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NERVESPARING SURGERY IN CERVICAL 51
CARCINOMA
Shingo Fujii, MD
Kentaro Sekiyama, MD
Introduction Figure 2. Locations of surgical damages to the pelvic nerves dur-
ing Okabayashi‘s radical hysterectomy and Wertheim’s radical
Radical hysterectomy was introduced in 1911 by hysterectomy.
Wertheim (1), and now there are many different types
of radical hysterectomy in all over the world (2, 3). (2). Locations of nerve damages during radical
Interestingly, almost all types of radical hysterectomy hysterectomy (4) (Figure 2)
were often associated with severe bladder dysfunction During radical hysterectomy, surgical procedures to the
and colorectal motility disorders that deteriorated the uterosacral ligament and the rectovaginal ligament can
patient’s quality of life. The cause exists in the surgical scarify the hypogastric nerve. Surgery to the deep uterine
processes of radical hysterectomy for the removal of the vein in the cardinal ligament can scarify the pelvic
longer vaginal cuff. The nerves to the urinary bladder splanchnic nerve. All surgical steps shown in the Figure 2
and the rectum in the paracervix area have a possibility can scarify the pelvic nerves during Okabayashi’s radical
to be damaged during radical hysterectomy. hysterectomy (2). In contrast, Wertheim’s method usually
Anatomy of the Pelvic Nerve and Nerve-Sparing does not divide the deep uterine vein in the cardinal
Surgery ligament, it is difficult to injure the pelvic splanchnic
(1). Nerve supply to the uterus, rectum and urinary nerve. However, Wertheim’s method (1) tries to remove
bladder (4) (Figure 1) the uterosacral ligament as much as possible, and can
scarify the hypogastric nerve during the division of
The uterus, vagina, urinary bladder and rectum are the uterosacral ligament. Instead to divide the cardinal
innervated by a motor and sensory autonomic nerve ligament, by the division of the parametrial tissues and
supply (sympathetic and parasympathetic origin). rectovaginal ligament, Wertheim’s method can scarify
The sympathetic fibers coming from T10-L2 form the the inferior hypogastric plexus itself. Moreover, by the
inferior hypogastric nerve. The parasympathetic fibers division of the paracervical tissues that contains vaginal
coming from S2, 3 and 4 at the pelvic wall form the pelvic blood vessels (paracolpium) and the posterior leaf of the
splanchnic nerve. These fibers merge and construct vesicouterine ligament, Wertheim’s method can scarify
the inferior hypogastric plexus that has branches to the the bladder branch from the inferior hypogastric plexus.
uterus, the rectum and the urinary bladder.
(3). Efforts on nerve-sparing radical hysterectomy
Figure 1. Nerve supply to the uterus, rectum and urinary bladder Kobayashi modified Okabayashi’s method in an attempt
and cross-shaped inferior hypogastric plexus. to preserve nerve functions during radical hysterectomy.
In 1961, Kobayashi described the technique that result
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