This chapter should be cited as follows:
Ceccaroni M, Roviglione G, et al, Glob. libr. women's med.,
ISSN: 1756-2228; DOI 10.3843/GLOWM.420783
The Continuous Textbook of Women’s Medicine Series – Gynecology Module
Volume 8
Gynecological endoscopy
Volume Editors:
Professor Alberto Mattei, Director Maternal and Child Department, USL Toscana Centro, Italy
Dr Federica Perelli, Obstetrics and Gynecology Unit, Ospedale Santa Maria Annunziata, USL Toscana Centro, Florence, Italy
Chapter
Anatomical Spaces in Radical Hysterectomy for Cervical Cancer
First published: October 2024
Study Assessment Option
By completing 4 multiple-choice questions (randomly selected) after studying this chapter readers can qualify for Continuing Professional Development awards from FIGO plus a Study Completion Certificate from GLOWM
See end of chapter for details
INTRODUCTION
Radical hysterectomy (RH) is the recommended surgical treatment in patients with a primary diagnosis of locally advanced cervical cancer of FIGO stage IB2–IIA.1 After the Laparoscopic Approach to Cervical Cancer Trial,2 the minimally invasive approach has been limited to cases of locally advanced cervical cancer up to FIGO stage IB1 and with a greatest dimension of ≤2 cm.
The classification system for RH has been modified since the time that Wertheim’s procedure3 was first performed, up until the most recent and accepted revision by Querleu and Morrow, who introduced the concept of the ‘paracervix’, together with ‘side-tailored radicality’, based on tumor characteristics and clinical manifestations.4
One of the most important innovations in this kind of surgical procedure is introduction of the ‘nerve-sparing’ concept, with the aim of reducing the postoperative impairment of bladder, rectal and sexual functions experienced by cervical cancer patients after classical RH.5,6 Neural preservation has also been codified and applied to modern minimally invasive techniques, based on anatomical studies on cadavers, resulting in better and faster restoration of pelvic functions with unaltered survival outcomes.7,8
The ‘nerve-sparing’ technique requires specific knowledge of pelvic surgical anatomy. The essential concepts required are thorough knowledge of retroperitoneal structures and their fine anatomical interconnections, which represent the ‘must-know’ for the pelvic gynecological oncologist surgeon.
The pelvis is composed of several compartments containing vessels, nerves and supportive tissue, together with avascular spaces that separate these compartments. Knowledge and identification of these spaces enable surgeons to perform the surgical steps necessary to decrease the risk of hemorrhage, as well as to minimize damage to the nerve supply to the pelvic organs. Some of these avascular spaces, such as the paravesical or pararectal spaces, may be easily developed.9 Conversely, Okabayashi’s paravaginal space and Yabuki’s fourth space need to be carefully developed using precise maneuvers and proper dissection.
The opening of retroperitoneal spaces gives access to further parametrial structures (the posterior, lateral and anterior parametria), which represent the cornerstone to performing a proper and safe RH. The lateral extent and section modulation of these structures defines the various classes of RH described in the literature, including the ‘nerve-sparing’ approach.10
The pelvis is divided into lateral retroperitoneal spaces (i.e. paravesical spaces and pararectal spaces, both divided into lateral and medial) and the median septa (the vesicocervical and vesicovaginal septa, rectovaginal septum and presacral space). The dissection of these avascular spaces is crucial for the isolation of parametrial structures (posterior, lateral and anterior), the bladder, the ureter and the rectum. These surgical steps are of utmost importance in order to reduce the risk of any injury during RH. Certain surgical steps are moreover essential for correct isolation of the ureter in the prevesical tract, and especially for dissection of the various components of the anterior parametrium (ureteral tunnel, Okabayashi’s paravaginal space and Yabuki’s fourth space).
The aim of this chapter is to describe the anatomical landmarks together with the standardized surgical steps for proper opening and development of all retroperitoneal spaces during RH using an approach that is both anatomy- and function-sparing.
MEDIAL AND LATERAL PARAVESICAL SPACES
The anatomical limits of the paravesical space are shown in Figure 1a–c and Figure 2a:
Caudally: the superior pubic ramus, the arcuate line of the os ilium
Cranially: the cardinal ligament including the parametrium (over the ureter) and the paracervix (below the ureter), the uterine artery/vein
Medially: the caudal portion of the vesicouterine ligament, the bladder
Laterally: the obturator internus fascia/muscle, the external iliac artery/vein
Some authors consider the paravesical space as a lateral continuation of the Retzius space. Development of the paravesical space gives initial access to the anterolateral compartment of the pelvis during RH, pelvic lymphadenectomy, Burch colposuspension, paravaginal defect repair and some endometriosis operations after opening the retroperitoneal space. The paravesical space is covered by the peritoneum of the anterior leaf of the broad ligament and contains the umbilical artery, the vesicouterine ligament, the superior vesical artery, the obturator nerve, lymphatic tissue and accessory obturator vessels.
The obliterated umbilical artery and umbilical pre-vesical fascia divide this space into the lateral paravesical space (LPVS) and the medial paravesical space (MPVS).
1
(a) Laparoscopic image of the left medial paravesical space, developed between the obliterated umbilical artery and the uterine artery. (b) Laparoscopic image of the right lateral paravesical space, developed between the umbilical artery and the pelvic wall. (c) Laparoscopic image of the bilateral lateral paravesical spaces, developed between the umbilical arteries and the pelvic wall. (d) Laparoscopic image of the left medial pararectal space (Okabayashi’s space), developed between the mesorectum and the ureter and mesoureter, with the initial approach to the rectovaginal septum. CL, cardinal ligament; CM, corona mortis; D, Douglas pouch; EIA, external iliac artery; EIV, external iliac vein; GFN, genitofemoral nerve; HN, hypogastric nerve; IPB, ischiopubic branch; LPVS, lateral paravesical space; MPRS, medial pararectal space; MPVS, medial paravesical space; MU, mesoureter; OA, obturator artery; ON, obturator nerve; Ov, ovary; OV, obturator vein; PB, pubic bone; PM, psoas muscle; R, rectum; RVL, rectovaginal ligament; UA, uterine artery; Ur, ureter; USL, uterosacral ligament; Ut, uterus.
2
(a) Laparoscopic image of the right lateral pararectal space (Latzko’s space), developed between the hypogastric artery and the uterine artery, and the ureter and the mesoureter. (b) Laparoscopic image of right lateral parametrium with the ureteral tunnel (Morrow’s space) containing the uterine artery, the superficial uterine vein, the deep uterine vein and the pelvic splanchnic nerves. (c) Laparoscopic image of the left lateral parametrium during clipping of the uterine artery at its origin. (d) Laparoscopic image of the left pelvic splanchnic nerves piercing the parietal pelvic fascia at the bottom of the lateral pararectal space, and entering the left parametrium. CL, cardinal ligament; DUV, deep uterine vein; EIA, external iliac artery; EIV, external iliac vein; HA, hypogastric artery; HN, hypogastric nerve; HV, hypogastric vein; IHP, inferior hypogastric plexus (or pelvic plexus); LPRS, lateral pararectal space; LPVS, lateral paravesical space; MPVS, medial paravesical space; MU, mesoureter; PC, paracervix; PPF, parietal pelvic fascia; PSNs, pelvic splanchnic nerves; RVL, rectovaginal ligament; SUV, superficial uterine vein; UA, uterine artery; VUL, vesicouterine ligament.
The anatomical limits of the LPVS are shown in Figure 1b,c:
Laterally: the parietal pelvic fascia, the external iliac vein and artery, Bogros’ retroinguinal space
Medially: the obliterated umbilical artery
Cranially: the lateral parametrium with the uterine artery and vein
Caudally: Bogros’ retroinguinal space and the ischiopubic branches
Ventrally: the round ligament and peritoneum of the anterior leaf of the broad ligament
Dorsally: the pelvic floor
Development of the LPVS provides access to the distal portion of the obturator vasculonervous structures and external iliac vessels with their anastomotic network, the so-called corona mortis. Opening of the LPVS is required to perform pelvic lymphadenectomy or during sentinel lymph node detection for cervical or endometrial cancer. Development of this space should start with transection of the lateral portion of the round ligament. Then the anterior and posterior peritoneal layers of the broad ligament are opened in the craniocaudal and dorsoventral directions, allowing the identification of the ureter. After subsequent ventral dissection, the obliterated umbilical artery is identified, following its course to the anterior abdominal wall. The LPVS is then developed by gentle medial traction of the umbilical artery, together with the fascial sheet of the lateral umbilical ligament, bluntly developing the loose connective tissue between the umbilical artery and external iliac vessels. This space can be developed to the level of the pelvic floor, if such radicality is required, identifying pelvic nodes and the obturator nerve and vessels entering in the obturator foramen at the level of the pelvic wall.
The anatomical limits of the medial paravesical space (MPVS) are shown in Figure 1a–d:
Laterally: the obliterated umbilical artery and LPVS
Medially: the umbilical prevesical fascia, the bladder wall and the paracolpium
Cranially: the lateral parametrium
Caudally: the bladder wall
Ventrally: the round ligament and peritoneum of the anterior leaf of the broad ligament
Dorsally: the pelvic floor
The MPVS may be considered as an anatomical continuation of the LPVS. By lateral traction of the umbilical ligament, the MPVS is extended to the LPVS. The MPVS is developed in cases of RH in order to achieve better identification of anatomical structures, such as the parametrium/paracervix, vesicouterine ligament, ureter and bladder. Development of the MPVS also enables a safe bladder dissection in conditions of adherent uterovesical fold due to previous cesarean delivery, and sometimes for mobilization of the bladder during exenteration or ureteric re-anastomosis.
PARARECTAL SPACES
The opening and development of the pararectal spaces (Figure 1d and Figure 2a) represents key steps to approach the retroperitoneum and to obtain correct isolation of the ureter. The pararectal spaces are classified into the medial pararectal space (MPRS, Okabayashi’s space)11 and lateral pararectal space (LPRS, Latzko’s space).12 The anatomical landmark that divides the pararectal spaces in MPRS and LPRS is the ureter, together with the mesoureter.
Lateral pararectal space (Latzko’s space)
The anatomical limits of Latzko’s LPRS (Figure 2a–d) are:
Laterally: the hypogastric artery and piriformis muscle covered by the parietal pelvic fascia
Medially: the ureter and mesoureter with the hypogastric nerve
Cranially: the presacral fascia and sacral bone
Caudally: the lateral parametrium containing the deep uterine vein and the pelvic splanchnic nerves
Ventrally: the peritoneal layer over the ureter, the uterine artery and the superficial uterine vein
Dorsally: the pelvic floor (i.e. the levator ani muscle)
This space is obtained by opening of the retroperitoneum at the level of the sacral promontorium. Medial traction of the periureteral peritoneum allows identification of retroperitoneal areolar tissue covering the ureter and the hypogastric artery. By blunt dissection laterally and parallel to the ureter and medially to the hypogastric artery, this space is dissected in the craniocaudal, dorsoventral and mediolateral directions until the presacral fascia, covering the pelvic splanchnic nerves, is reached. These fibers (up to 2–4 per hemipelvis) represent the pregangliar parasympathetic component of visceral pelvic innervation, merging from the sacral roots (S2–S4) and piercing the presacral fascia (the specific name of the parietal pelvic fascia in this area).13
The medial limit of the LPRS is represented by the mesoureter, arising from the visceral pelvic fascia, which continues dorsomedially with the presacral fascia. It is also connected to the hypogastric nerve, which lies medially and dorsally of the ureter.
Ventral dissection of the LPRS is preparatory to identification of the structures of the lateral parametrium (Mackenrodt’s ligament) with its vascular, lympho-adipose and neural components.
From the ventral to dorsal direction, the lateral parametrium contains the uterine artery and the superficial uterine vein, the ureter, the deep uterine vein and the inferior hypogastric plexus or pelvic plexus (formed by the connection of the pelvic splanchnic nerves and the hypogastric nerve). These structures are surrounded by connective and lympho-adipose tissue, named the ‘paracervix’ in Querleu–Morrow’s classification.10 It is further divided into medial and lateral components. The former is a condensation of connective tissue, and the latter is formed of fatty tissue that contains lymph nodes and surrounds vessels and nerves. The anatomical landmark that marks the limit between these two parts is the paravesical portion of the ureter.
Development of the LPRS represents a crucial step for strategic planning of the uterine artery section level, as it defines the extent of lateral radicality during RH.
Medial (Okabayashi’s) pararectal space
The anatomical limits of Okabayashi’s pararectal space (MPRS) (Figure 1a–d) are:
Laterally: the ureter, hypogastric nerve, mesoureter and Latzko’s pararectal space
Medially: the visceral endopelvic rectal fascia (fascia propria recti), lateral ligaments of the rectum (rectal pillars) and the rectal sidewall
Cranially: the sacral bone
Caudally: the blood vessels and connective tissue of the lateral parametrium
Ventrally: the peritoneal layer over the ureter (already divided)
Dorsally: the pelvic floor (i.e. the levator ani muscle).
Okabayashi’s MPRS is obtained by dissecting between the rectal sidewall and the pelvic fascia containing the ureter and the hypogastric nerve, known as the mesoureter. The mesoureter is the connective tissue bundle that emerges between Okabayashi’s pararectal space (medially) and Latzko’s pararectal space (laterally).
After ureteral isolation within the mesoureter, the ureter is bluntly dissected laterally in order to move it away from mesorectum. Development of Okabayashi’s MPRS may start from the sacral promontorium or, more caudally, from the division of the uterosacral ligament. In the MPRS, the hypogastric nerve is identified as running approximately 2–3 cm on the dorsal side of the ureter to which it is connected by the mesoureter. Then Okabayashi’s MPRS is extended laterally towards Latzko’s pararectal space. Caudad dissection of the hypogastric nerve in the MPRS allows identification of the middle rectal artery and the course of the deep uterine vein, which represents a constant anatomical landmark that is used to identify the plane dividing the parametrial pars vasculosa (represented by the deep uterine vein) (ventrally and cranially) from the pars nervosa (inferior hypogastric plexus), which should be preserved in the course of nerve-sparing RH (dorsally and caudally).14
Development of the MPRS allows skeletonization of the uterosacral and rectovaginal ligaments in the context of the posterior parametrium,15 in order to modulate posterior radicality in RH and preserve neural function. In the case of nerve-sparing RH, the hypogastric nerve is isolated and preserved down to the inferior hypogastric plexus at the lower lateral cervix.16
AVASCULAR SPACES RELATED TO DEVELOPMENT OF THE ANTERIOR PARAMETRIUM (VESICOUTERINE LIGAMENT)
The vesicouterine ligament has been divided by Okabayashi into ventral and dorsal layers (Figure 2a and Figure 3a,b).17
Okabayashi’s ventral layer of the vesicouterine ligament is a connective tissue layer that covers the ureter between the uterine cervical fascia and the urinary bladder. By dividing the ventral layer of the vesicouterine ligament at the level of the prevesical ureter, Okabayashi’s dorsal layer of the vesicouterine ligament is exposed. This ventral layer contains the distal segment of the ureteral tunnel’s roof (Morrow’s space) and a superficial connective tissue layer covering the ureter. Okabayashi's dorsal layer comprises the connective tissue bundle that lies between the urinary bladder and the lower lateral cervix and contains the middle and inferior vesical veins connecting the deep uterine vein in the lateral parametrium and the efferent branches of the inferior hypogastric plexus.18,19
3
(a) Laparoscopic image of dissection of the ventral portion of the left vesicouterine ligament after development of Yabuki’s fourth space (in the paravaginal portion of the paracervix) between the ureter and the cervical fascia in the so-called Okabayashi paravaginal space. (b) Laparoscopic image of dissection of the ventral portion of the left vesicouterine ligament after the development of Yabuki’s fourth space (in the paravaginal portion of the paracervix) between the ureter and the cervical fascia. CL, cardinal ligament; DUV, deep uterine vein; PC, paracervix; RVL, rectovaginal ligament; UA, uterine artery; VUL, vesicouterine ligament.
URETERAL TUNNEL IN THE VENTRAL LAYER OF THE VESICOUTERINE LIGAMENT
Once exposure of the paravesical and pararectal spaces is completed, the surgical procedure should focus on dissection of the ureter at the crossing with the uterine artery and on transection of the uterine artery from its origin from the hypogastric artery. When the artery is identified and isolated, it should be clipped or ligated and then cut.
Medial and upward traction on the pedicle of the uterine artery allows exposure of the ureter as it enters the ventral layer of the vesicouterine ligament. The uterine artery and the superficial uterine vein should be separated from the ventral surface of the ureter. Then the loose connective avascular space between the ureter and the ventral layer of the vesicouterine ligament is visible. This is the entrance of the ureteral tunnel and is called Morrow’s space.20
Ureteral tunnel (Morrow’s space)
Dissection of the ureteral tunnel is one of the most important steps in a RH. The anatomical limits of the ureteral tunnel avascular space are shown in Figure 2b:
Laterally: the medial side of the ureter
Medially: the uterine cervix and the lateral vaginal fornix
Cranially: the uterine artery
Caudally: an artery and a vein crossing over the ureter from the cervix to the urinary bladder (referred to as cervicovesical vessels)
Ventrally: the uterine artery and the superficial uterine vein
Dorsally: the dorsal layer of the vesicouterine ligament
In order to expose the ureteral tunnel, the bladder should be pushed ventrally, while cephalad traction is be applied to the uterus. The ureter is then lateralized in order to expose the space at the entrance of the ureteral tunnel, and the ventral layer of the vesicouterine ligament is separated along the medial side of the ureter, paying attention to not injuring the artery and the vein crossing over the ureter from the cervix to the urinary bladder. The connective tissue of the cranial side of the ventral layer of the vesicouterine ligament is divided in order to expose the medial side of the ureter. Thus it is possible to separate and divide the anterior layer of the vesicouterine ligament from the portion where the ureter inserts into the urinary bladder. By separating the loose connective tissue between the cervix and the medial side of the ureter, the ureter itself is sufficiently laterally mobilized to expose the entire connective tissue of the dorsal layer of the vesicouterine ligament.21
OKABAYASHI’S PARAVAGINAL SPACE
The anatomical limits of Okabayashi’s paravaginal space are shown in Figure 3a:
Laterally: the ureter and dorsal layer of the vesicouterine ligament
Medially: the vaginal wall, paracolpium and bladder branches of the inferior hypogastric plexus
Cranially: the border region between the paracolpium and the dorsal layer of the vesicouterine ligament
Caudally: the bladder wall
Ventrally: the ventral layer of vesicouterine ligament (already divided)
Dorsally: the paravesical space
Once the surface of the dorsal layer of the vesicouterine ligament is recognized, the ureter is separated and retracted toward the inguinal region. Then separation of the urinary bladder with ureter from the cervix/upper vagina is required. On the lateral bladder side and just 1 cm laterally from the upper vaginal wall of the dorsal layer of the vesicouterine ligament, the entrance of an avascular space named the ‘paravaginal space’ by Okabayashi may be identified.22 Okabayashi’s paravaginal space is an avascular space filled with adipose tissue that is continuous with the paravesical space. Okabayashi’s paravaginal space is developed between the vaginal/cervical blood vessels (paracolpium) and the bladder branch of the inferior hypogastric plexus and the medial side of the dorsal layer of the vesicouterine ligament. Through development of the paravaginal space, it is possible to dissect the medial side of the dorsal layer of the vesicouterine ligament. As the dorsal layer of the vesicouterine ligament contains at least two venous blood vessels from the urinary bladder to the deep uterine vein (i.e. the inferior and middle vesical veins, draining into the deep uterine vein),23 this step completely separates the dorsal layer of the vesicouterine ligament from the urinary bladder; moreover, the urinary bladder and the ureter are freed from the vaginal wall.24 Consequently, caudal dissection of the paravaginal space exposes the paracolpium on the upper vagina in order to obtain the most appropriate length of vaginal cuff.
One of the major differences between Okabayashi’s RH technique and Latzko’s and Wertheim’s RH techniques is whether or not the dorsal layer of the vesicouterine ligament is separated from the paracolpium (vaginal blood vessels) and the bladder branch. To obtain the appropriate length of vaginal cuff and to accomplish a nerve-sparing RH, development of Okabayashi’s paravaginal space is fundamental.25 By complete division of the dorsal layer of the vesicouterine ligament, the bladder branches of the inferior hypogastric plexus are exposed to run parallel to and dorsal with the vaginal blood vessels (paracolpium).
Separation of the connective tissues between the vaginal blood vessels and the bladder branch is necessary in order to preserve the bladder branches. The bladder branch is shifted dorsally on the rectovaginal ligament compared to its original location. Then the rectovaginal ligament is divided at the level of the appropriate vaginal cuff length between the lower cervix/upper vagina and the rectum. The bladder branch is preserved on the divided rectal side of the rectovaginal ligament. Once the vaginal blood vessels (paracolpium) on the vaginal wall are ligated and divided, the uterus is removed, preserving the bladder branch on the rectal side.
YABUKI’S FOURTH SPACE
The anatomical limits of Yabuki’s space are shown in Figure 3a,b:
Laterally: the MPVS
Medially: the medial half of the dorsal layer of the vesicouterine ligament that includes the vaginal wall and the paracolpium
Cranially: the ureteral tunnel
Caudally: the bladder wall
Ventrally: the superficial leaf of the ventral layer of the vesicouterine ligament
Dorsally: the paravesical space
After separation of the ureter from the connective tissue covering the ureter, Yabuki developed a loose connective tissue space from the ventral layer of the vesicouterine ligament via the mid-portion of the dorsal layer of the vesicouterine ligament into the paravesical space. This space was named ‘the fourth space’ by Yabuki.26,27,28,29 Opening of Yabuki’s fourth space is performed by dissecting the space that lies between the areolar connective tissue and the ventral layer of the vesicouterine ligament, including the ureter and the mid-portion of the dorsal layer of the vesicouterine ligament, at approximately 2 cm proximal to the entrance to the bladder. This technique is important in order to preserve urinary function, as some vesical nerve fibers run around the superior vesical veins. In the half of the dorsal layer of the vesicouterine ligament that includes the ureter and superior vesical vein, some fine small nerve fibers may be found, but not a definite nerve bundle that has a direct connection with the inferior hypogastric plexus. The bladder branches lie in the lateral lower cervix/upper vagina, running parallel with and dorsal to the vaginal blood vessels (paracolpium).
The surgical significance of Yabuki’s fourth space may be appreciated by clinicians who perform Wertheim’s or Latzko’s RH, as these surgeries do not require separation of the dorsal layer of the vesicouterine ligament from the paracolpium and the bladder branches of the inferior hypogastric plexus.30 Development of Yabuki’s space appears to help reduce bleeding while performing semi-radical hysterectomy or when using a modified technique for nerve-sparing RH. However, the penetration of Kelly's forceps into the dorsal layer of the vesicouterine ligament for development of Yabuki’s space may lead to injury of the vesical veins with subsequent heavy bleeding.
RECTOVAGINAL SEPTUM
The anatomical limits of the rectovaginal septum are shown in Figure 1d:
Laterally: the rectal pillars/lateral rectal ligament, the uterosacral ligament and the rectovaginal ligament (posterior parametrium)
Cranially: the anterior surface of the rectum
Caudally: the urogenital diaphragm
Ventrally: the anterior layer of the endopelvic visceral fascia (Denonvilliers’ fascia), the posterior vaginal wall and the posterior vaginal fornix
Dorsally: the anterior surface of rectum and the low rectum (retroperitoneal part), up to the anal verge
Dissection of the rectovaginal septum may be useful in order to perform posterior preparation for RH or for surgical treatment of pelvic organ prolapse, as well as for the surgical approach for deep endometriosis of the posterior compartment.
The anterolateral rectum is connected to the vagina through two longitudinal structures composed of fibrovascular tissue, the so-called rectal pillars, which form the posterior parametrium together with the uterosacral and rectovaginal ligaments. The rectovaginal space is located between these parallel structures, and is covered by a thickening of the visceral endopelvic fascia. The anterior layer of this fascia constitutes the rectovaginal septum (Denonvilliers’ fascia), which adheres more to the vagina than to the rectum. The back layer is the rectal fascia, which may be dissected from the rectum. The suggested approach for surgical development of this space is a craniocaudal and lateromedial route, starting from the previously developed MPRS. Using caudocranial traction of the rectum, as well as uterine manipulation (when feasible), it is possible to completely detach the posterior surface of vagina from the retroperitoneal rectum, up to the anal verge.
VESICOCERVICAL SEPTUM AND VESICOVAGINAL SEPTUM
The anatomical limits of the vesicocervical septum and the vesicovaginal septum are:
Laterally: the vesicouterine ligament/anterior parametrium (ventral and dorsal layers)
Cranially: the anterior surface of the uterus and the cervix
Caudally: the retrotrigonal part of the bladder and the urogenital diaphragm
Ventrally: the vesicouterine fold and the pubocervical/vaginal fascia (Halban’s fascia)
Dorsally: the anterior portion of the cervix, the anterior vaginal fornix and the anterior vaginal wall, up to the urethrovaginal septum
This anatomical space has two separate parts, the vesicocervical septum and the vesicovaginal septum, which are divided by the vesicocervical ligament, a transverse structure that merges the supratrigonal portion of the bladder with the anterior vaginal fornix. Its anatomical dissection is performed during routine gynecological surgical procedures (such as Cesarean section or total hysterectomy), but is also extremely useful during anatomical dissection of the anterior pelvic compartments during RH, during urogynecological procedures and in the surgical treatment of deep endometriosis of the anterior compartment, always using a lateromedial and craniocaudal surgical approach.31
PRACTICE RECOMMENDATIONS
- Opening of retroperitoneal spaces is essential for skeletonization of retroperitoneal structures, especially the ureter and the parametria
- An extensive knowledge of the anatomical retroperitoneal landmarks guides the dissection movements and leads to a safe surgical procedure with minimal blood loss
- Identification of the vascular components of the parametria allows correct modulation of radicality
- Identification of the visceral pelvic neural structures is essential for the nerve-sparing approach, which is a useful tool to ensure radicality while reducing pelvic visceral dysfunction and preserving the quality of life of the patient
- An extensive knowledge of surgical anatomy ensures safe, rapid and function-sparing surgery
- Development of Okabayashi’s paravaginal space and Yabuki’s fourth space are essential surgical steps that ensure correct section of the anterior parametrium’s dorsal layer and to obtain the adequate level of vaginal section.
CONFLICTS OF INTEREST
The author(s) of this chapter declare that they have no interests that conflict with the contents of the chapter.
Feedback
Publishers’ note: We are constantly trying to update and enhance chapters in this Series. So if you have any constructive comments about this chapter please provide them to us by selecting the "Your Feedback" link in the left-hand column.
REFERENCES
NCCN Clinical Practice Guidelines. Cervical cancer version 1.2020. Available from: https://www.nccn.org. | |
Ramirez PT, Frumovitz M, Pareja R, Lopez A, Vieira M, Ribeiro R, Buda A, Yan X, Shuzhong Y, Chetty N, Isla D, Tamura M, Zhu T, Robledo KP, Gebski V, Asher R, Behan V, Nicklin JL, Coleman RL, Obermair A. Minimally invasive versus abdominal radical hysterectomy for cervical cancer. N Engl J Med 2018;379(20):1895–1904. doi: 10.1056/NEJMoa1806395. | |
Wertheim E. The extended abdominal operation for carcinoma uteri (based on 500 operative cases). Am J Obstet Dis Women Child 1912;66:169–232. | |
Querleu D, Morrow CP. Classification of radical hysterectomy. Lancet Oncol 2008;9(3):297–303. doi: 10.1016/S1470-2045(08)70074-3. | |
Piver MS, Rutledge F. Five classes of extended hysterectomy for women with cervical cancer. Obstet Gynecol 1974;44:265–272. | |
Landoni F, Maneo A, Zapardiel I, Zanagnolo V, Mangioni C. Class I versus class III radical hysterectomy in stage IB1–IIA cervical cancer. A prospective randomized study. Eur J Surg Oncol. 2012;38(3):203–209. doi: 10.1016/j.ejso.2011.12.017. | |
Ceccaroni M, Roviglione G, Spagnolo E, Casadio P, Clarizia R, Peiretti M, Bruni F, Peters I, Aletti G. Pelvic dysfunctions and quality of life after nerve-sparing radical hysterectomy: a multicenter comparative study. Anticancer Res. 2012;32(2):581–588. | |
Ceccaroni M, Roviglione G, Malzoni M, Cosentino F, Spagnolo E, Clarizia R, Casadio P, Seracchioli R, Ghezzi F, Mautone D, Bruni F, Uccella S. Total laparoscopic vs. conventional open abdominal nerve-sparing radical hysterectomy: clinical, surgical, oncological and functional outcomes in 301 patients with cervical cancer. J Gynecol Oncol. 2021;32(1):e10. doi: 10.3802/jgo.2021.32.e10. | |
Zapardiel I, Ceccaroni M, Minig L, Halaska MJ, Fujii S. Avascular spaces in radical hysterectomy. Int J Gynecol Cancer 2023;33(2):285–292. doi: 10.1136/ijgc-2022-004071. | |
Querleu D, Cibula D, Abu-Rustum NR. 2017 update on the Querleu–Morrow classification of radical hysterectomy. Ann Surg Oncol 2017;24(11):3406–3412. doi: 10.1245/s10434-017-6031-z. | |
Okabayashi H. Radical abdominal hysterectomy for cancer of the cervix uteri. Surg Gynecol Obstet 1921;33:335–341. | |
Latzko W, Schiffmann WJ. Klinisches und Anatomisches zur Radikaloperation des Gebärmutterkrebses. Zbl Gynäkol 1919;34:689–705. | |
Ceccaroni M, Fanfani F, Ercoli A, Scambia G. Innervazione viscerale e somatica della pelvi femminile. Rome: Edizioni CIC; 2006; pp. 72–84. | |
Fujii S, Takakura K, Matsumura N, Higuchi T, Yura S, Mandai M, Baba T, Yoshioka S. Anatomic identification and functional outcomes of the nerve-sparing Okabayashi radical hysterectomy. Gynecol Oncol 2007;107(1):4–13. doi: 10.1016/j.ygyno.2007.08.076. | |
Ceccaroni M, Clarizia R, Roviglione G, Ruffo G. Neuro-anatomy of the posterior parametrium and surgical considerations for a nerve-sparing approach in radical pelvic surgery. Surg Endosc 2013;27(11):4386–4394. doi: 10.1007/s00464-013-3043-z. | |
Ercoli A, Delmas V, Gadonneix P, Fanfani F, Villet R, Paparella P, Mancuso S, Scambia G. Classical and nerve-sparing radical hysterectomy: an evaluation of the risk of injury to the autonomous pelvic nerves. Surg Radiol Anat 2003;25(3–4):200–206. doi: 10.1007/s00276-003-0137-7. | |
Okabayashi H. Radical operation for cancer of uterine cervix. Tokyo: Kanehara; 1952. In Japanese. | |
Fujii S, Takakura K, Matsumura N, Higuchi T, Yura S, Mandai M, Baba T. Precise anatomy of the vesico-uterine ligament for radical hysterectomy. Gynecol Oncol 2007;104(1):186–191. doi: 10.1016/j.ygyno.2006.07.041. | |
Mauroy B, Bizet B, Bonnal JL, Crombet T, Duburcq T, Hurt C. Systematization of the vesical and uterovaginal efferences of the female inferior hypogastric plexus (pelvic): applications to pelvic surgery on women patients. Surg Radiol Anat 2007;29(3):209–217. doi: 10.1007/s00276-007-0195-3. | |
Fujiwara T. Preservation of the ureteral branches of the uterine artery in radical hysterectomy. Gynecol Oncol 1997;5:239–245. doi: 10.1016/0090-8258(77)90032-4. | |
Lichtenegger W, Anderhuber F, Ralph G. Operative anatomy and technique of radical parametrial resection in the surgical treatment of cervical cancer. Baillieres Clin Obstet Gynecol. 1998;2:841–856. doi: 10.1016/S0950-3552(98)80012-6. | |
Fujii S, Sekiyama K. Precise neurovascular anatomy for radical hysterectomy. Singapore: Springer; 2020. | |
Puntambekar SP, Barse SP, More SA, Goel A, Raj LC, Chitale M, Rao TS, Bharambe SA. Anatomical description of anterior parametrium: a probable answer to pelvic recurrence following radical hysterectomy. Indian J Surg Oncol 2023;14(2):510–517. doi: 10.1007/s13193-023-01709-9. | |
Yabuki Y. Anatomy of the pelvis for radical hysterectomy; does extensive resection of the vagina result in severer bladder dysfunction? The 16th Annual Review Course on Gynecologic Oncology and Pathology. Kyoto, Japan; 2007. | |
Muallem MZ, Miranda A, Muallem J. Nerve-sparing radical hysterectomy – Muallem technique with explanation of parametrium and paracolpium anatomy. Int J Gynecol Cancer 2021;31:795–796. doi: 10.1136/ijgc-2020-001607. | |
Yabuki Y, Sasaki H, Hatakeyama N, Murakami G. Discrepancies between classic anatomy and modern gynecologic surgery on pelvic connective tissue structure: harmonization of those concepts by collaborative cadaver dissection. Am J Obstet Gynecol 2005;193(1):7–15. doi: 10.1016/j.ajog.2005.02.108. | |
Yabuki Y, Asamoto A, Hoshiba T, Nishimoto H, Nishikawa Y, Nakajima T. Radical hysterectomy: an anatomic evaluation of parametrial dissection. Gynecol Oncol 2000;77:155–163. doi: 10.1006/gyno.1999.5723. | |
Yabuki Y, Asamoto A, Hoshiba T, Nishimoto H, Satou N. A new proposal for radical hysterectomy. Gynecol Oncol 1996;62:370–378. doi: 10.1006/gyno.1996.0251. | |
Yabuki Y. New theory and technique for radical hysterectomy. Tokyo: Mejikarubyūsha; 2002. | |
Meigs JV. Carcinoma of the cervix – the Wertheim operation. Surg Gynecol Obstet 1944;78:195–198. | |
Peham HV, Amreich J. Operative gynecology (translated by LK Ferguson). Philadelphia: JB Lippincott; 1934. |
Online Study Assessment Option
All readers who are qualified doctors or allied medical professionals can now automatically receive 2 Continuing Professional Development credits from FIGO plus a Study Completion Certificate from GLOWM for successfully answering 4 multiple choice questions (randomly selected) based on the study of this chapter.
Medical students can receive the Study Completion Certificate only.
(To find out more about FIGO’s Continuing Professional Development awards programme CLICK HERE)