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1-st Basic Course Yerevan Sept 31 – Oct 01. Nerve sparing radical hysterectomy (our experience). Artem Stepanyan MD,PhD. “ Shengavit ” Medical Center. Rationale. Resection of pericervical tissue ( parametria ) Anterior ( vesico -uterine) Lateral (cardinal) Posterior ( utero -sacral)

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nerve sparing radical hysterectomy our experience

1-st Basic Course

Yerevan

Sept 31 – Oct 01

Nerve sparing radical hysterectomy(our experience)

Artem Stepanyan MD,PhD

“Shengavit” Medical Center

rationale
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
anatomy
Anatomy
  • Pelvic ligaments
  • Pelvic spaces
anatomy5
Anatomy

A. Stepanyan

anatomy6
Anatomy

A. Stepanyan

classification
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
classification8
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)
slide9

A

B

C

D.Querleu

survival rates11
Survival rates

Stage 5-Year Survival Rate

I 91%  

IA 98%  

IB 88%

II 61%  

IIA 67%  

IIB 58%

III 47%

IV 16%

pelvic nerve supply
Pelvic nerve supply

B. Rabischong et al.

pelvic nerve supply14
Pelvic nerve supply

Type II (B)

Type III (C)

nerve sparing procedures
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

our data
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
specimen
Specimen

A.Stepanyan

A.Stepanyan

specimen23
Specimen

A.Stepanyan

our data24
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

our data25
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

our data26
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

our data27
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)

our data28
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.