Nerve-Sparing Radical Hysterectomy

To ensure a nerve-sparing radical hysterectomy, a clear neurovascular anatomy of the paracervical area is essential. After isolation of the pelvic splanchnic nerve in the most dorsal side of the cardinal ligament and the hypogastric nerve on the rectal sidewall of the pararectal space, presence of the inferior hypogastric plexus is confirmed by the confluence of the hypogastric nerve and the pelvic splanchnic nerve. When the paracolpium (vaginal vessels) is separated from the dorsal layer of the vesicouterine ligament, a bladder branch running dorsal to the paracolpium can be seen. The uterine branch can be isolated from the loose connective tissue space between the vaginal vessels and the bladder branch, and only the uterine branch can be divided. Since the bladder branch runs on the rectal side of the rectovaginal ligament (the ligament between the rectum and the vagina), the rectovaginal ligament can be cut to the position where the vaginal vessels are to be divided, leaving the T-shaped inferior hypogastric plexus for removal of the uterus. In this chapter, the surgical steps to perform a reliable nerve-spring radical hysterectomy are described, and the neurovascular anatomy is detailed.