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456 Nerve-Sparing Surgery in Cervical Carcinoma

in improved postoperative bladder function preserving Figure 3. Principle of nerve-sparing radical hysterectomy is the
the pelvic splanchnic nerve by the separation of the division of only the uterine branch from the inferior hypogastric
vascular part (containing the deep uterine vein) from plexus. The cross-shaped inferior hypogastric plexus changes
the lower hard bundle (containing the pelvic splanchnic into the T-shaped inferior hypogastric plexus by the division of
nerve) during the division of the cardinal ligament (5). only the uterine branch.
In 1983, Fujiwara (6) at Kitano Hospital described the
importance of the preservation of the bladder branch as T-shaped inferior hypogastric plexus is the goal of this
well as the hypogastric nerve with the pelvic splanchnic surgery, with the outcome of the satisfactory urinary
nerve by the division of only uterine branch from the function for patients (4, 10).
inferior hypogastric plexus. Since then, many surgeons (6). Indication of nerve-sparing radical hysterectomy
have adopted the nerve-sparing radical hysterectomy The nerve-sparing radical hysterectomy separates and
(7). Nevertheless, almost all published papers on nerve- preserves medially one tissue’s layer (containing pelvic
sparing radical hysterectomy could not clearly show a nerve plane) more than the classical radical hysterectomy
surgical anatomy of the inferior hypogastric plexus with (4) (Figure 4). Nerve-sparing radical hysterectomy is
bladder branch and uterine branch. Publications using recommended for patients with FIGO Ib stage disease.
Wertheim or Piver type III (8) surgery show mainly the However, during the nerve-sparing radical hysterectomy
process of isolation of the inferior hypogastric nerve; for patients with FIGO Ib2 stage, if invasion is strongly
however, they usually lack a clear description of the suggested in the area of the inferior hypogastric plexus,
isolation of the pelvic splanchnic nerve and the bladder the surgery should abandon the preservation of the nerve.
branch from the inferior hypogastric plexus. The reason Indication of nerve-sparing radical hysterectomy is not
is that Wertheim or Piver type III surgeries usually recommended to the patients with FIGO IIb stage disease,
neither reveal nor isolate the deep uterine vein beneath because the location of the inferior hypogastric plexus is
where the pelvic splanchnic nerve is residing. Moreover, usually very close to the invasive foci of IIb lesion. In this
although these surgeries divide the anterior leaf of case, some doctors recommend the nerve-sparing radical
the vesicouterine ligament, the concept of separation hysterectomy to the side that is not invaded by cervical
and division of the posterior leaf of the vesicouterine cancer (7). However, it is very important to confirm
ligament, beneath where the bladder branch is residing, the extension of the cancer lesion very carefully. In case
is lacking. In contrast, Japanese doctors usually perform of younger aged patients with invasive lesion in the
Okabayashi’s radical hysterectomy. Okabayashi’s radical cardinal ligament of either side, total extirpation of the
hysterectomy separates and divides the posterior leaf of
the vesicouterine ligament. Therefore, the publications Figure 4. Cutting line of the Okabayashi’s radical hysterectomy
from Japan had been showing both inferior hypogastric and that of nerve-sparing radical hysterectomy are illustrated as
nerve and pelvic splanchnic nerve, and more information a cross section view on the level of cervix.
on the inferior hypogastric plexus (9). In 2007, Fujii et
al. (10) published a clear surgical anatomy of the cross-
shaped inferior hypogastric plexus (Figure 1) and showed
how to divide only the uterine branch from the plexus. If
only the uterine branch is divided, the urinary bladder
function is perfect after the surgery. This publication
stimulated many doctors and nerve-sparing radical
hysterectomy became popular.

(4). Principle of nerve-sparing radical hysterectomy
(Figure 3)
The principle of nerve-sparing radical hysterectomy is
very simple. Identify the inferior hypogastric nerve, and
confirm the cross-shaped inferior hypogastric plexus, the
branches to the uterus (uterine branch) and the urinary
bladder (bladder branch). Only the uterine branch is
isolated and should be divided (4).

(5). A destination of anatomy for nerve-sparing
radical hysterectomy (Figure 3)
The division of the uterine branch changes the cross-
shaped inferior hypogastric plexus into the T-shaped one
composed of hypogastric nerve, the pelvic splanchnic
nerve and the bladder branch. The preservation of