Revisiting Querleu–Morrow Radical Hysterectomy: How to Apply the Anatomy of Parametrium and Pelvic Autonomic Nerves to Cervical Cancer Surgery?
Abstract
:Simple Summary
Abstract
1. Introduction
Discrepancies between Anatomical Nomenclature and Surgical Anatomy of the Parametrium
2. Parametrium and Pelvic Autonomic Nerve System
Pelvic Autonomic Nerve System and Possible Injury Areas with Respect to Cervical Cancer Surgery
- SHP—Low paraaortic lymphadenectomy
- HN—Rectouterine ligament dissection
- PSNs—Lateral paracervix dissection and medial paracervix dissection
- IHP—Medial paracervix dissection and rectovaginal ligament dissection
- Vesical branches of the IHP—VVL dissection and medial paracervix dissection near the paracolpium
3. Types of Radical Hysterectomy According to the Querleu and Morrow (Q–M) Classification
- Radical Hysterectomy Types and Summary of Parametrium
- Supraureteric Parametrium/Ventral Part of the Parametrium:
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- Ventral: Vesicouterine
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- Lateral: Parauterine
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- Dorsal: Rectouterine
- Infraureteric Parametrium/Dorsal Part of the Parametrium:
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- Ventral: Vesicovaginal
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- Lateral: Paracervix (the medial aspect adjacent to the upper-middle vagina, called paracolpium, indeed a part of paracervix)
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- Dorsal: Rectovaginal
3.1. Type A RH—Minimal Radical Hysterectomy
3.1.1. Indications for Type A RH Are as Follows [23]
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- Stage IA CC (selected cases with risk factors and patients who do not desire future fertility)
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- Low-risk stage IB1 CC (cervical tumor ≤ 2 cm, absence of lymphovascular space invasion, absence of deep stromal invasion, absence of metastatic pelvic lymph nodes)
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- In rare cases, as a final procedure after neoadjuvant chemoradiation (or radiation or chemotherapy alone) or primary chemoradiation due to advanced CC
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- Application in future clinical trials
3.1.2. During Type A Minimal RH, the Resection Lines of the Three Parametria Are as Follows [14,15,23,26]
- Ventral parametria
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- Transverse: The VUL is minimally resected close to the uterine cervix. The ureteric tunnel is not totally dissected, and the distal ureter is not unroofed.
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- Longitudinal plane: The VVL is not transected.
- Lateral parametria
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- Transverse plane: The paracervix is transected medial to the ureter and lateral to the pericervical fascia. The PALT is removed separately.
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- Longitudinal plane: The resection extends caudally to the level of the vaginal fornices at the medial edge of the ureteric line.
- Dorsal parametria
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- Transverse plane: The rectovaginal ligament is minimally transected close to the posterior vaginal fornix.
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- Longitudinal plane: The transection level does not extend more caudally than the the vaginal fornices.
3.1.3. Comments
3.2. Type B Radical Hysterectomy
3.2.1. Type B1 RH—Modified Radical Hysterectomy
During Type B1 RH, the Resection Lines of the Three Parametria Are as Follows [15,19,23,26]
- Ventral parametria
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- Transverse: Partial resection of the VUL is performed—halfway between the urinary bladder and uterus.
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- Longitudinal plane: The VVL is not resected, and the vesical nerve branches are left untouched.
- Lateral parametria
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- Transverse plane: The parauterine and paracervix tissue is resected at the level of the ureter (at the level of the ureteral tunnel).As an additional mark, the parauterine tissue can be transected at the level of the IIA above the ureter in order to remove the PALT. If possible, PALT could be removed separately, without transection of the uterine artery/superficial uterine vein at the level of the internal iliac vessels.
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- Longitudinal plane: The resection line of the paracervix depends on the longitudinal plane of the vaginal cuff resection.
- Dorsal parametria
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- Transverse plane: Partial resection of the rectovaginal ligament occurs after identification and lateralization of the ureter, mesoureter, and HN. The resection is performed halfway between the rectum and the uterus.
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- Longitudinal plane: This depends on the resection plane of the vagina. The resection length is comparable to the amount of paracervix removed. The IHP should be spared during the excision of the longitudinal plane of the rectovaginal ligament.
Comments
3.2.2. Type B2 RH—B1 plus Paracervical Lymphadenectomy
Comments
3.3. Type C RH—Classic Radical Hysterectomy
3.3.1. Type C1 RH—Nerve-Sparing Radical Hysterectomy
During Type C1 RH, the Resection Lines of the Three Parametria Are as Follows
- Ventral parametrium
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- Transverse: The resection line of the VUL is at the level of the bladder.
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- Longitudinal: The resection line is formed by the vesical nerve branches, which are identified dorsolaterally to the course of the distal ureter after the development of Okabayashi’s paravaginal space. The VVL is dissected from the paracervix/paracolpium by preserving the vesical nerve branches, and only the cranial (proximal) part of the ligament is resected.
- Lateral parametrium
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- Transverse: The resection line of the parauterine and paracervix tissue is at the axis of the internal iliac artery.
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- Longitudinal: The paracervix tissue is resected at the level of the deep uterine vein (vaginal vein), regarding the preservation of the PSNs, which lie dorsal to the deep uterine vein.
- Dorsal parametrium
- -
- Transverse: Resection of the rectovaginal ligament is performed at the level of the rectum, considering that the uterosacral (rectouterine) ligament is a peritoneal fold, not a true ligament, which is dissected and resected at the level of the rectum to reach the entire rectovaginal ligament.
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- Longitudinal: The HN and the mesoureter are dissected laterally from the rectovaginal ligament. The proximal part of the IHP is identified (during the dissection of the RVL—dorsolateral to the upper vagina) and spared. The caudal limit of resection of the rectovaginal ligament depends on the resection plane of the vagina.
Comments
3.3.2. Type C2 RH—Classic Radical Hysterectomy
- Ventral parametrium
- -
- Transverse: Complete resection of the VUL at the level of the bladder and total dissection and lateralization of the distal ureter up to the ureterovesical junction.
- -
- Longitudinal: The resection line depends on the level of the paracolpium and vaginal cuff resection, primarily to the level of the pelvic floor (the levator ani/pubococcygeus muscle), transecting the entire VVL, some parts of the paracolpium, and the vesical nerve branches of the IHP.
- Lateral parametrium
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- Transverse: The lateral resection line is at the axis of the internal iliac artery.
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- Longitudinal: Complete resection of the LP. The paracervix and parts of the paracolpium are entirely removed, extending primarily to the level of the pelvic floor (the levator ani/iliococcygeus muscle). Thus, the paravesical and pararectal spaces merge into one entity. The PSNs, which are located at the dorsal part of the paracervix, are transected.
- Dorsal parametrium
- -
- Transverse: Resection of the rectovaginal ligament at the level of the rectum.
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- Longitudinal: Maximal dorsal resection of the rectovaginal ligament, deep to the sacral fascia attachments, sacrificing the HN and part of the PSNs along with the IHP.
Comments
3.3.3. Selective Systematic Nerve–Sparing Type C2 Radical Hysterectomy (Type C2N)
Comments
3.4. Type D—Laterally Extended Resection for RH
3.4.1. Type D1 RH—Laterally Extended Parametrectomy (LEP)
Comments
3.4.2. Type D2 RH—Laterally Extended Endopelvic Resection (LEER)
Comments
4. Discussion
5. Surgico-Anatomical Tips to Perform Radical Hysterectomy
6. Complications
7. Conclusions
- The proposed update of the RH classification should reflect the resection of the PALT in Type A and B RH.
- Clarification of the anatomical landmarks between the paracervix and paracolpium is not easy; however, the paracolpium is the medial aspect of the paracervix adjacent to the upper-middle vagina.
- A precise anatomical description of the paracervical lymph nodes is needed, and a step-by-step guide for paracervical lymphadenectomy will help surgeons clearly understand its surgical application.
- The paracervical lymph nodes are located lateral/dorso-lateral from the axis of the internal iliac vessels.
- Paracervical lymphadenectomy should be an integral part of Type B and C RH and all RH types in which lymph node dissection is performed.
- A nerve-sparing approach can be adopted for Type C2 resection and should be included in the classification: Selective-Systematic Nerve-Sparing Type C2 RH, C2N. This could improve the radicality of parametrial/paracervical resection and decrease functional morbidity.
- Type D1 has no applications according to recent guidelines for CC treatment, but it still has a role in recurrent or persistent CC after definitive radiation or chemoradiation.
- Type D2 could be termed “modified LEER”—without resection of other organs and anatomical structures.
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Types of RH According to Q-M Classification | Parauterine Tissue Paracervix | Vesicouterine/Vesicovaginal Ligaments | Rectouterine/Rectovaginal Ligaments |
Type A | Resection between the ureter and the pericervical adventitia. The ureter is not unroofed. | Vesicouterine ligament—minimal resection—5 mm Vesicovaginal ligament—not resected. | Rectouterine/Rectovaginal ligaments—minimal resection—5 mm. |
Type B1 | Resection at the ureteral tunnel. The ureter is unroofed. | Vesicouterine ligament—partial resection. Vesicovaginal ligament—not resected. | Rectouterine/Rectovaginal ligaments—partial resection. |
Type B2 | B1 plus paracervical lymphadenectomy. | ||
Type C1 | At the level of the internal iliac vessels. At the level of the deep uterine vein. | Vesicouterine ligament—complete resection. Vesicovaginal ligament—only proximal (cranial resection). | Rectouterine/Rectovaginal ligaments—complete resection at the level of the rectum. |
Type C2 | The entire lateral parametrium is resected at the level of the internal iliac vessels. | Vesicouterine/Vesicovaginal ligaments—complete resection at the level of the bladder. | Rectouterine/Rectovaginal ligaments—complete resection at the level of the rectum. |
Type D1—LEP | At the pelvic wall with transection of the internal iliac vessels. | Vesicouterine/Vesicovaginal ligaments—complete resection at the level of the bladder. | Rectouterine/Rectovaginal ligaments—complete resection at the level of the rectum. |
Type D2—LEER | At the pelvic wall with transection of the internal iliac vessels. Resection of obturator fascia/muscle, coccygeus muscle, and sacrospinous ligament. | Vesicouterine/Vesicovaginal ligaments—complete resection at the level of the bladder. | Rectouterine/Rectovaginal ligaments—complete resection at the level of the rectum. |
Types of RH According to Our Update | Parauterine Tissue Paracervix | Vesicouterine/Vesicovaginal Ligaments | Rectouterine/Rectovaginal Ligaments |
Type A | PALT transected—if cannot be removed separately, the uterine artery and superficial uterine vein composing the parauterine tissue is removed together with the PALT at the level of the internal iliac artery Paracervix—resection between the ureter and the pericervical adventitia | Vesicouterine ligament—minimal resection—5 mm. Vesicovaginal ligament—not resected. | Rectouterine/Rectovaginal ligaments—minimal resection—5 mm. |
Type B1 | Parauterine tissue—at the level of the internal iliac artery in order to remove the PALT. Paracervix—at the level of the ureteral tunnel. | Vesicouterine ligament—partial resection. Vesicovaginal ligament—not resected. | Rectouterine/Rectovaginal ligaments—partial resection. |
Type B2 | B1 plus paracervical lymphadenectomy. | ||
Type C1 | At the level of the internal iliac artery. At the level of the deep uterine vein. Paracervical lymphadenectomy PSNs and IHP are spared. | Vesicouterine ligament—complete resection. Vesicovaginal ligament—only proximal (cranial resection). Bladder nerve branches are spared. | Rectouterine/Rectovaginal ligaments—complete resection at the level of the rectum. The HN and IHP are spared. |
Type C2 | The entire lateral parametrium is resected at the level of the internal iliac artery. Paracervical lymphadenectomy PSNs and IHP are resected. | Vesicouterine/Vesicovaginal ligaments—complete resection at the level of the bladder. Bladder nerve branches are resected. | Rectouterine/Rectovaginal ligaments—complete resection at the level of the rectum. The HN is resected. |
Type C2—selective-systematic nerve sparing | The entire lateral parametrium (parauterine/paracervix) is resected at the level of the internal iliac artery. Paracervical lymphadenectomy PSNs and IHP are selectively spared. | Vesicouterine/Vesicovaginal ligaments—complete resection at the level of the bladder. Bladder nerve branches are selectively spared. | Rectouterine/Rectovaginal ligaments—complete resection at the level of the rectum The HN is spared. |
Type D—LEP or modified LEER | LEP—at the pelvic wall with transection of the internal iliac vessels. Modified LEER—at the pelvic wall with transection of the internal iliac vessels. Partial resection of the obturator fascia/muscle, and pelvic floor muscles—coccygeus muscle or sacrospinous ligament. No resection of other organs or anatomical structures (terminal ureter). | Vesicouterine/Vesicovaginal ligaments—complete resection at the level of the bladder. | Rectouterine/Rectovaginal ligaments—complete resection at the level of the rectum. |
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Kostov, S.; Kornovski, Y.; Watrowski, R.; Yordanov, A.; Slavchev, S.; Ivanova, Y.; Yalcin, H.; Ivanov, I.; Selcuk, I. Revisiting Querleu–Morrow Radical Hysterectomy: How to Apply the Anatomy of Parametrium and Pelvic Autonomic Nerves to Cervical Cancer Surgery? Cancers 2024, 16, 2729. https://doi.org/10.3390/cancers16152729
Kostov S, Kornovski Y, Watrowski R, Yordanov A, Slavchev S, Ivanova Y, Yalcin H, Ivanov I, Selcuk I. Revisiting Querleu–Morrow Radical Hysterectomy: How to Apply the Anatomy of Parametrium and Pelvic Autonomic Nerves to Cervical Cancer Surgery? Cancers. 2024; 16(15):2729. https://doi.org/10.3390/cancers16152729
Chicago/Turabian StyleKostov, Stoyan, Yavor Kornovski, Rafał Watrowski, Angel Yordanov, Stanislav Slavchev, Yonka Ivanova, Hakan Yalcin, Ivan Ivanov, and Ilker Selcuk. 2024. "Revisiting Querleu–Morrow Radical Hysterectomy: How to Apply the Anatomy of Parametrium and Pelvic Autonomic Nerves to Cervical Cancer Surgery?" Cancers 16, no. 15: 2729. https://doi.org/10.3390/cancers16152729