Radical hysterectomy is the gold standard surgical treatment for early-stage cervical
cancer.[1 ] However, despite its efficacy in cancer control, this procedure often results in
significant postoperative complications. Many patients experience prolonged urinary
dysfunction, such as urinary retention, incontinence, and frequent urinary tract infections,
as well as gastrointestinal issues, including constipation and defecation disorders.
These complications can severely diminish the quality of life, posing long-term challenges
to patients' well-being.
Given these concerns, there is a growing need for surgical techniques that not only
achieve the oncological objectives of radical hysterectomy but also minimize damage
to the autonomic nerves responsible for bladder and rectal function. The preservation
of these functions is crucial for improving postoperative recovery and long-term quality
of life.
In response to this need, Querleu and Morrow[2 ] proposed the type C1 nerve-sparing radical hysterectomy in 2008, which focuses on
preserving autonomic nerve function within the pelvis. This innovative approach aims
to reduce the incidence of urinary and gastrointestinal complications by carefully
sparing the pelvic nerves during surgery.
The technique was further refined in 2017,[3 ] incorporating advancements in surgical anatomy and dissection techniques. As a result,
the type C1 nerve-sparing surgery has gained recognition and has been endorsed by
several clinical guidelines, including those of the National Comprehensive Cancer
Network,[4 ] as a recommended approach for the surgical management of early-stage cervical cancer.
The adoption of nerve-sparing techniques, such as the C1 approach, represents a significant
advancement in gynecologic oncology, offering a balance between effective cancer control
and the preservation of essential pelvic functions. As more surgeons adopt these methods,
we can anticipate improved outcomes for patients, not only in terms of survival but
also in their overall quality of life after surgery.
Performing the type C1 nerve-sparing radical hysterectomy, a procedure known for its
exceptionally high level of difficulty, presents significant challenges. This complexity
is a major concern for many surgeons. Successfully implementing and executing this
surgery requires achieving both an adequate extent of resection and the preservation
of the nerves that innervate the bladder. This task is critically important yet incredibly
challenging. The primary difficulty lies in accurately identifying and preserving
these autonomic nerves without causing any damage, while also ensuring that the surgical
resection is sufficiently extensive for effective cancer control.
The type C1 surgical procedure focuses on preserving pelvic autonomic nerve function,
particularly the inferior hypogastric plexus (IHP), which is formed by the convergence
of the pelvic splanchnic nerves and the hypogastric plexus.[5 ] Although the specific locations and pathways of these nerves are extensively documented,
there is a notable lack of detailed, step-by-step surgical methods for effectively
implementing this nerve-sparing approach.
Through detailed anatomical studies of cervical cancer surgery, we have discovered
that the pelvic splanchnic nerves are located posterior to the deep uterine veins
([Fig. 1A ]), while the hypogastric plexus is found within the retroperitoneal tissue, posterior
to the ureter ([Fig. 1A, B ]). Consequently, their convergence does not occur at the parametrium but rather within
the paracolpium ([Fig. 1C ]). The paracolpium contains a complex network of venous plexuses, making the precise,
bloodless dissection of the IHP while preserving the bladder branches of the pelvic
autonomic nerves a significant challenge. Therefore, a comprehensive understanding
of the paracolpium's anatomy is crucial for successful implementation.
Fig. 1 (A, B ) Images showing the location of the pelvic autonomic nerves and the hypogastric plexus.
(C ) Image showing the convergence of the pelvic autonomic nerves and the hypogastric
plexus at the dorsolateral aspect of the deep uterine veins within the paracolpium.
(D ) Image showing the vascular plane formed by the deep uterine veins and the bladder
venous plexus, which is located within the vesicovaginal ligament and drains into
the deep uterine veins. (E ) Image showing the neural plane located posterior to the vascular plane within the
paracolpium and the bladder branches of IHP. (F ) Image showing the paracolpium as a three-dimensional structure composed of contributions
from the ventral, lateral, and dorsal parametrium. IHP, inferior hypogastric plexus.
Three-dimensional anatomical dissection of the paracolpium ([Fig. 1F ]) reveals its composition as follows: the deep uterine veins and the surrounding
lymphatic adipose tissue of lateral parametrium, the uterosacral ligaments of dorsal
parametrium, and the vesicovaginal ligament of ventral parametrium. The vesicovaginal
ligament houses the bladder venous plexus, which drains into the deep uterine veins.[6 ]
[7 ] Consequently, the ventral aspect of the paracolpium comprises a vascular plane formed
by the deep uterine veins and the bladder venous plexus. The posterior aspect of this
vascular plane consists of a neural plane formed by the hypogastric plexus and the
pelvic splanchnic nerves, along with the nerve branches originating from this plexus.
The posterior aspect of the neural plane is further defined by the sacral ligaments.
To achieve optimal surgical outcomes, the vascular plane should be mobilized medially
as a cohesive unit ([Fig. 1D, E ]), thereby exposing the underlying neural plane ([Fig. 1E ]). The goal of this maneuver is to preserve the bladder branches by carefully transecting
the medial branches of the IHP . This approach not only aims to minimize nerve damage
but also ensures that the bladder's autonomic innervation is retained, thereby improving
patient outcomes and preserving functional capabilities.
