Okabayashi's Radical Hysterectomy Research Articles

The Okabayashi Radical Hysterectomy: Basic Principle and Step-by-Step Procedure.

Abdominal radical hysterectomy is the standard operation for stage IB–IIB cervical cancer in the world, which was established by Professor Hidekazu Okabayashi in 1921. In this article, the basic principle and step-by-step procedure of Okabayashi radical hysterectomy are presented, especially for young doctors to understand clearly the important points of this surgery and to realize its radicality and safety for better survival and quality of life of patients with cervical cancer.

A Novel Direct Approach to the Deep Uterine Vein in Laparoscopic Radical Hysterectomy

To describe a direct approach to the deep uterine vein in laparoscopic radical hysterectomy. Demonstration of the laparoscopic technique with narrated video footage. Securing sufficient radicality is extremely important when performing a radical hysterectomy for cervical cancer, either by laparotomy or by minimally invasive surgery. The nerve-sparing Okabayashi radical hysterectomy (NS-RH) was originally aimed at achieving both radical resection and function preservation [1-3]. A key procedure when performing NS-RH is intraoperative identification of the relationship between the deep uterine vein and pelvic splanchnic nerve fibers [4]. With this in mind, a safe and easy method for identifying the crossing point of the deep uterine vein and pelvic splanchnic nerve in the initial phase of the surgery may greatly improve the safety and efficacy of functional preservation in NS-RH. Herein, we describe a minimally invasive "direct approach" to the deep uterine vein. Before undergoing the pelvic lymphadenectomy, all steps of laparoscopic radical hysterectomy were performed. First, we identified the ureter on the posterior peritoneum, and the peritoneum was dissected just above the ureter. By continuously exploring the pelvic cavity along the ureter, especially through the opening of the space below the ureter in a cranial to caudal direction, we could easily identify the deep uterine vein. This procedure also exposed the fibers of the hypogastric nerve, clarifying the relationship of these structures. Because the relationship between the deep uterine vein and nerve fibers is the most important guidepost of this surgery, their identification in the early phase of the surgery enables us to perform the subsequent procedure precisely and securely. This direct approach to the deep uterine vein can be easily and safely performed.

Original film of the Okabayashi's radical hysterectomy by Okabayashi himself in 1932, and two films of the precise anatomy necessary for nerve-sparing Okabayashi's radical hysterectomy clarified by Shingo Fujii

Almost 100 years ago, radical hysterectomy was established by Ernst Wertheim as the surgical technique for the treatment of invasive cervical cancer. However, due to the complicated anatomy of the female pelvis, the method has been modified by many surgeons. Among these modifications, the method by Hidekazu Okabayashi at Kyoto Imperial University in Japan, published in 1921, was more radical and outstanding. Then, Okabayashi's method became a standard surgical procedure for invasive cervical cancer in Japan. We have discovered the historical film of radical hysterectomy performed by Okabayashi himself in 1932. In order to share the information of Okabayashi's radical hysterectomy, we decided to distribute the film through the website of IJGC. Moreover, as the direct descendant of Okabayashi, I have further modified the operation clarifying precise anatomy necessary for Okabayashl's radical hysterectomy. In addition, I also clarified the anatomy necessary for nerve sparing Okabayashi's radical hysterectomy. These two films modified by Shingo Fujii are also available on the IJGC website in the hope that these anatomical findings will be useful for young gynecologic surgeons.

Anatomic identification and functional outcomes of the nerve sparing Okabayashi radical hysterectomy

Objectives. To clarify the anatomy necessary for the nerve sparing Okabayashi's radical hysterectomy, we meticulously separated the blood vessels and connective tissues to preserve the pelvic splanchnic nerve, the hypogastric nerve, and the bladder branch of the inferior hypogastric plexus under magnification (× 2.5) during the Okabayashi radical hysterectomy. Methods. Twenty-four patients (FIGO stage IB, n = 22, and stage IIA, n = 2) underwent meticulous nerve sparing radical hysterectomy during 2004 to 2006. Postoperative assessment of bladder function consisted of the time to (a) achieve a postvoid residual urine volume (PVR) less than 50 ml, (b) obtain a sensation of bladder fullness, and (c) obtain satisfaction of micturition. Results. Isolation of the deep uterine vein could preserve one of the branches of the pelvic splanchnic nerve. The hypogastric nerve in the lateral rectal wall was isolated to the inferior hypogastric plexus. During the division of the posterior leaf of the vesicouterine ligament (VUL), isolation of the inferior vesical vein could reveal the bladder branch from the inferior hypogastric plexus. Only the uterine branch from the inferior hypogastric plexus was isolated and divided. Then, the T-shaped nerve plane consisting of the hypogastric nerve, the pelvic splanchnic nerve and the bladder branch from the inferior hypogastric plexus is preserved. Urinary functions: (a) 11 out of 24 patients had measured PVR of less than 50 ml by postoperative day (POD) 14 and all patients had achieved this by day 21 (mean POD: 14.64 ± 2.04). (b) Twenty-two out of 24 patients reported a sensation of bladder fullness by POD 14 and all by POD 21 (mean POD: 11.25 ± 1.78). (c) Seventeen out of 24 patients reported satisfaction of micturition by POD 14 and all by POD 21 (mean POD: 12.34 ± 2.32). Conclusion. In order to accomplish the nerve sparing Okabayashi's radical hysterectomy, it is necessary to meticulously divide the posterior leaf of the vesicouterine ligament. By the separation of the inferior vesical vein in the posterior leaf of the vesicouterine ligament, the bladder branch from the inferior hypogastric plexus can be identified and preserved. All patients recovered their urinary function completely by POD 21.

Effect of simple omentoplasty and omentopexy in the prevention of complications after pelvic lymphadenectomy

This multicenter collaborative study prospectively evaluated the effect of omentoplasty and omentopexy on the prevention of complications after pelvic lymphadenectomy. Sixty-four consecutive patients (42 cervical and 22 endometrial cancer) were enrolled and examined periodically for 12 months. All patients underwent simple, semiradical, or Okabayashi's radical hysterectomy and complete pelvic lymphadenectomy. The infracolic omentum was longitudinally divided in half and omentoplasty was performed so that bilateral omental flaps would reach the pelvic floor. The omental flaps were inserted into the retroperitoneal space and the edges of the flaps were sutured to the psoas muscle. The omental flap was then covered by the peritoneum. Incidence of lymphocele, lymphedema, and severe complications associated with lymphocele, such as infection or urinary stenosis, was evaluated at intervals for at least one year after surgery.Among the 64 patients, 12 patients received pelvic radiation because of occult lymph node metastasis. Planned omentoplasty was not possible in one patient because her omentum was too small; therefore, only unilateral omentopexy was performed. Asymptomatic lymphoceles only were detected by ultrasonogram in 12 patients (18.8%). Three patients (4.7%) had a symptomatic but pressure-only lymphocele. Hydronephrosis and bladder compression probably due to lymphocele were observed in one patient, respectively (3.1%), but resolved within 6 months. Lymphedema was observed in seven patients (10.9%) and persisted for more than 6 months in two patients (3.1%). We conclude that this simple technique of omentoplasty and omentopexy appeared to be effective in reducing the incidence of complications after pelvic lymphadenectomy.

Recurrent cervical carcinoma after radical hysterectomy: an analysis of clinical aspects and prognosis.

Samlal RAK, van der Velden J, van Eerden T, Schilthuis MS, Gonzalez Gonzalez D, Lammes FB. Recurrent cervical carcinoma after radical hysterectomy: an analysis of clinical aspects and prognosis. Int J Gynecol Cancer 1998; 8: 78-84. The purpose of the present study was to evaluate the clinical aspects and prognosis of patients with tumor recurrence in surgically treated stage IB and IIA cervical carcinoma patients. Two hundred and seventy-one stage IB and IIA cervical carcinoma patients underwent a Wertheim Okabayashi radical hysterectomy with pelvic lymphadenectomy. The median follow-up time was 60 months. Recurrence occurred in 27 patients (10%): 14 had a pelvic recurrence and 13, and extrapelvic recurrence. The site of recurrence was influenced by various pathological factors as well as by the primary treatment mode. 77% of recurrences were detected within three years after primary treatment. The median recurrence-free interval in patients with a pelvic recurrence was significantly shorter than in patients with an extrapelvic recurrence (14 months vs. 17 months, P = 0.03). The mortality rate of the group of patients with recurrent disease was 85% (23/27). Patients with a pelvic central recurrence had a significantly better outcome than did patients whose recurrences were located at the pelvic sidewall. Two patients with a pulmonary recurrence were treated with surgery and show no evidence of disease after 4 and 8 years respectively, of follow-up. The overall detection rate of recurrent disease by routine follow-up was only 36%. However, asymptomatic patients had a significantly better prognosis when compared with symptomatic patients. Therefore, we recommend frequent follow-up visits during the first 3 years after primary treatment to detect recurrence in an early stage.

Pelvic lymph node metastasis of uterine cervical cancer

The state of pelvic lymph node metastasis was observed in 627 cases of Okabayashi's radical hysterectomy performed from 1950 to 1984 of which 589 cases with a known 5-year survival rate were examined according to their relationship to prognosis. (1) The incidence of lymph node metastasis was 29.7%, becoming progressively higher with succeeding clinical stages. (2) The metastasis rates according to site were 6.9% hypogastric nodes, 4.9% obturator nodes, 4.4% iliac nodes, and 25.0% parametrial nodes. (3) Among the factors considered in the postoperative classification, lymph node metastasis demonstrated high values in cervical infiltration cancer, positive parametrial infiltration, positive vaginal invasion, and infiltration into the uterine body and L type of CPL classification. (4) The 5-year survival rate was 83.0% in negative cases of pelvic lymph node metastasis, while in positive cases, it was as poor as 45.8%. (5) Considering the relationship of various factors, it is shown that the presence of lymph node metastasis has a great effect on prognosis.

Recurrent carcinoma of the vagina following Okabayashi's radical hysterectomy for cervical carcinoma

Between 1962 and 1976, 1847 cases of cervical cancer were treated by Okabayashi's radical hysterectomy. Of these, 42 cases developed vaginal invasive carcinoma and 5 developed vaginal intraepithelial carcinoma thereafter, giving a recurrence rate of 2.5%. The vaginal recurrence rate declined annually during the period 1962–1976, and was thought to be due to the efficacy of routinization of postoperative vaginal cuff irradiation. Of the 47 recurrent cases 33 were discovered within 2 years following the operation. Seventy-two percent of the recurrent cases were asymptomatic. The importance of close follow-up of the patients during the first 2 postoperative years was denoted. The incidence of developing a secondary vaginal cancer in the cases of cervical adenocarcinoma was 10.0%, higher than the 2.2% for squamous cell carcinoma. All the recurrent cases were treated with vaginal cuff irradiation, either alone or with external irradiation and/or chemotherapy. The 3-year survival rate of the patients who had vaginal recurrence alone was 40.0%, better than that of the cases accompanied with recurrence at the other sites.