神経温存広汎子宮全摘術における根治性拡大と機能温存(<特集>第56回日本産科婦人科学会シンポジウム4 : 安全性および確実性の向上を目指した婦人科手術の工夫)

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Nerve-sparing radical hysterectomy was established by Japanese gynecologists to preserve the pelvic autonomic nerves while maintaining a high curability. During nerve-sparing radical hysterectomy, the cardinal ligament is divided into two parts. The superficial (ventral) vascular part that contains the uterine, vaginal and inferior vesical vessels is dissected, while the deep (dorsal) neural part that contains the pelvic splanchnic nerves is preserved. According to this method, the pelvic splanchnic nerves are considered to run through the nerve part of the cardinal ligament. Recently, we have demonstrated that the pelvic splanchnic nerves arise from the dorsomedial portion of the neural part of the cardinal ligament, based on operative findings as well as fresh cadaver studies. The pelvic splanchnic nerves occupy a much deeper or more medial position than expected by gynecologists, so the current concept of nerve topography leads to over-preservation of the cardinal ligament. However, the cardinal ligament lymphatics represent one of the most frequent sites for the metastasis of cervical cancer. We have devised a new method of nerve-sparing radical hysterectomy that is performed as follows. After ligation of each vessel the vascular part of the cardinal ligament is divided as close as possible to the pelvic wall. The pelvic splanchnic nerves arising from S3 are completely exposed and preserved. The neural part of the cardinal ligament is dissected immediately above the middle rectal artery. For complete preservation of the pelvic plexus, the visceral stump of the cardinal ligament is mobilized ventrally above the hypogastric nerve before dissection of the uterosacral and rectovaginal ligaments. Thus, the hypogasrtic nerve serves as a good landmark for preservation of the pelvic plexus. If there is deep myometrial invasion or parametrial invasion, mobilization of the stump of the ligament should be avoided, so the pelvic plexus is preserved partially. Between November 1, 2001 and October 30, 2003 31 patients with stage I b-IV b cervical carcinoma underwent radical hysterectomy with dissection of the neural part of the cardinal ligament. Intraoperative biopsies were collected from the neural part of the cardinal ligament immediately above the middle rectal artery in 4 out of 31 patients. Histological examination revealed that it was composed of connective tissue with lymphatics and small nerve fibers. Two parameters was used for assessment of the recovery of bladder function recovery : the time until spontaneous voiding occurred and the time until residual urine volume was less than 50 ml. Sixty-four patients who underwent the traditional procedure that preserved the neural part of the cardinal ligament (operated on by one gynecologist from 1993 to 1998)were used as a historical control group. After the new procedure, patients with bilateral complete preservation of the pelvic plexus showed recovery of bladder function as quickly as after the traditional method with no significant difference. Even patients with partial unilateral preservation showed recovery to a residual urine volume of less than 50 ml at a median of 24.5 days postoperatively. This was significantly later than in the control group, but they did not need to perform self-catheterization. We reviewed traditional nerve-sparing radical hysterectomy because there is the possibility of improving its radicality by correcting the current concept of nerve anatomy that leads to over-preservation of the cardinal ligament. As a result, we propose a method of extended nerve-sparing radical hysterectomy with more extensive and deeper dissection of the cardinal ligament to increase radicality.
社団法人日本産科婦人科学会の論文
2004-12-01

神経温存広汎子宮全摘術における根治性拡大と機能温存(<特集>第56回日本産科婦人科学会シンポジウム4 : 安全性および確実性の向上を目指した婦人科手術の工夫)

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