| Background and ObjectjveCervical cancer is the worldwide incidence of female genital tract malignancy, 493,000 new cases each year and 274,000 deaths, of which 83%of cervical cancer in developing countries. Each year about 13 million or more new cases in China, about 2 to 3 million women die of cervical cancer. With the increase of the HPV infection rates in recent years, the incidence of cervical cancer was significantly increased,and younger patients with cervical cancer under the age of 35 composition ratio of up to 24.9%. The treatment of cervical cancer mainly is surgery and radiotherapy, after over a hundred years of practice proved that effect of radiotherapy was good, but it has a long-term serious of complications such as narrow of the vagina, premature ovarian failure and so on, that impact on patients quality of life., especially young patients.At the beginning of the last century, Wertheim-Meigs put forward the radical hysterectomy (RH) and pelvic lymph node dissection, that has become the classic surgical treatment of cervical cancer. With the accumulation of experience, surgical treatment getting better effect and 5-year survival rate has reached 75%-90%. So the current principles for the treatment of patients with early stage cervical cancer: surgery, fundamentally; radiotherapy, supplemented; if necessary, preoperative neoadjuvant chemotherapy.However, surgical treatment got the noticeable effect also brought a more serious and irreversible complications, especially under the urethra/bladder dysfunction (sensory loss, urinary storage and voiding dysfunction, urinary incontinence, bladder pressure instability), anal/rectal dysfunction (blood stools, constipation/diarrhea, change in bowel habits) and the vulva/vagina dysfunction (low sexual desire, arousal disorder, orgasmic disorder and sexual pain)etc., all is seriously affecting the patient’s quality of life. A number of studies confirm that the above-mentioned complications mainly due to the damage of the pelvic autonomic nerve (PAN), so how avoid to and reduce to the injury of the PAN is the key to preventing complications.As early as 1960s, Japanese scholars Kobayashi first proposed for paring parasympathetic nerve that innerve bladder and subsequently by the efforts Sakamoto, etc.1990s gradually formed Okabayashi improved surgical technique, namely, Systematic Nerve-sparing radical hysterectomy (SNSRH) and called " Tokyo method ". on the basis of Tokyo method, SNSRH was modified, such as the use of liposuction surgery, electrical stimulation technology. Currently reported in the literature NSRH has achieved good efficacy, the majority patients with short indwelling catheter time, ability of restoration spontaneous voiding early. Meanwhile the bowel function and sexual function also improved, the quality of life can also be improved.So far, due to the lack of a prospective multi-center randomized controlled study,the long-term efficacy and prognosis in oncology of the patients who unwent Systematic Nerve-sparing Radical Hysterectomy are not yet quite clear, which make scholars suspicious of treatment effect of this surgical, First, can the pelvic autonomic nerve in cardinal ligament during SNSRH surgery really be retained? Second, is the resection extent of SNSRH enough?can the lymphatic and blood vessels of cardinal ligament as a path of tumor metastasis be kept also? can the long-term prognosis of patients after this kind of operation be affected by this surgical? The purpose of this study is to explain and clearify the first two questions, Since the period of the experiment is limited, a direct conclusion is not derived from this experiment,but some subservienc evidence can be provided.The aim of this study is to compare cardinal ligament of cervical cancer patients after RH with that of patients undergoing SNSRH by immunohistochemical、Various special stainingand organisms inspection Quantification in order to explain①the Organizational structure and characteristics of cardinal ligament,especially the distribution②whether the nerves aer safely sparing after SNSRH and retained nerve quatity.③whether the surgical reception extent is not adequate and this operation methoad increase potential oncology insecurity factors:lymphatic and blood vessels.This study was designed to explore possibilities and feasibility of reducing the incidence of pelvic organ dysfunction based on no affecting the removal scope of the cardinal ligament with SNSRH.Materials and methods1. SpecimenApril 2008 to March 2009, twenty-five patients of cervical caner, who visits in Nanfang Hospital and Sun Yat-sen University Cancer Center, had been selected. they ware Randomly divided into two groups, one group received radical hysterectomy (RH group), another group received nerve-sparing radical hysterectomy (SNSRH group) and 13patients brought into RH group, while 12patients brought into SNSRH group. After the operation the cardinal ligament ware collected. Twenty-two cardinal ligament specimens ware collected from RH group and twenty-four cardinal ligament specimens ware collected from SNSRH.2. Drawing materialsEvery cardinal ligament specimen is cut to three parts by one centimeter, starting from the part where the cardinal ligament is inserted to cervix. They are named the close part, the middle part and the distal part, the close part and the middle part is one centimeter length, and the left part is the distal part. Margin reserved to pathology diagnosis.3. DyeingThen every tissue is fixed up by 10% formalin, to be embedded by routine paraffine, to be sliced up to four slices. At last, we do qualitative research on the histological structure of the cardinal ligament by using HE staining, immunohistochemical staining and special staining.4. Collection imagesPlaces the slides under the microscope Olympus bx 51 to collected images, each slide is randomly checked 10 fields of vision on the upper half and lower half.5. Image analysisThen entered the images into the computer, used the Imagepro Image Analysis System to measure the positive targets’ area density, meanwhile measured the area density of photos.6. The computation of volume densityUsing the formula of Biostereology:volume density (Vv)=testing area density of observed positive/consulted space area density, calculates the volume density of every positive target.7. The statistics method:The results are expressed by average±standard deviation; the volume density was analysised by two sample T test. If P<0.05 then the difference has statistical significance. All statistical evaluation was performed using the spss 13.0 statistical software package.Results:1. Two groups in age, body mass index, tumor diameter, clinical stage, no significant difference, (P>0.05). Two uterine length and width of the cardinal ligaments were no significant differences(P>0.05); postoperative indwelling catheter for 7 days,8 were tested for residual urine, RH group and SNSRH group were (342.31±125.37)ml and (213.00±130.77)ml, two groups were significantlydifferent(t=2.524, P= 0.019); indwelling catheter time RH group and SNSRH group were (17.38±4.77)days (9.42±1.83)days, two groups were significantly different (t=5.422, P= 0.000); surgery RH group, and after exhaust time SNSRH group were (62.46±18.16) hours and (50.58±14.21) hours, two groups were not significantly different (t= 1.810, P= 0.083); postoperative recovery defecation RH group and SNSRH group were (99.15±23.33) hours and (79.29±17.64) hours, the two groups were significantly different (t=2.389, P=0.026)2. Microstructure of the cardinal ligament1)HE staining results:a large number of fibrous connective tissue, adipose tissue; plenty of blood vessels (including small, medium, micro-artery and micro-vein), nerve tissue; scattered lymph vessels; occasional lymphoid tissue.2) Immunohistochemical staining and special staining results:①The improve method of Masson’s trichrome staining shows that collagen fibers are azure blue to deep blue, Unna’s orcein staining shows elastic fibers are brown-red. The cardinal ligament contains a lot of collagen fibers, and few elastic fibers and muscle fibers were scattered.②The results of S-100 antibody immunohistochemical staining of specific marked nerves confirms that the cardinal ligament is rich in nerve tissue, improved Loyes’s special staining shows myelin is negative, it proves that the nerve tissue of the cardinal ligament is pelvic autonomic nerve. Further staining with immunohistochemistry, the result of TH antibody specific marked sympathetic nerve is positive, and the VIP antibody specific marked parasympathetic’s result is positive, it proves that the cardinal ligament’s autonomic nervous system including the sympathetic nerve and parasympathetic nerve. The cardinal ligament contains of abundant nerve, they are scattered and regularity, relative concentration in the lower half of the cardinal ligament.③The CD34 antibody immunohistochemical staining of specific marked vessel confirms that the blood vessels of the cardinal ligament are arteriovenous, and improved aldehyde fuchsin-periodic acid Schiffs double staining shows that the artery are rose Bengal. The artery and vein in the cardinal ligament contains abundance artery and vein, we can see medium and small-sized artery and vein, including a large number of red blood cells. They distribute relative concentration of the upper part of the cardinal ligaments in the uterus.④The result of D2-40 antibody immunohistochemical staining on specific marked lymphatic is positive. The lymphatic vessels are scattered, including different sizes of all levels of ramus. Occasionally shows lymph nodes.3. the volume density of sympathetic, parasympathetic, lymphatic and vascular in the two groups1) The volume density of sympathetic in the two groups.The volume density of sympathetic in the RH group (0.0665±0.0671) ware significantly higher than SNSRH group (0.0191±0.0159) (t=3.233, P= 0.002),and in the proximal, middle and lateral segment the RH group ware higher than SNSRH group too. In the proximal segment, the volume density ware (0.0563±0.0537) and (0.0228±0.0178) respectively, t=2.788, P= 0.010; In the middle segment, the volume density ware(0.0666±0.0396)and (0.0210±0.0227)respectively, t=3.0134, P= 0.007; In the lateral segment, the volume density ware (0.0764±0.0109) and (0.0134±0.0173) respectively, t=2.797, P= 0.008.2) The volume density of parasympathetic in the two groups.The volume density of parasympathetic in the RH group (0.0374±0.0239) ware significantly higher than SNSRH group (0.0092±0.0096) (t=2.323, P= 0.000),and in the proximal, middle and lateral segment the RH group ware higher than SNSRH group too. In the proximal segment, the volume density ware (0.0284±0.0231) and (0.0106±0.0131) respectively, P= 0.022; In the middle segment, the volume density ware (0.0320±0.0416) and (0.0109±0.0130) respectively, P= 0.029; In the lateral segment, the volume density ware (0.0519±0.0449) and (0.0061±0.0092) respectively, P= 0.000;3) The volume density of lymphatic in the two groups.Volume density of lymphatic vessels in the RH group (0.0061±0.0033) and SNSRH group(0.0057±0.0032) no significant difference, (t= 0.418, P= 0.678), and in the proximal, middle and lateral segment the RH group and SNSRH group no significant difference too. In the proximal segment, the volume density ware (0.0053±0.00325) and (0.0055±0.0049), respectively, t=-0.198, P=0.844; In the middle segment, the volume density ware (0.0057±0.0043) and (0.0056±0.0031); respectively, t=0.111,P=0.913; In the lateral segment, the volume density ware (0.0074±0.0066) and (0.0062±0.0056) respectively, t=0.634, P=0.529;4) The volume density of vascular in the two groups.Volume density of vascular in the RH group(0.1478±0.06020)and SNSRH group (0.1353±0.06732) no significant difference, (t= 0.647, P= 0.521). And in the proximal, middle and lateral segment the RH group and SNSRH group no significant difference too. In the proximal segment, the volume density ware (0.1503±0.1103) and (0.1701±0.1173), respectively, t=-0.555, P=0.582; In the middle segment, the volume density ware (0.1489±0.9535) and (0.1398±0.0677) respectively, t= 0.363, P=0.719; In the lateral segment, the volume density ware (0.1441±0.0794) and (0.1409±0.0741) respectively, t=0.137,P=0.892.Conclusion1. Compared with patients receiving radical hysterectomy, nerve-sparing patients after radical hysterectomy the lower urinary tract/bladder function and anal/rectal function was improved:patients with indwelling catheter time was shorting and after the operation the ability to restore self-voiding was earlier, bladder residual urine volume was decreased; postoperative recovery time of defecation also shorting.2. Cardinal ligament, that accepted radical hysterectomy and nerve-sparing radical hysterectomy are similar, contains a large number of fibrous connective tissue, collagen fibers in the main; and a lot of fat tissue. It’s rich in nerve tissue, including the sympathetic and parasympathetic, regular distribution; rich in blood vessels at all levels and regular distribution. The distribution of lymphatic is scattered, including the lymphatic vessels; occasional lymphoid tissue and lymph nodes.3. Compared with radical hysterectomy, the sympathetic and parasympathetic were significantly reduced in the cardinal ligament which received nerve-sparing radical hysterectomy. The nerve ware really spared.4. compared with radical hysterectomy, the lymphatic and blood vessels no significant changes. The lymphatic and vessels ware not spared.In summary, the nerve (sympatheticus nerve and parasympathetcus nerve) was reserved in the nerve-sparing radical hysterectomy, while the blood vesse and lympgatic vessel was not reserved. So it is possible that the patients of cervical cancer reduced the incidence of pelvic organ function dysfunction or severity meanwhile not reduces the radicalty while patients receive the nerve-sparing radical hysterectomy. |
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