Nerve sparing radical hysterectomy (our experience)

1. 1-st Basic Course Yerevan Sept 31 – Oct 01 Nerve sparing radical hysterectomy(our experience) Artem Stepanyan MD,PhD “Shengavit” Medical Center

2. Rationale • Resection of pericervical tissue (parametria) • Anterior (vesico-uterine) • Lateral (cardinal) • Posterior (utero-sacral) • Upper vagina resection • 1/3 • 1/2 • Lymphadenectomy • Pelvic • Para-aortic

3. Anatomy • Pelvic ligaments • Pelvic spaces

4. Anatomy

5. Anatomy A. Stepanyan

6. Anatomy A. Stepanyan

7. Classification • Piver, Rutledge , Smith (1974) • Class I – extrafascial hysterectomy • ClassII – modified radical hysterectomy (1/2 of lateral anterior and posterior parametria and 1/3 of vaginal cuff resection) • Class III – entire parametria and upper 1/2 of vagina resection) • Class IV – periuretheral tissue, vesico-umbilical artery and 3/4 of vagina resection • Class V – urinary bladder and/or ureter resection

8. Classification • D.Querleu (2008) • Class A – extrafascial hysterectomy + excision of 1 cm of upper vagina • Class B – partial resection of vesucouterine and uterosacral ligament, cardinal ligament resected medially to the ureter • Class C – vesicouterine ligament at the baldder wall; uterosacral ligament at the rectum; ureter completely mobilised; paracervix resected at hypogastric vessels (2 subtypes) • Class D – laterally extended parametrialresection (2 subtypes)

9. A B C D.Querleu

10. Survival rates

11. Survival rates Stage 5-Year Survival Rate I 91%   IA 98%   IB 88% II 61%   IIA 67%   IIB 58% III 47% IV 16%

12. Morbidity (Landoni et al. 2000, 243 pts)

13. Pelvic nerve supply B. Rabischong et al.

14. Pelvic nerve supply Type II (B) Type III (C)

15. Nerve sparing procedures •Kobayashi 1961 • Sakamoto 1980 • Hoeckel 1998 • Possover 1999 • Maas, Trimbos 2000 • Kuwabara 2000 • Kato, Murakami, Yabuki 2000-2003 • Querleu 2002 • Raspagliesi 2004 • Sakuragi 2005

16. Nerve sparing procedures Trimbos et al.

17. Nerve sparing procedures Trimbos et al.

18. Our data • Technique (basic steps) • Opening para spaces • Lymphadenectomy • Resection of lateral parametria (cardinal ligament) up to the rectal vessels • Dissection of the ureter and inferior hypogastric nerve • Resection of anterior parametria (vesivo uterine lig.) preserving it’s dorso lateral part • Resection of posterior parametria (utero sacral lig.) • Specimen removal

19. Our data (NSRH technique)

20. PALND

21. PALND

22. Specimen A.Stepanyan A.Stepanyan

23. Specimen A.Stepanyan

24. Our data 2008 – 2009 18 cases FIGO stage IA2-IB1-2 2006-2007 20 cases FIGO stage IA2-IB1-2 Patients/methods NSRH RH type III

25. Our data Mean operative time 195±11.2 min 370±40 ml 180 ±15.3 min 358±54 ml P<0.05 Mean intraoperative blood loss P=0.345 NSRH RH type III

26. Our data No of lympnodes Avg – 23,2 Range 16-33 No of lymphnodes Avg – 26,2 Range 18-35 P>0,05 NSRH RH type III

27. Our data • Indwelling cath removed on the 5-th post op day • Post voiding residual urine • ≤ 100 ml – 16 cases • > 100 ml – 2 cases • In both cases bladder contractility recovered in 2 weeks of self catheterization • Indwelling cath removed after 2 weeks post surgery • Post voiding residual urine • ≤ 100 ml – 11 cases • > 100 ml – 9 cases • 7 cases - 2 weeks self catheterization • 2 cases - 5 weeks self catheterization NSRH (18 pts) RH type III (20 pts)

28. Our data Conclusion despite of statistically significant prolonged operative time NSRH occurs to be a safe and feasible procedure with good functional results if compared with classical approach. A longer observation period and higher number of patients needed to assess its impact on survival rate.

29. Thank you very much for your attention!