Anatomical Basis Of Pelvic Anatomy Of Nerve-sparing Radical Hysterectomy

Objective: Almost half of all new cases died from cervical cancer whichwas one of the common gynecological malignancies. In the past few decades,the morbidity and mortality of cervical cancer had been successfully reducedin developed countries. But it was still one of the malignant tumour with highincidence in women of developing countries. As the world’s most populouscountry, China was still confronted with severe ordeal although it had madesignificant achievements in the diagnosis and treatment for cervical cancer.Surgery, which made the5-year survival rates of early cervical cancer over90%, was the major therapeutic method to cervical cancer. It was an importantstep for human to conquer cancer. But the postoperative quality of life wasaffected significantly due to wide resection, such as bladder dysfunction(micturition desire loss, urinary incontinence, urinary retention, etc.),colorectal disorders (constipation, altered bowel habit, etc.) and sexualdysfunction (vaginal dryness、sexual arousal disorder and dyspareunia). Andbladder dysfunction, the most significant complication which incidence was70%-85%, was mainly due to damaged of bladder branches from pelvicsplanchnic nerve (PSN) and inferior hypogastric plexus (IHP). So somescholars put forward nerve-sparing radical hysterectomy (NSRH). But it wasrestricted to some extent to make the popularization and application of NSRHfor many reasons for example: a. the position of pelvic organs was too deep toexpose; b. there was little residual space to operate for the compact organs; c.it was difficult to distinguish because multiple variation existed in thedirection and number of the blood vessels; d. anatomy knowledge of tissue inpelvic cavity was a little defective. It was fully needed to understand theanatomic location among pelvic organs, blood vessels and nerves in women.There for, this study was designed. It could be understand the distribution and direction of variation of vessel in obturator formamen and its positionalrelation with obturator nerve, the deep uterine vein in cardinal ligament, thedistribution of blood vessels in vesico-cevical ligament and the distributioncharacteristics of the bladder branches of inferior hypogastric plexus byfemale autopsy. The distribution of vessels and nerves and their positionalrelation with tissues in pelvic cavity could be observed and the conclusioncould provide anatomical basis for clinical treatment.Methods: Following the way of nerve-sparing radical hysterectomy, wedissect15cases of adult women corpses carefully and pictures of bloodvessels and nerves intraoperative and postoperative were collected. The followones had to be observed attentively: a. relative position of deep uterine vein inpelvic cavity and information of its branches; b. the composition and directionof blood vessels in vesico-cevical ligament; and c. the characteristics of pelvicPSN, IHP and their branches. And the data of variant vessels was collected todo statistical analysis.Results:1. About6.7%of the obturator artery came from external iliacartery which often had variant obturator vein, and about20%of the obturatorvein came from external iliac vein.2. Multiple variation exits in the obturatorartery,20percents of which come from internal iliac artery. And the obturatorvein exits variation too. We should pay attention to this situation. The positionof deep uterine vein was fixed relatively which located at the top half ofcardinal ligament (below the uterine artery and above the pelvic splanchnicnerve) and could be served as the landmark of surgical resection. There were3-6branches from deep uterine vein and63%of which were3branches. Therewere3-5branches from vesical vein，went on the bottom and the side wall ofthe bladder，and into the DUV.3. Vesico-cevical ligament was composed ofanterior leaf and posterior leaf. Anterior leaf mainly contains superficialvesical vein and2parallel vesico-cevical blood vessels and the posterior leafmainly contains middle vesical vein, inferior vesical vein and inferior vesicalartery which attached to posterior leaf.4. The neural plate shape of cross,which was seen below the deep uterine vein, was composed of cephalic part, caudal part, ventral part and dorsal part which was hypogastric nerve, bladderbranch, cervical branch and pelvic splanchnic nerve respectively. Bladderbranches from the IHP ran through the paravaginal soft tissues, most of whichat the inner side and dorsal part of the bladder entrance of the ureter. Thesuperficial bladder branch and inferior bladder branch, subdivided frombladder branches, located in bladder wall and fundus of urinary bladder.Conclusions:1. Deep uterine vein can be served as a landmark of NSRH, and it shouldbe identified first for reserving the nerves of cardinal ligament.2. Vesico-cevical ligament is the main part of operation bleeding whichlocated in the deep, closely linked to the surrounding connective tissue andhad complex vessels with thin wall.3. Bladder branches can be subdivided into superficial bladder branchand inferior bladder branch, and the former would be injured in NSRH but notcardinal ligament, pelvic splanchnic nerve or the inferior bladder branch.