Anatomical basis of radical

hysterectomy

Denis Querleu

Institut Bergonié Cancer Center, Bordeaux, France

denis.querleu@mcgill.ca
 PART 1 : SURGICAL ANATOMY

• Classical spaces
• Non existing structures
• Less classical spaces
• Autonomic nerves anatomy
The classical spaces
Prevesical

Paravesical

Latzko 1919

Pararectal

Retrorectal
 Landmarks of the paravesical fossa
(right side)

External iliac vessels

Umbilical artery

Obturator nerve

Hypogastric sheath
 Paravesical fossa, caudal part
(left side)

Pubic bone

Obturator nerve
Levator ani fascia
 The wrong plane The right plane
Lateral retrovesical Paravesical
fossa fossa

Medial Lateral

Right uterine
artery Landmark : superior vesical/umbilical artery
 Limits of the pararectal fossa

Uterine
artery

Middle rectal
artery

Internal iliac
Sacrum vessels
Lateral limits of vesicouterine septum
(left side)
Bladder

« Bladder pillar »

Vesicouterine septum

Ureter

Uterine vessels

Vesicouterine ligament
Vesicouterine ligament
(left side) Vesicouterine ligament

Vesicouterine septum

Origin of the
uterine artery

Ureter
Ascending uterine
vessels
 Access to the (right) ureteric tunnel
Entrance point 11 h *

Traction on the uterine artery

Lateroumbilical
placement of trocars

* 1 h on the left side

 The « cardinal ligament » is
not a ligament (coronal section)
Uterine artery
Uterine
artery Ureter

Ureter

Medial part
Internal iliac vessels Lateral part

Paracervix (Nomina Anatomica)

 The uterosacral ligament
does not exist (axial section)

Bladder

Ureter
Vagina

Cervix

Medial part
Internal iliac vessels Lateral part

Paracervix
… the « uterosacral ligament » is
actually the hypogastric plexus
RR : rectum RRS
RRS : retrorectal space
R

Right inferior hypogastric plexus

ERR

Sacral splanchnic
roots RRS

Superior hypogastric nerve

 The uterosacral ligament does not exist

Inferior hypogastric plexus

Sacrouterine space
Left
pelvic sidewall

Paravesical fossa

Ureter

Pararectal fossa
« USL» : a peritoneal fold
 Other inexisting or misnamed
structures
• « Lateral parametrium » = paracervix
• « Anterior parametrium » = vesical lateral
ligament = umbilical and superior vesical
arteries
• « Posterior parametrium » = « uterosacral
ligament » = nothing but a fibrous
condensation close to the torus uterinus
• « Deep vesicouterine ligament » =
vesicovaginal ligament
 Less classical spaces

• The same spaces, from below

• « New spaces »
– Retrovesical spaces (lateral/medial)
– Sacrouterine space
• The pelvic sidewall layers
– vascular plane
– sacral nerves plane
Pararectal fossa
Vesicouterine septum
Paravesical fossa

Vesicouterine
septum

Bladder pillar

Paravesical fossa
Access to paravesical fossa

2h

3h
Application to prolapse surgery
Application to prolapse surgery
Ureter
 Lateral retrovesical fossa (left side)
Lateral to the ureter, medial to the umbilical ligament
(« lateral vesical ligament »)

Lateral retrovesical
space
The « wrong » Paravesical fossa
plane

Pararectal fossa
 Lateral retrovesical fossa (left side)
Lateral to the ureter, medial to the umbilical ligament (« lateral
vesical ligament »)

« Lateral vesical Lateral retrovesical

ligament » fossa

Paracervix

Paravesical fossa Left uterine

artery

Pararectal fossa
Left ureter
Lateral retrovesical fossa (right)
after division of the uterine artery
Lateral retrovesical
fossa

Right ureter « Lateral vesical ligament

Medial retrovesical space (right)
Lateral retrovesical
fossa

Medial retrovesical
space

Ureter
Paracervix
 Medial retrovesical space
Medial to the ureter

Left

Right
 Okabayashi (sacrouterine) space

« Uterosacral » peritoneal fold

 Limits of the sacrouterine space

Uterosacral fold

Inferior hypogastric plexus

Access to the sacrouterine space (1)
Division of the posterior leaf of the broad ligament
Access to the sacrouterine space (2)
Reaching the uterosacral fold

Sacrouterine space

Right ureter

Right uterosacral fold

« Mesoureter » (autonomic nerves)

Individualization of the (right) paracervix
(medial part)

Lateral retrovesical
fossa

Medial retrovesical
space

Ureter

Sacrouterine space
 Laterovascular
space
Transperitoneal laparoscopic
approach, lateral to vessels,
right side

External iliac vein

Obturator nerve

Internal iliac vessels

Technique of resection
of the vascular plane
After resection of the vascular system
(Mibayashi 1942)

Obturator vessels

Pudendal vessels

Gluteal vessels
The sacral plexus plane
 The sacral plexus plane
(laparoscopic approach, lateral to vessels)

Obturator nerve
Internal iliac vessels Obturator nerve
The resectable area of the pelvic sidewall
(Höckel 1999)

From
D. Querleu, E Leblanc, P Morice, G Ferron

Chirurgie des cancers gynécologiques

2ème édition, Elsevier-Masson, Paris 2014

 Autonomic nerve anatomy
- (1) The « uterosacral ligament» can be Rectum
laterally separated from the hypogastric
nerve (« mesoureter »)

Retrorectal space
Rectovaginal septum
USL

Sacrum

Right inferior hypogastric plexus

Left Yabuki’s sacrouterine space

 Autonomic nerve anatomy
- (2) The nerve plane is prolonged by the
hypogastric plexus, that lies lateral to the rectum
and vagina

Mauroy et al. Raspagliesi et al.

 Autonomic nerve anatomy
- (3) The « bladder pillar »
is divided into a
« superficial » (cranial,
anterior) component
containing and a « deep »
(caudal, posterior)
component, the latter
critical for bladder nerve
preservation

Bladder nerves
PART 2 : A « NEW » WAY TO
MANAGE THE PARACERVIX
(« cardinal ligament ») :
PARACERVICAL
LYMPHADENECTOMY
 Surgical anatomy of the paracervix
(transverse section)

Bladder

Ureter
Vagina
Cervix

Medial part
Internal iliac vessels Lateral part

Paracervix
 Surgical anatomy of the paracervix
(coronal section)

Cervix Ureter
Vagina

Medial part
Internal iliac vessels Lateral part

Paracervix
The concept of paracervical
lymphadenectomy
Right paracervical lymph node
dissection, ventral step
 Right paracervical lymph node
dissection, dorsal step

Middle rectal
artery
Right paracervical
dissection.
Lateral step
Left paracervical node dissection
Paracervical lymph node dissection as an
« expander »
of « modified »
rad. hyst.

Removal of medial
paracervix Paracervical lymph node dissection
 PART 3 : ANATOMICAL
CLASSIFICATION OF
RADICAL HYSTERECTOMIES
• Tailoring has become a major issue
in cancer surgery (adverse vs
curative effects)
• « Extended » or « radical »
hysterectomies encompass a variety
of different surgeries
• Eponyms are altered with time
 Need for a new classification
• Piver/Rutledge/Smith
– Does not take into account Terminologia Anatomica
– Ignores nerve preservation techniques
– Applies to open surgery only
– Mixes lateral, dorsal, and vaginal extent
– Class I is not « radical » ; Class III and IV are not
clearly defined ; Class V is obsolete
– Templates are not clear
 Need for a new classification
• Piver/Rutledge/Smith : unclear sketches
 Need for standardization of
anatomical nomenclature

• (1) Spatial orientation in the pelvis according to

the international anatomical nomenclature
– Medial / lateral
– Caudal / cranial
– Dorsal/ventral
• (2) Adopt a uniform name for the lateral
attachments of the cervix and upper vagina :
paracervix (Nomina Anatomica)
– Avoiding confusing terms as « cardinal ligament »,
« Mackenrodt’s ligament », « lateral parametrium »
 Design of the new
classification 2 1
3
(Querleu-Morrow Lancet Oncol 2008)
• Defines four main categories
according to extent of removal
of paracervix
• Uses only reliable landmarks
- (1) ureter
- (2) internal iliac vessels
- (3) pelvic wall
• Defines as sub categories
– Nerve preservation techniques
– Paracervical lymphadenectomy
• Takes into account other details, but only as modifiers
Four classes according to lateral extent

B1
C
D
B2
C AA

BB D
 The four categories
• Class A : minimal resection of paracervix
cervix removed in toto

• Class B : resection of the paracervix at the ureter

resection of the fibrous component

• Class C : resection of the paracervix at the pelvic

sidewall resection of entire paracervix

• Class D : extension of resection to the anatomical

structures of the pelvic sidewall exenterative
procedures
 Class A : the paracervix is transected
medial to the ureter but lateral to the cervix
(half-way)
– Extrafascial hysterectomy in which the position of the
ureters is determined by palpation or direct vision (after
opening the ureteral tunnels) without freeing the ureters
from their beds
– The bladder and rectal pillar are not transected at a
distance from the uterus

• Goal : make sure that the cervix has been removed

in toto by a gynecologic oncologist
Class A
 Class A
Uretère Right paracervix

Ureter
Retrovesical space

Paracervix

Sacrouterine space
 Do we need a new
« less radical » type ?

• Tailoring surgery for early cervical cancers, less

than 2 cm, with no LVSI, with negative pelvic nodes
(simple hysterectomy may not remove the entire cervix)
• Limiting the extent and consequently adverse
effects of hysterectomies after radiation therapy
(ERT is supposed to control microscopic paracervical
disease, ureter at risk if not identified)
Class B : the paracervix is divided at the
ureter
– The ureter is unroofed and rolled laterally
permitting transection of the paracervix at the level
of the ureteral tunnel
– The neural component of the paracervix is not
transected
– The bladder and rectal pillars are resected at a
distance from the uterus
– Subcategories : B1 : as described
B2 : with additional lateral
paracervical lymph node dissection or liposuction.
 Class B
B
Type A versus type B
 Class B
sub-types

B1 B2
Removal of proximal Paracervical lymph node dissection
paracervix
 Class C : Resection of the
paracervix at the junction with
hypogastric vessels

- Resection of the rectal pillar at the rectum and

bladder pillar at the bladder

- The ureter is completely mobilized.

 Class C
Ureter

C
 Retrovesical fossa Left side

External iliac
vessels Right side
Internal iliac a.
Sup. ves. a.

Obt. a.
Uterine pedicle
Ext. iliac
vessels
Posterior branch
of internal iliac artery

Middle rectal artery

 … and introducing sub categories
C1 : Resection of the medial and lateral
components of the bladder pillar, the cranial and
caudal components of the paracervix, and the
rectal pillar with a nerve sparing dissection.

C2 : without NSD

From Raspagliesi et al.

 C
A B