Vesicouterine Ligament Research Articles

Clinical implications of the superficial uterine vein pattern for the dissection of the anterior layer of the vesicouterine ligament in radical hysterectomy.

To describe anatomic patterns of the superficial uterine vein (sUV) and assess their association with aspects of the dissection procedure of the anterior layer of the vesicouterine ligament (aVUL) by retrospectively reviewing surgical videos. We analyzed patients who underwent laparoscopic radical hysterectomy for early-stage cervical cancer from 2014 to 2019. The primary endpoint was the time required for aVUL dissection. Multiple linear regression analyses were performed to identify factors influencing the time required for aVUL dissection. Fifty-three Japanese patients were included. Two sUV configurations were observed: type 1 (the vein ran ventral to the ureter along the uterine artery) and type 2 (the vein did not run along the usual ventral course; it ran dorsal to the ureter or was absent). Approximately 30% of the sUVs were type 2. The total time for dissection of both sides of the aVUL was significantly shorter for type 2 sUVs than for type 1 sUVs. The number of hemostatic interventions during dissection of each side of the aVUL was significantly lower for type 2 sUVs than for type 1 sUVs. In the multivariate analysis, the sUV configuration was the factor significantly influencing the duration of aVUL dissection on each side (right side: β=-143.4; left side, β=-160.4). We demonstrated that the sUV had 2 types of courses, ventral and others, and its course affected the time required for dissection and the number of hemostatic interventions. Our results provide information supportive of improved radical hysterectomy outcomes.

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.

A confirmatory trial of modified radical hysterectomy for patients with FIGO stage IB1 cervical cancer with tumor diameter preoperatively estimated at 2 cm or less: Japan Clinical Oncology Group study, JCOG1101.

5532 Background: The standard surgery for Stage IB1 uterine cervical cancer is radical hysterectomy (RH, Piver class III hysterectomy). However, RH is highly invasive, and there is a need to establish less invasive techniques. We conducted a single-arm confirmatory trial (JCOG1101) to evaluate the efficacy and safety of modified radical hysterectomy (MRH) in patients with tumor diameter ≤ 2 cm Stage IB1 cervical cancer (jRCT: jRCTs031180167). Methods: From January 2013 to August 2017, 240 patients were enrolled from 40 institutions in Japan. Eligibility criteria included: (1) FIGO 2008 Stage IB1 cervical cancer; (2) histologically proven squamous cell carcinoma, adenocarcinoma (mucinous or endometrioid) or adenosquamous carcinoma; (3) tumor diameter ≤ 2 cm (measured by MRI or conization specimen); and (4) neither distant LN metastasis nor distant metastasis in CT. In case that the cancer could be microinvasive, conization was required to exclude Stage IA cases. The protocol surgery involved cutting the anterior layer of the vesicouterine ligament of the uterus and dissecting regional lymph nodes. Only laparotomy was permitted: laparoscopy and robotic surgery were not allowed. Postoperative irradiation was administered in cases where pelvic LN or parametrial invasion was positive, depth in the cervical wall invasion was ≥ 2/3, or surgical margin was < 1 cm by pathological findings. The primary endpoint was 5-year overall survival (OS). We set the expected 5-year OS of MRH at 95.8% (5-year OS of RH in JCOG0806A, retrospective observational study) and the threshold 5-year OS at 90.8%. Results: Among 225 eligible patients, 193 (85.8%) were pT1b1 (UICC 7th), and 184 (81.8%) had pathological maximal tumor diameter ≤ 2 cm. Parametrial involvement, lymph node metastasis, ≥ 2/3 stromal invasion and < 1 cm surgical margin were observed in 3 (1.3%), 16 (7.1%), 30 (13.3%) and 11 (4.9%) patients, respectively. Thirty-nine patients (17.3%) underwent adjuvant (chemo)radiation. Median follow-up was 77.7 months. Five patients (2.2%) died, and 5-year OS was 98.2% (90% CI: 96.0-99.2, > 90.8%). Thirteen patients (5.8%) relapsed (8 local recurrence and 5 distant recurrence), and 5-year relapse-free survival was 94.7% (95% CI: 90.8-96.9%). Self-urination was observed in all patients, and residual urine disappearance up to 56 days after urethral catheter removal was observed in 213 patients (94.7%). Median time to disappearance of residual urine after urethral catheter removal was 1 day. There was no treatment-related death. Grade 3/4 non-hematological adverse events were observed in 17 patients (7.6%), including 8 infection and 4 hemorrhage. Conclusions: In this study, MRH was as effective as RH and less invasive. MRH can be considered a standard surgery for tumor diameter ≤ 2 cm Stage IB1 uterine cervical cancer. Clinical trial information: UMIN000009726 , jRCTs031180167 .

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.

Nerve-Sparing Radical Hysterectomy: Kobayashi's Method.

After Prof. S. Okabayashi introduced Okabayashi Operation in 1921, several surgeons introduced numerous improvements in Japan. One of them is so-called the Tokyo Method which was improved and revised by Dr. Kyusaku Ogino (1950), Prof. Takashi Kobayashi, University of Tokyo (1961, 1970), and Prof. Shoichi Sakamoto, University of Tokyo (1981). The nerve-sparing radical hysterectomy without sacrificing radicality was introduced in 1961 1 and improved in 1970 by Prof. Kobayashi. 2 The autonomic nerve pathway including hypogastric nerve (sympathetic nerve), pelvic splanchnic nerve (parasympathetic nerve), and pelvic nerve plexus as a junction of the two nerves and the branch of the plexus to the bladder (vesical nerve branch) are preserved except in advanced cases. He divided the process of nerve-sparing surgery into four steps for separating the autonomic nerve pathway from adjacent tissues along the pathway consisting of cardinal, sacrouterine, rectouterine/vaginal, and vesicouterine ligaments. The first step is separation of the cardinal ligament (deep uterine vessels) from the pelvic splanchnic nerve. The second step is separation of the medial side of severed cardinal ligament from the pelvic nerve plexus. The first and second steps are performed in the lateral side of the autonomic nerve system. The third step is separation of sacrouterine and rectouterine/vaginal ligaments from hypogastric nerve and pelvic nerve plexus. The third step is necessary for achieving high radicality, namely, for severing the sacrouterine and rectouterine/vaginal ligaments near the rectum without damage to the pelvic nerve plexus. The fourth step is separation of paravaginal tissues and posterior (deep) layer of the vesicouterine ligament from the vesical nerve branches of the plexus. The third and fourth steps are performed in the medial side of the autonomic nerve system.

Ultrasound of the Uterosacral Ligament, Parametrium, and Paracervix: Disagreement in Terminology between Imaging Anatomy and Modern Gynecologic Surgery.

Ultrasound is an effective tool to detect and characterize lesions of the uterosacral ligament, parametrium, and paracervix. They may be the site of diseases such as endometriosis and the later stages of cervical cancer. Endometriosis and advanced stages of cervical cancer may infiltrate the parametrium and may also involve the ureter, resulting in a more complex surgery. New functional, surgical anatomy requires the complete diagnostic description of retroperitoneal spaces and tissues that contain vessels and nerves. Most endometriosis lesions and cervical cancer spread involve the cervical section of the uterosacral ligament, which is close to tissues, namely the parametrium and paracervix, which contain vessels and important nerves and nerve anastomoses of the inferior hypogastric plexus. Efferent fibers of the plexus travel to the rectum, uterus, rectovaginal ligament, deep vesicouterine ligament, and bladder. These efferent fibers are essential for bladder and rectal functionality so tailored nerve-sparing surgery became a standard approach for treating deep infiltrating endometriosis and cervical cancer. An accurate diagnosis by ultrasound has significant clinical impact and is important for appropriate treatment. In this article, we try to establish a common terminology between imaging diagnostic and modern surgical anatomy.

Laparoscopic Nerve Sparing Technique for Bladder Endometriosis Infiltrating the Anterior Parametrium

Study Objective The purpose of this video is to demonstrate the Nerve Sparing (NS) technique for resection of infiltrating endometriosis on the upper part of the trigone, which extends to the left anterior parametric (deep portion of the vesicouterine ligament). Design The NS technique for resection of an endometriotic lesion infiltrating the anterior parametrium aims at preserving the anterior efferent bundles (vesical nerve), which transmit the parasympathetic stimuli for the contraction of the detrusor muscle (motor nerve). Setting Cystoscopy was used to determine the exact location of the lesion in relation to the trigone and ureteral openings. The laparoscopic procedure was performed with a 3D camera. Patients or Participants A 38-year-old patient presented with cyclic urinary pain. MRI showed a 3.0 cm endometriotic lesion located on the upper part of the trigone, close to the ureteral opening and extending to the deep portion of the vesicouterine ligament. The lesion was palpable upon vaginal touch. Interventions The vesicocervical and vesicovaginal spaces were dissected and the endometriotic lesion was individualized. The left vesicouterine ligament was isolated and the structures were individualized. The vesical arteries (superior, middle and inferior) were dissected and the first two were sectioned. The uterine artery and the ureter were individualized and isolated through dissection and sectioning of the intraligamentous connective tissue, thus, separating them from the infiltrative lesion. The lesion was removed and the bladder was sutured. The left anterior efferent bundles, coming from the inferior hypogastric plexus and originating from S2-S3-S4 (Pelvic Splancnic Nerves), were identified and preserved. Measurements and Main Results There were no intraoperative complications. After 1 year the patient remains asymptomatic. MRI in the 3rd postoperative month showed absence of endometriotic lesion. Conclusion The Laparoscopic Nerve Sparing technique is safe and effective to treat bladder endometriosis infiltrating the anterior parametrium.

Three Ways of Approach for Uterine Cervical Myoma during Laparoscopic Hysterectomy

Study Objective To show surgical strategy during laparoscopic hysterectomy for cervical myomas. Design Step-by-step video demonstration of the surgical procedure. Setting Leiomyomas location in the uterine cervix can reduce the mobility of the uterus and also distort the anatomical position of neighboring structures, such as the uterine artery and ureter, possibly leading to massive bleeding or ureteral injury. Thus, the surgery for cervical myomas is difficult and challenging. In this presentation, I will show our surgical strategy during laparoscopic hysterectomy for cervical myomas. Patients or Participants N/A Interventions We categorize our approaches to cervical myoma into three methods based on the myoma size and the mobility of the uterus. 1. The first method is to perform standard Total laparoscopic hysterectomy(TLH) using our usual steps. However, the lateral mobilization of the ureter is occasionally necessary to dissect the area around the cervix and parametrium safely, consequently, separation of the anterior leaf of the vesicouterine ligament may be necessary. 2.The second method is to perform partial or total enucleation of the leiomyoma via laparoscopy. After reducing the volume of the uterus and obtaining uterine mobility by enucleation, hysterectomy is performed. 3. The third method is transvaginal myomectomy assisted laparoscopic hysterectomy. Due to poor Mobility of the uterus, large volume of the myoma and limited working space, we couldn't perform enucleation of the myoma via laparoscopy. Therefore, we tried to performed transvaginal myomectomy. After that, we could resect the uterus via laparoscopy. However, this technique is possible only if there is adequate surgical space in the vagina, and the cul-de-sac can be reached easily. Measurements and Main Results Laparoscopic surgery was completed safely without requiring a conversion to laparotomy. Conclusion Using these three methods step by step customizing the surgery to best address each case, safe laparoscopic surgery is possible, and open surgery can be avoided.

A practical method of using the anatomical space of the vesicouterine ligament for laparoscopic radical hysterectomy: a retrospective cohort study.

ObjectiveTo investigate the practicality of a new method using anatomical spaces for performing standard laparoscopic radical hysterectomy (LRH) without ureteral injury in patients with cervical cancer.MethodsClinicopathological characteristics and perioperative complications were retrospectively analysed in 440 patients with stages IB1 to IIB cervical cancer. The patients were assigned to two of the following groups: LRH by our method of using anatomical landmarks (anatomical space group, n = 217) and the traditional method (traditional group, n = 223).ResultsThe mean operative duration and time of vesicouterine ligament (VUL) dissection were significantly shorter (173.87 ± 30.39 vs. 210.83 ± 44.55 minutes; 32.75 ± 7.23 vs. 43.48 ± 11.22 minutes), and blood loss was less in the anatomical space group compared with the traditional group. The rate of the intraoperative complication of ureteral injury was also significantly lower in the anatomical space group compared with the traditional group (0 vs. 5).ConclusionsLRH by the anatomical method, using the axillary space and other potential spaces as anatomical landmarks, results in less blood loss and reduced ureteral injury compared with the traditional method. This method is safe and practical for separating the ureter from the VUL in patients with cervical cancer.

Standardized terminology of apical structures in the female pelvis based on a structured medical literature review

The objectives of this study were to review the published literature and selected textbooks, to compare existing usage to that in Terminologia Anatomica, and to compile standardized anatomic nomenclature for the apical structures of the female pelvis. MEDLINE was searched from inception until May 30, 2017, based on 33 search terms generated by group consensus. Resulting abstracts were screened by 11 reviewers to identify pertinent studies reporting on apical female pelvic anatomy. Following additional focused screening for rarer terms and selective representative random sampling of the literature for common terms, accepted full-text manuscripts and relevant textbook chapters were extracted for anatomic terms related to apical structures. From an initial total of 55,448 abstracts, 193 eligible studies were identified for extraction, to which 14 chapters from 9 textbooks were added. In all, 293 separate structural terms were identified, of which 184 had Terminologia Anatomica-accepted terms. Inclusion of several widely used regional terms (vaginal apex, adnexa, cervico-vaginal junction, uretero-vesical junction, and apical segment), structural terms (vesicouterine ligament, paracolpium, mesoteres, mesoureter, ovarian venous plexus, and artery to the round ligament) and spaces (vesicocervical, vesicovaginal, presacral, and pararectal) not included in Terminologia Anatomica is proposed. Furthermore, 2 controversial terms (lower uterine segment and supravaginal septum) were identified that require additional research to support or refute continued use in medical communication. This study confirms and identifies inconsistencies and gaps in the nomenclature of apical structures of the female pelvis. Standardized terminology should be used when describing apical female pelvic structures to facilitate communication and to promote consistency among multiple academic, clinical, and surgical disciplines.

Laparoscopic technique for step-by-step nerve-sparing Okabayashi radical hysterectomy

In Japan, the standard procedure for radical hysterectomy is based on Okabayashi’s approach reported in 1921.[1][1] A novel aspect of this technique is the discovery of the paravaginal space between...

Clinical Anatomy Required in Identifying Pelvic Autonomic Nerve System

Video Objective Comprehension of structure of pelvic autonomic nerve system is mandatory for constant preservation of voiding function while maintaining oncological outcome of radical hysterectomy. Setting 47 years old, cervical cancer T1bN0M0. Total laparoscopic nerve sparing radical hysterectomy is presented. Interventions Superior hypogastric nerve plexus and inferior hypogastric nerves are in the same layer between pararectal space of Latzko and Okabayashi. Two subperitoneal fasciae are identified in pelvic retroperitoneal space: pre-hypogastric nerve fascia in ventral side, ureterohypogastric fascia in dorsal side of ureter and hypogastric nerves. Pelvic splanchnic nerves are identified in lateral side of pre-hypogastric nerve fascia, so preservation of these fasciae during operation result in protection of hypogastric and pelvic splanchnic nerves. Pelvic nerve plexus is identified in dorsal side of deep uterine vein and superior vesical vein. Careful slice up of these veins and preserve underlying fasciae result in protection of pelvic nerve plexus. Vesical nerve branch is identified in caudal side of posterior leaf of vesicouterine ligament (VUL). Division of posterior leaf of VUL is required to visualize vesical nerve branch, but constant preservation of voiding function is feasible once location of vesical nerve branch is understood. Outline of surgical procedure to identify and preserve hypogastric nerves and vesical nerve branch is presented in the video of TLRH for cervical cancer stage 1B1. Conclusion Once visualization of pelvic autonomic nerve system is experienced, stable preservation of voiding function in radical hysterectomy is realized.

Basic Standard Procedure of Abdominal Hysterectomy: Part 1.

Total abdominal hysterectomy (TAH) is commonly referred to as extrafascial hysterectomy. This article explains the basic surgical procedure of TAH as taught to residents. TAH is an operation to remove the uterus with the outer wall of the uterus, and is a fundamental operation that gynecologists must master. Possible complications during TAH include ureteral injury, intestinal damage, and bladder injury. To avoid operative complications, it is important to follow the correct release layer procedure and ensure that “the uterus has been naturally removed.”The two most important points of the authors' method to avoid complications are as follows: (1) cut sequentially from the ligament away from the ureter which moves the ureter further away from the cervix with each transection stage; (2) cut the parametrial tissue along the circumference of the cervix in the next three steps:First step: clamping and cutting the uterine artery and upper part of the cardinal ligament; second step: clamping and cutting the sacrouterine ligament and the posterior half of the cardinal ligament; third step: clamping and cutting the vesicouterine ligament and anterior half of the cardinal ligament.

Local anatomy around terminal ureter related to the anterior leaf of the vesicouterine ligament in radical hysterectomy

ObjectivesRadical hysterectomy is performed for invasive cervical cancer. In this surgery, separation of the anterior leaf and posterior leaves of the vesicouterine ligament (VUL) is important. We studied the local anatomy of the anterior leaf of the VUL, especially the branches of the umbilical artery from the view point of surgery and cadaver dissection. Study DesignWe observed the cervicovesical blood vessels and the connective tissue layer continued from umbilical artery and searched for the origin of the cervicovesical blood vessels in radical hysterectomy. We also dissected a formalin-fixed female cadaver, and observed the same points. ResultsAfter separation of the connective tissue of urinary bladder from the cervical fascia, we could discern the outline of the distal ureter near the ureterovesical junction. We separate the connective tissue of the so-called anterior leaf of the VUL enwrapping the ureter gently, and then the ureter with the connective tissue is completely rolled out laterally. We identified a cervicovesical vessel crossing over the ureter. We looked for the central side of the cervicovesical vessel and found that cervicovesical vessel was a branch of the superior vesical artery. And, during cadaver dissection, we found that the connective tissue and the branches of the superior vesical artery were similarly observed. ConclusionsWe found the precise anatomy of the connective tissue layer from umbilical artery to urinary bladder and the superior vesical artery. Our procedure based on the precise anatomy obtained in this study is reasonable anatomically as a method for separation of the vesicouterine ligament during radical hysterectomy.

Three-Dimensional Modelization of the Female Human Inferior Hypogastric Plexus: Implications for Nerve-Sparing Radical Hysterectomy

Background/Aims: This study aims to describe the autonomic nervous network of the female pelvis with a 3D model and to provide a safe plane of dissection during radical hysterectomy for cervical cancer. Methods: Pelvises of 3 human female fetuses were studied by using the computer-assisted anatomic dissection. Results: The superior hypogastric plexus (SHP) was located at the level of the aortic bifurcation in front of the sacral promontory and divided inferiorly and laterally into 2 hypogastric nerves (HN). HN ran postero-medially to the ureter and in the lateral part of the uterosacral ligament until the superior angle of the inferior hypogastric plexus (IHP). IHP extended from the anterolateral face of the rectum, laterally to the cervix and attempted to the base of the bladder. Vesical efferences merged from the crossing point of the ureter and the uterine artery and ran through the posterior layer of the vesico-uterine ligament. Conclusions: The SHP could be injured during paraaortic lymphadenectomy. Following the ureter and resecting the medial fibrous part of the uterosacral ligament may spare the HN. No dissection should be performed under the crossing point of the ureter and the uterine artery.

Nerve-Sparing Technique during Laparoscopic Radical Hysterectomy: Critical Steps

Study ObjectiveTo show the feasibility and safety of nerve-preserving laparoscopic radical hysterectomy (type C1 Querleu-Morrow Classification [1]) for the treatment of early cervical cancer. DesignA surgical video article (Canadian Task Force classification III). SettingA university hospital (University Hospital of Barcelona, Barcelona, Spain). PatientsNerve-preserving radical hysterectomy is performed in a patient with Fédération Internationale de Gynécologie et d'Obstétrique stage 1B1 cervical cancer with deep stromal invasion. InterventionsThree steps are fundamental for the removal of the cérvix with a safe oncologic margin and preservation of the pelvic autonomic nerves [2].1. Step 1: for the correct preservation of the pelvic splanchnic nerves (ventral roots from spinal nerves S2-S4) and the inferior hypogastric plexus during the section of the paracervix, it is essential to identify the deep uterine vein. This vein will correspond with the inferior limit of the dissection.2. Step 2: during the dissection of the uterosacral ligament and after dissecting the Okabayashi space, the inferior hypogastric nerve is isolated. This nerve runs 2 cm parallel below the uterosacral ligament in the peritoneal leaf of the broad ligament.3. Step 3: during the section of the vesicouterine ligament, the lateral side must be preserved because it includes the medial and inferior vesical veins that drain to the deep uterine vein. ConclusionNerve-sparing laparoscopic radical hysterectomy is an attractive surgical approach for early-stage cervical cancer. Direct visualization of the pelvic autonomic nervous system (sympathetic and parasympathetic branches) innervating the bladder and rectum makes the nerve-sparing approach a safe and feasible procedure.

Indocyanine green-assisted parametrial dissection during type C1 radical hysterectomy after sentinel lymph node biopsy in early stage cervical cancer

ObjectivesThe standard treatment for FIGO stage 1B1 cervical cancer is radical hysterectomy (RH) [1]. Indocyanine-green (ICG) is a drug injected within the cervical stroma to detect the sentinel lymph node (SLN) in cervical cancer [2,3]. ICG travels through the lymphatic channels in the lateral parametrium, which results enhanced with green, before reaching the SLNs. This could help identifying the surgical landmarks. The aim of this video is to propose a new approach to perform parametrial dissection as part of RH under the guidance of ICG. MethodsThe patient was a 49-years old woman diagnosed with a FIGO 1B1 moderately-differentiated cervical squamous cell carcinoma. No evidence of lymphoadenopathy on pre-operative imaging. 0.25ml of ICG (1.25mg/ml) were injected superficially and deep at 3 and 9 o'clock in the cervix as first step of the operation. Bilateral SLN biopsy followed by type C1 RH with bilateral salpingo-oophorectomy and bilateral pelvic node dissection was performed. Near-infrared camera (PINPOINT® - Novadaq Technologies) was used during parametrial dissection. ResultsICG was used as a guide to demarcate the parametrial tissue and assist the dissection of the lateral (paracervix) and anterior (vesico-uterine ligament) parametrium off the surrounding structures (bladder and ureter). Operation time was 150min and intraoperative estimated blood loss was 50 mls. No intraoperative or postoperative complication was reported. ConclusionsICG-assisted parametrial dissection during RH after SLN biopsy in early stage cervical cancer can be a useful tool to guide the surgeon to perform the procedure and potentially improve surgical outcomes.

102 - Novel Dissection Technique for Vesicouterine Ligament to Prevent Ureter Injury in Laparoscopic Radical Hysterectomy

Study Objective: Dissection of vesicouterine ligament is a highlight of laparoscopic radical hysterectomy, but with technical difficulty due to anatomical complexity around ureter. We propose a novel dissection technique for vesicouterine ligament to easily visualize ureter and prevent its injury.

Total laparoscopic hysterectomy for large uterine cervical myoma.

Ureterolysis is a surgical method with a high level of difficulty, which may be necessary when performing total laparoscopic hysterectomy (TLH) for large cervical myoma, despite the benign nature of this tumor. The aim of the present study was to introduce techniques that are commonly applied in malignant tumor surgery in order to safely perform TLH for large cervical myoma. Between 2014 and 2016, TLH was performed at the Shimane University Hospital (Izumo, Japan) in 153 patients with benign tumors, including 25 cases with a large uterus (uterine weight ≥500 g). The surgical methods applied in 3 of these large uterine cervical myoma cases were investigated in detail, including techniques devised by our department. TLH was performed without enucleating myomectomy in all 3 cases; however, all 3 cases required ureterolysis, transection of the anterior layer of the vesicouterine ligament and isolation of the ureter. In conclusion, although radical laparoscopic hysterectomy is commonly performed for cervical cancer at our department, techniques used for malignant tumor surgery may prove useful for benign cases with a high level of difficulty.

Bases anatomiques et principe du nerve-sparing au cours de l’hystérectomie radicale pour cancer du col utérin

Radical hysterectomy (RH) is an effective treatment for early-stage cervical cancer IA2 to IIA1 but RH is often associated with several significant complications such as urinary, anorectal and sexual dysfunction due to pelvic nerve injuries. Pelvic autonomic nerves including the superior hypogastric plexus (SHP), hypogastric nerves (HN), pelvic splanchnic nerves (PSN), sacral splanchnic nerves (SSN), inferior hypogastric plexus (IHP) and efferent branches of the IHP. We aimed to precise the neuroanatomy of the female pelvis in order to provide key-points of surgical anatomy to improve NSRH for cervical cancer. The SHP could be injured during periaortic lymph node dissection and its preservation necessitates an approach on the right side of the aorta and a blunt dissection of the promontory before lomboaortic lymphadenectomy. Injuries to HN can occur during the resection of USL at the posterior pelvic wall and of rectovaginal ligaments and to preserve HN only the medial fibrous part of the uterosacral ligament should be resected. The middle rectal artery, the deep uterine vein and the ureter should be identified to preserve PSN and IHP during resection of paracervix. Vesical branches can be preserved by blunt dissection of the posterior layer of the vesicouterine ligament after identifying the inferior vesical vein. In most of cases, NSRH for cervical cancer can be performed. Anatomical landmarks as middle rectal artery, deep uterine vein, inferior vesical vein and ureter and the respect of nervous part of uterine ligament and of parametrium provide to surgeon a safe preservation of pelvic innervation without compromising oncological outcomes.