing and non-nerve-sparing radical hysterectomy. A total of 1257 patients were included. Of note, 883 patients (70.2%) underwent nerve-sparing radical hysterectomy, and 374 patients (29.8%) underwent non-nerve-sparing radical hysterectomy. Baseline differences between the study groups were found for tumor stage and diameter (higher use of non-nerve-sparing radical hysterectomy for tumors >2 cm or with vaginal involvement; P<.0001). The use of adjuvant therapy in patients undergoing nerve-sparing and non-nerve-sparing radical hysterectomy was 27.3% vs 28.6%, respectively (P=.63). Five-year disease-free survival in patients undergoing nerve-sparing vs non-nerve-sparing radical hysterectomy was 90.1% (95% confidence interval, 87.9-92.2) vs 93.8% (95% confidence interval, 91.1-96.5), respectively (P=.047). Non-nerve-sparing radical hysterectomy was independently associated with better disease-free survival at multivariable analysis performed on the entire cohort (hazard ratio, 0.50; 95% confidence interval, 0.31-0.81; P=.004). Furthermore, 5-year overall survival in patients undergoing nerve-sparing vs non-nerve-sparing radical hysterectomy was 95.7% (95% confidence interval, 94.1-97.2) vs non-nerve-sparing 96.5% (95% confidence interval, 94.3-98.7), respectively (P=.78). In patients with a tumor diameter ≤20 mm, 5-year disease-free survival was 94.7% in nerve-sparing radical hysterectomy vs 96.2% in non-nerve-sparing radical hysterectomy (P=.22). In patients with tumors between 21 and 40 mm, 5-year disease-free survival was 90.3% in non-nerve-sparing radical hysterectomy vs 83.1% in nerve-sparing radical hysterectomy (P=.016) (no significant difference in the rate of adjuvant treatment in this subgroup, P=.47). This was confirmed after propensity match score analysis (balancing the 2 study groups). The pattern of recurrence in the propensity-matched population did not demonstrate any difference (P=.70). For tumors ≤20 mm, no survival difference was found with more radical hysterectomy. For tumors between 21 and 40 mm, a more radical hysterectomy was associated with improved 5-year disease-free survival. No difference in the pattern of recurrence according to the extent of radicality was observed. Non-nerve-sparing radical hysterectomy was associated with better 5-year disease-free survival than nerve-sparing radical hysterectomy after propensity score match analysis.

Simplified robot assisted nerve sparing radical hysterectomy for small volume cervical cancer

Simplified robot assisted nerve sparing radical hysterectomy for small volume cervical cancer

Urinary retention between nerve-sparing radical hysterectomy and radical hysterectomy for cervical cancer: A meta-analysis.

This study intended to assess the urinary retention between nerve-sparing radical hysterectomy and radical hysterectomy in cervical cancer. Relevant studies were selected from databases of PubMed, Embase, Wanfang, and China National Knowledge Internet with the last report up to January 15, 2022. Hazard ratio (HR) and 95% confidence interval (CI) were chosen as the evaluation index. Heterogeneity was assessed using Cochran Q test and I2 test. Subgroup analysis was conducted based on areas and cancer types (primary and metastatic cancer). A total of 8 articles (retrospective cohort studies) were selected in the meta-analysis. There were significant correlations between nerve-sparing radical hysterectomy and radical hysterectomy in related with urinary retention (HR [95% CI] = 1.78 [1.37, 2.31], P < .001) and (HR [95% CI] = 2.49 [1.43, 4.33], P = .001) of cervical cancer patients. Egger test revealed a significant publication bias (P = .014). Sensitivity analysis via omitting 1 study at each time showed that omission of any study made significant difference (P < .05), indicating reliability and good stability for the analysis. Additionally, there were significant heterogeneities in most subgroups.

Anatomical location of the surgically identifiable bladder branch of the inferior hypogastric plexus for nerve-sparing radical hysterectomy

ObjectiveWe aimed to demonstrate the entire structure of the inferior hypogastric plexus in the female pelvis focusing on surgically identifiable nerve bundles to the urinary bladder. MethodsSurgical videos of transabdominal nerve-sparing radical hysterectomy for 10 patients with cervical cancer at International Federation of Gynecology and Obstetrics (FIGO 2009) stage IB1–IIB were retrospectively analyzed. The paracervical tissue dorsal to the ureter was separated into the lateral component (dorsal layer of the vesicouterine ligament) and medial component (paracolpium) using Okabayashi’s technique. Any bundle-like structures in the paracervical area were isolated and divided using cold scissors, and each cut edge was inspected to determine whether the bundle was a blood vessel or a nerve. ResultsIn all cases, the surgically identifiable nerve bundle of the bladder branch was identified on the rectovaginal ligament running parallel and dorsal to the vaginal vein of the paracolpium. The bladder branch was revealed only after complete division of the vesical veins in the dorsal layer of the vesicouterine ligament where no definitive nerve bundles were observed. The bladder branch was derived laterally from the pelvic splanchnic nerve and medially from the inferior hypogastric plexus. ConclusionsThe surgical identification of the nerve bundle of the bladder branch is essential for a safe and secure nerve-sparing radical hysterectomy. The preservation of the surgically identifiable bladder branch from the pelvic splanchnic nerve as well as from the inferior hypogastric plexus can provide satisfactory postoperative voiding function.

Analysis of the Efficacy of LNSRH Surgery for Early Cervical Cancer Based on T, B, and NK Lymphocytes

Background: The analysis is based on the level of T, B, NK lymphocytes to evaluate the efficacy of laparoscopic nerve-sparing radical hysterectomy (LNSRH) for early cervical cancer. Methods: Selected 30 patients with early cervical cancer who underwent LNSRH surgery in Tianjin Fifth Central Hospital from December 2019 to January 2021 as the cervical cancer group, and 30 healthy female who underwent physical examination in our hospital during the same period were selected as the control group. The expressions of CD4+, CD8+, CD20+, and CD57+ were detected by flow cytometer, female sexual function index (FSFI) and overall assessment scale of cancer treatment function (FACT-G) score were used to evaluate female sexual function and quality of life, and the receiver operating characteristic curve (ROC) was used to analyze the expression predictive value of CD4+, CD8+, CD20+, and CD57+ in LNSRH of early cervical cancer. Results: The expression of CD4+ and CD57+ in the cervical cancer group was lower than that in the healthy group,and the expression of CD8+ and CD20+ was higher than that in the healthy group (p &lt; 0.05). The expression of preoperative CD4+ and CD57+ was higher for postoperative, and the expression of preoperative CD8+ and CD20+ was lower (p &lt; 0.05) for postoperative. The expression of postoperative 1 day CD4+ and CD57+ was higher for at 3 days postoperative, and the expression of postoperative 1 day CD8+ and CD20+ was lower at 3 days postoperative (p &lt; 0.05). CD4+, CD57+ expression was positively correlated with FSFI score, and CD8+, and CD20+ expression was negatively correlated with FSFI score, CD4+, and CD57+ expression was positively correlated with FACT-G score, and CD8+, and CD20+ expression was negatively correlated with FACT-G score (p &lt; 0.05). ROC analysis of CD4+, CD8+, CD20+, CD57+ expression sensitivity was lower than the four-item combination, the specificity was higher than the four-item combination and the results with significant statistical difference (p &lt; 0.05) and the four combined tests have good predictive value for the efficacy of LNSRH for early cervical cancer (p &lt; 0.05). Conclusions: Cervical cancer patients were mainly cellular immunity and performed low expression of CD4+, high expression of CD8+, high expression of CD20+, and low expression of CD57+. T, B, and NK lymphocytes could be used for immunological detection of cervical cancer.

Surgical Anatomy of Nerve as Seen in Nerve Sparing Radical Hysterectomy for Endometrial CA (>50% INVASION)

<h3>Study Objective</h3> surgical anatomy of nerves in nerve sparing radical hysterectomy in endometrial CA (>50% invasion). <h3>Design</h3> Prospective analysis. <h3>Setting</h3> Patient underwent 3D laparoscopy all the procedure done by experienced and qualified team/ <h3>Patients or Participants</h3> CA endometrium with >50 % invasion. <h3>Interventions</h3> Nerve sparing laparoscopy done. <h3>Measurements and Main Results</h3> in all patients reviewed at monthly interval followed by 3 monthly interval with USG (A+P) PET scan done at the end of 6 month did not reveal any recurrence. median follow-up 18 months. faster recovery of bladder function, good anorectal function, better sexual arousal and response. <h3>Conclusion</h3> By knowing the better knowledge about all pelvic nerves we can achieve a laparoscopic nerve sparing radical hysterectomy and give better life to patient. as a surgeon knowledge of predictive surgical anatomy of nerve is must.

Postsurgical urodynamic study of total laparoscopic nerve-sparing radical hysterectomy for uterine cervical cancer.

To evaluate the impact on urodynamic results between the laparoscopic nerve-sparing radical hysterectomy (LRH) following a step-by-step procedure and abdominal nerve-sparing radical hysterectomy (ARH) for patients with uterine cervical cancer. This retrospective study enrolled 76 patients with cervical cancer: 35 in the LRH group and 41 in the ARH group. We analyzed their postoperative bladder function in a urodynamics study and examined the volume of resected pelvic nerves contained in parametrial sections using S-100 antibody staining. Estimated blood loss and hospital stay after operation for the LRH group were significantly better than those in the ARH group (p < 0.0001). As well, the number of harvested lymph nodes was significantly higher in the LRH group (p=0.044). There was no difference in perioperative complications between the two groups in this study. The 5-year disease-free survival rates and overall survival rates were 91.2% and 94.0% in the LRH group and 87.8% and 95.1% in the ARH group, both respectively. Although the median residual urine volume were no statistical differences between the LRH group and the ARH group, the recovery of postoperative bladder function (uroflowmetry) in the LRH group rapidly reached presurgery levels at 1month, and the LRH group had a smaller number of s-100 antibody stained nerves contained the parametrial sections. We demonstrated that LRH following a step-by-step procedure could achieve a higher level of prevention of damage to the bladder branch of the pelvic splanchnic nerve plexus and thus restore bladder function more rapidly.

The Effects of Hysterectomy on Urinary and Sexual Functions of Women with Cervical Cancer: A Systematic Review.

This systematic review aims at describing the prevalence of urinary and sexual symptoms among women who underwent a hysterectomy for cervical cancer. A systematic search in six electronic databases was performed, in September 2019, by two researchers. The text search was limited to the investigation of prevalence or occurrence of lower urinary tract symptoms (LUTS) and sexual dysfunctions in women who underwent a hysterectomy for cervical cancer. For search strategies, specific combinations of terms were used. A total of 8 studies, published between 2010 and 2018, were included in the sample. The average age of the participants ranged from 40 to 56 years, and the dysfunctions predominantly investigated in the articles were urinary symptoms (n = 8). The rates of urinary incontinence due to radical abdominal hysterectomy ranged from 7 to 31%. The same dysfunction related to laparoscopic radical hysterectomy varied from 25 to 35% and to laparoscopic nerve sparing radical hysterectomy varied from 25 to 47%. Nocturia ranged from 13%, before treatment, to 30%, after radical hysterectomy. The prevalence rates of dyspareunia related to laparoscopic radical hysterectomy and laparoscopic nerve sparing radical hysterectomy ranged from 5 to 16% and 7 to 19% respectively. The difficulty in having orgasm was related to laparoscopic radical hysterectomy (10 to 14%) and laparoscopic nerve sparing radical hysterectomy (9 to 19%). Urinary and sexual dysfunctions after radical hysterectomy to treat cervical cancer are frequent events. The main reported disorders were urinary incontinence and dyspareunia.

Sexuality and quality of life after nerve-sparing radical hysterectomy for cervical cancer: A prospective study

ObjectiveNerve-sparing radical hysterectomy (NSRH) decreases the negative postoperative consequences of radical surgery for cervical cancer, such as bladder evacuation disorders, colorectal motility disorders, and sexual dysfunction. The aim of this study was to prospectively assess the sexuality and quality of life in a group of women who underwent NSRH with lymphadenectomy for cervical cancer. Materials and methodsA total of 65 patients with early-stage cervical cancer underwent NSRH between 2014 and 2016. Patient examinations and questionnaire surveys (Female Sexual Function Index questionnaire and European Organization for Research and Treatment of Cancer questionnaires QLQ-C30 and QLQ-CX24) were conducted, before and one year after the surgery. ResultsAfter the exclusion of 19 sexually inactive women and 10 women who received adjuvant anticancer treatment, 36 sexually active patients treated solely with nerve-sparing surgery were eligible for evaluation. The mean age was 47 years. The average preoperative vaginal length was 9.4 cm, whereas the postoperative length was shortened to 7.1 cm. This study showed no negative impact of NSRH on sexual desire, arousal, satisfaction, orgasm, pain, sexual activity, sexual enjoyment, and sexual worry. The worsening of sexual functioning was recorded during the one-year follow-up. The QLQ-C30 questionnaire confirmed postoperative improvement in global health status and role, emotional, and social functioning. ConclusionOur study showed using standardized questionnaires that NSRH has no negative impact on sexual desire, arousal, satisfaction, orgasm, pain, sexual activity, frequency of sexual intercourse, sexual enjoyment, and sexual worry, while only the worsening of sexual functioning was recorded. Moreover, NSRH did not cause postoperative deterioration in the quality of life parameters.

Surgical and functional impact of nerve-sparing radical hysterectomy for parametrial deep endometriosis: a single centre experience.

Deep endometriosis (DE) usually creates a distortion of the retroperitoneal anatomy and may infiltrate the parametria with an oncomimetic pathway similar to cervical cancer. The condition represents a severe manifestation of endometriosis that may result in a functional impairment of the inferior hypogastric plexus. An extensive surgical resection may be required with an associated risk of increased neurogenic postoperative pelvic organ dysfunction. To evaluate the post-operative function and complications following hysterectomy with posterolateral parametrial resection for DE. In total, 23 patients underwent radical hysterectomy for DE with the parametria involved. The severity of pain was assessed by the Visual Analogue Scale (VAS) score. The KESS, GQLI, BFLUTS and FSFI were used to examine the gastrointestinal, urinary and sexual functions respectively. Intra and post-operative complications were recorded. The main outcomes were gastrointestinal, urinary and sexual function and intra and post-operative complications. Dyschezia, dyspareunia and chronic pelvic pain were significantly reduced following hysterectomy. Furthermore, an improvement of gastrointestinal function was observed, while sexual functions, examined by FSFI and urinary symptoms, examined by BFLUTS, was not shown to be significant. The modified nerve-sparing radical hysterectomy for DE results in an improvement of symptoms. Nevertheless, despite the nerve-sparing approach, this procedure may be associated with a not-negligible risk of post-operative bladder voiding deficit. This is the first study that focuses on parametrial endometriosis using validated questionnaires to assess functional outcomes following radical hysterectomy for DE.

Stage FIGO IB1 lymphoepithelioma-like carcinoma of the uterine cervix in a 57-year-old female

Lymphoepithelioma-like carcinoma (LELC) of the uterine cervix is a rare type of cervical cancer. The etiopathogenesis of cervical LELC involves consideration of the human papillomavirus (HPV) and Epstein–Barr virus infection. We present the case of a 57-year-old female diagnosed with a unique HPV-59 with the absence of Epstein–Barr virus, which is characteristic for European women. The treatment included a radical hysterectomy with nerve-sparing radical hysterectomy, which has not been used in patients with LELC so far. Complementary treatment included combined radiotherapy and cisplatin infusion.

Survival Impacts of Perineural Invasion on Patients Under Different Radical Hysterectomies Due to Early Cervical Cancer.

ObjectiveCervical cancer is a common gynecological malignancy. In addition to the open radical hysterectomy (ORH) and laparoscopic radical hysterectomy (LRH), laparoscopic nerve-sparing radical hysterectomy (LNSRH) could be another treatment option since it could preserve urinary, colorectal, and sexual functions. However, LNSRH might result in early cancer metastasis and recurrence due to inadequate tumor resection. Additionally, whether LNSRH should be considered based on perineural invasion (PNI) status remains controversial. To assess different types of hysterectomy on the outcome of early cervical cancer with PIN.MethodsA retrospective study was performed in early cervical cancer patients who received ORH, LRH, or LNSRH between January 2012 and December 2019. Age, FIGO cancer stages, histopathological types, tumor size, histological grade, invasion depth, lymph node metastasis, lymphovascular space invasion, and PNI were documented. Disease-free survival (DFS) and overall survival (OS) were recorded.ResultsA total of 174 patients were included, with 33, 69, and 72 patients received LRH, ORH, and LNSRH, respectively. Twenty-one patients (12.1%) had PNI. DFS (P = 0.000) and OS (P = 0.022) periods were shortened in positive PNI patients than in negative PNI patients (P = 0.000 and 0.022, respectively). In patients with positive PNI, lymph node metastasis, but not the surgery type, was an independent risk factor for DFS and OS (P = 0.000).ConclusionEarly cervical cancer patients with PNI had shorter postoperative DFS and OS periods. In these patients, lymph node metastasis, but not the type of hysterectomy, was independently associated with DFS and OS.

A simplified procedure of nerve-sparing radical hysterectomy.

We devised a simplified nerve-sparing radical hysterectomy that is simpler than commonly used procedures. We retrospectively examined 16 cases of classical non-nerve-sparing radical hysterectomy (non-nerve-sparing group) and 16 cases of simplified nerve-sparing radical hysterectomy (nerve-sparing group) performed between 2019 and 2020. We examined and compared the duration of surgery, blood loss, perioperative complications, postoperative urinary function (presence or absence of urinary sensation, number of days with residual urine measurement, and frequency and duration of oral sustained release urapidil capsules and self-catheterization), and short-term prognosis between the two groups. Compared to conventional non-nerve-sparing radical hysterectomy, the duration of surgery for nerve-sparing radical hysterectomy was significantly shorter (407 [339-555] min vs. 212 [180-356] min; p < 0.001), and blood loss was significantly less. Compared to the nerve-sparing group, the non-nerve-sparing group had more cases of oral urapidil use and a higher frequency of clean intermittent catheterization. Clean intermittent catheterization was required in two cases in the nerve-sparing group; however, it was withdrawn at 180 and 240 days. Conversely, clean intermittent catheterization was still required in three cases in the non-nerve-sparing group. There were no statistically significant differences in progression-free survival and overall survival between the two groups. The simple nerve-sparing radical hysterectomy resulted in shorter duration of surgery and less blood loss as well as in a clear improvement in the postoperative urinary status and short-term prognosis. This technique simplifies nerve-sparing radical hysterectomy, which is commonly thought to be complicated, making it easier to understand.

Type C1 radical hysterectomy in advanced squamous cell carcinoma of the cervix postdefinitive concurrent chemoradiation: An argument.

This study aimed to evaluate the feasibility and outcomes of patients with advanced cervical cancer treated with definitive concurrent chemoradiotherapy followed by Type C 1 nerve-sparing radical hysterectomy. This is a prospective study to assess the feasibility of Type C 1 nerve-sparing radical hysterectomy postdefinitive chemoradiation in advanced carcinoma cervix. We analyzed 25 patients with cervical cancer evaluated and treated with concurrent chemoradiation followed by surgery. Twenty patients underwent Type C 1 nerve-sparing radical hysterectomy by open surgery and five patients by laparoscopic approach. Postoperative morbidity and pathology were analyzed. Analysis of the outcomes was done by arithmetical calculations. Eight patients (32%) had persistent residual disease after definitive chemoradiation followed by surgery. Rest of the patients had pathological complete response. Two patients (8%) had node-positive disease. None of the patients in the laparoscopic group had bladder morbidity. One patient in the laparoscopic group had persistent vaginal discharge. Type C1 nerve-sparing radical hysterectomy is technically feasible with minimal morbidity following definitive chemoradiation in advanced squamous cell carcinoma of the cervix.

Surgery for cervical cancer: consensus & controversies.

Surgery plays an important role in the management of early-stage cervical cancer. Type III radical hysterectomy with bilateral pelvic lymph node dissection using open route is the standard surgical procedure. There is level I evidence against the use of laparoscopic/robotic approach for radical hysterectomy for cervical cancer. Emerging data support the use of sentinel lymph node biopsy and nerve sparing radical hysterectomy in carefully selected patients with early-stage disease. In locally advanced cervical cancer patients, the use of neoadjuvant chemotherapy (NACT) followed by radical surgery yields inferior disease-free survival compared to definitive concurrent chemoradiation therapy. Therefore, definitive concurrent chemoradiation is the standard treatment for locally advanced disease. Fertility preserving surgery is feasible in highly selected young patients. Role of less-radical surgical procedures in patients’ with low-stage disease with good prognostic factors is under evaluation.

Nerve-Sparing Robotic Radical Hysterectomy for the Beginner in Robotic Surgery.

Robotic surgery is considered to be the optimal means of performing nerve-sparing radical hysterectomy (RH) because this procedure requires very precise surgery. Nerve-sparing RH has become increasingly popular in Japan. However, with open surgery the operating field is only visible to the surgeon performing this delicate procedure, which makes it difficult to educate trainee assistants. However, robotic surgery provides an expanded operation field that is visible to the surgeon and assistants, which makes it suitable for teaching purposes. To perform this procedure, it is necessary to become proficient in RH by laparotomy and then to become familiar with the characteristics of robotic surgery. In shifting from laparotomy to robotic surgery, we have found that experience with open surgery does not fully prepare surgeons for the new experiences and discoveries associated with robotic surgery, which may initially be problematic. We here provide clear instructions for the procedure with notes concerning particular potentially problematic aspects.

Nerve-Sparing Radical Hysterectomy Using the Okabayashi-Kobayashi Method.

Radical hysterectomy (RH) is a standard treatment for early-stage cervical cancer. This surgery extirpates the uterus along with the paracervical tissues, vagina, and the paracolpium to achieve local control. Pelvic lymphadenectomy is a critical component of RH performed for regional control. A clear understanding of pelvic anatomy is critical to safely performing a RH and achieving optimal oncological and functional outcomes. The various surgical steps can damage the pelvic autonomic nerves, and a systematic nerve-sparing technique is used for the preservation of autonomic nerves. There is an intricate vascular network in the lateral paracervix (cardinal ligament) and the pelvic sidewall. We need to comprehend the three-dimensional structure of the vascular and nerve anatomy in the pelvis to perform RH effectively and safely. We can create six spaces around the uterine cervix, including the paravesical spaces, pararectal spaces, a vesicovaginal space, and a rectovaginal space to reveal the target of extirpation. It is critical to find the proper tissue plane separated by the layers of membranous connective tissue (fascia), in order to minimize intraoperative bleeding.