Serviks Kanserinde radikal cerrahide sinir koruyucu yaklaşım

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1 Serviks Kanserinde radikal cerrahide sinir koruyucu yaklaşım Prof. Dr. Hüsnü Çelik Başkent Üniversitesi Tıp Fakulesi Jinekolojik Onkoloji Bölümü (Adana Yerleşkesi)

2 Maximal oncological control Minimal early and late morbidity Bladder Bowel Surgery for Cervical Cancer Sexual Function Kobayashi T. Rahim boynu kanseri nedeniyle pelvik lenfadenektomi ile abdominal radikal histerektomi. Tokyo: Nanzando; 1961 s

3 Nerve-sparing surgery for cervical cancer Nerves may be injured Presacral lymphadenectomy Superior hypogastric plexus Resection of dorsal paracervix (uterasacral ligaments and rectovaginal ligaments) Hypogastric nerves bilaterally Resection of dorsal paracervix or preparation of pararectal space Proximal part of the inferior hypogastric plexus and splanchnic nerves Resection of lateral part of the paracervix in space of deep uterine vein Inferior hypogastric plexus and splanchnic nerves Resection of deep vesicouterine ligaments Distal part of the inferior hypogastric plexus Rob L, Lancet Oncol,2010, Fujii S, Gynecologic Oncology 2007

4 Failure: DPC was 57 days ( 5 22 days), Unilateral:34 days ( 5 45 days) Bilateral: 6 days (range, 3 12 days) Unilateral, and bilateral preservation of junctions between hypogastric and splanchnic nerves (H S junction) and between splanchnic nerve and vesical branch of pelvic plexus (S V junction); Kim HS, Ann Surg Oncol. 2015

5 Sexual Dysfunction Controls Conventional RHL Nerve sparing RHL Objective report: VPA (mv)/ Subjective report: sexual arousal (Likert scale) Neutral stimulus 1 Erotic stimulus 1 Neutral stimulus 2 Erotic stimulus ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± 1.4 Pieterse QD, Int J Gynecol Cancer, 2008

6 Nerve-sparing surgery for cervical cancer Rob L, Lancet Oncol,2010

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8 Operative procedure Step 1: Isolation and separation of the deep uterine vein from the pelvic splanchnic nerve Step 2: Isolation and separation of the hypogastric nerve Step 3: Separation of the connective tissue between the rectum and the vagina Step 4: Division of the uterosacral ligament Step 5: Separation of the cut end of the deep uterine vein from the pelvic splanchnic nerve Step 6: Separation of blood vessels in the anterior leaf of the vesicouterine ligament Step 7: Separation of blood vessels in the posterior leaf of the vesicouterine ligament Step 8: Identification of the bladder branch from the inferior hypogastric plexus Step 9: Separation and division of the uterine branch from the inferior hypogastric plexus Step 10: Division of the rectovaginal ligament Step 11: Separation and division of the paracolpium Fujii S, Gynecologic Oncology 2008

9 (A) Separation and isolation of the deep uterine vein in the parametrium. (B) Illustration of the deep uterine vein in the parametrium. Fujii S, Gynecologic Oncology 2007

10 (A) Division of the deep uterine vein reveals the pelvic splanchnic nerve. (B) Illustration of the pelvic splanchnic nerve beneath the deep uterine vein. Fujii S, Gynecologic Oncology 2007

11 (A) Separation of the hypogastric nerve, the pelvic splanchnic nerve and the bladder branch clearly reveals the inferior hypogastric plexus and the uterine branch from the plexus. These nerves comprise a plane that we call the pelvic nerve plane. (B) Illustration of the inferior hypogastric plexus. Fujii S, Gynecologic Oncology 2007

12 T (A) Isolation of the inferior vesical vein reveals the bladder branch from the inferior hypogastric plexus. (B) Illustration of the relationship between the inferior vesical vein and the bladder branch from the inferior hypogastric plexus. Fujii S, Gynecologic Oncology 2007

13 (A) Clamping the blood vessels of the paracolpium. The bladder branch from the inferior hypogastric nerve is clearly separated from the paracolpium. (B) Illustration of the relationship between the paracolpium and the bladder branch from the inferior hypogastric plexus. Fujii S, Gynecologic Oncology 2007

14 Illustration of the T-shaped nerve plane after the removal of the uterus. Fujii S, Gynecologic Oncology 2007

15 New classification system of radical hysterectomy A Recto-uterine ligament; B Space between the recto-uterine ligament and mesoureter (hypogastric plexus); C branches of the hypogastric plexus; D Mesoureter; E Ureter C1, C2 Resection lines for types C1 and C2 radical hysterectomy. Cibula D, Gynecologic Oncology, 2011

16 Class II vs Class III RH in Stage IB IIA Cx CA: A Prospective Randomized Study Landoni F, Gynecologic Oncology, 2001

17 Class II vs Class III RH in Stage IB IIA Cx CA: A Prospective Randomized Study Landoni F, Gynecologic Oncology, 2001

18 Class III NSRH vs Standard Class III RH: An Observational Study ( 185 vs 311) Characteristic NSRH RH P-value Intraoperative complications 3 (1.62%) 11 (3.54%) Bladder function No recovery 10 (5.41%) 35 (11.59%) Recovery 175 (94.59%) 267 (88.41%) Presence of postoperative complications (grade 3 or higher) 18 (9.73%) 61 (19.61%) c Ditto A, Annals of Surgical Oncology, 2011

19 Class III NSRH vs Standard Class III RH: An Observational Study Five-year DFS estimate was 78.9% in NSRH and 79.8% in RH (P = 0.519) Five-year OS estimate was 90.8% in NSRH and 84.1% in RH (P = 0.192). Ditto A, Annals of Surgical Oncology, 2011

20 Oncologic effectiveness of NSRH in Cx CA n:652 : 325 (NSRH) and 327 (RH) Between 1980 and 1995, and between 2001 and year DFS NSRH 77.7% RH 84.5, p= year OS NSRH 90.4% RH 84.9%, p= year DFS NSRH 76.6% RH 75.6%, p= year OS NSRH 89.3% RH 79.4%, p=0.06 (A) 5-year DFS in NSRH and RH groups. (B) 5-year OS in NSRH and in RH groups. (C) 5-year DFS (NACT) in NSRH and RH groups. (D) 5-year OS (NACT) in NSRH and RH groups. Dittio A, J Gynecol Oncol. 2018

21 Nerve-Sparing Approach Minimally Invasive Radical Hysterectomy: Meta-Analysis. Year of Publicat ion Institution (s) Study Design Study Period Patie nts, n MRH, n (%) NS-MRH, n (%) Possover 2000 Germany RS (42.4) 38 (57.6) B Querleu[ 2002 France RS (50.5) 47 (49.5) B Liang 2010 China PS (49.7) 82 (50.3) B Bogani 2014 Italy RS (65.6) 33 (34.4) B Chen 2014 China PS (53.8) 30 (46.2) B Liu 2016 Beijing PS (50) 60 (50) B Raspagli esi 2017 Italy PS (50) 35 (50) B Level of Evidence (ACOG) Bogani G, J Minim İnvaziv Gynecol. 2018

22 Nerve-Sparing Approach Minimally Invasive Radical Hysterectomy: Meta-Analysis. Bogani G, J Minim İnvaziv Gynecol, 2018 Bogani G, J Minim İnvaziv Gynecol, 2018

23 Nerve-Sparing Approach Minimally InvasiveRadical Hysterectomy: Meta-Analysis Bogani G, J Minim İnvaziv Gynecol, 2018

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26 Conclusion NSRH correlates with lower morbidity rate and similar oncologic outcomes than RH. The findings may be useful to provide a more detailed preoperative and postoperative counselling to the patients. Well-designed, prospective non-inferiority trials are strongly required to confirm results.

27 Thank You

28 Fig.1. Development of the pararectal space and paravesical space. Fig. 2. Isolation of the deep uterine vein. Fig. 3. Division of the deep uterine vein reveals the pelvic splanchnic nerve. Fig. 4. Isolation and division of the hypogastric nerve. Fujii S, Gynecologic Oncology 2008

29 Panel Procedures and types of nerves which can be injured Presacral lymphadenectomy Superior hypogastric plexus Resection of dorsal paracervix (uterasacral ligaments and rectovaginal ligaments) Hypogastric nerves bilaterally Resection of dorsal paracervix or wasteful preparation of pararectal space Proximal part of the inferior hypogastric plexus and splanchnic nerves Resection of lateral part of the paracervix in space of deep uterine vein Inferior hypogastric plexus and splanchnic nerves Resection of deep vesicouterine ligaments Distal part of the inferior hypogastric plexus

30 Fig. 5. The anterior leaf of the vesicouterine ligament. Fig. 6. The posterior leaf of the vesicouterine ligament. Fujii S, Gynecologic Oncology 2008

31 Fig. 7. Blood vessels in the posterior leaf of the vesicouterine ligament. Fig. 8. Division of the middle vesical vein. Fig. 9. Division of the inferior vesical vein reveals the bladder branch from the inferior hypogastric plexus.

32 Fig. 10. Cross-shaped inferior hypogastric plexus and isolation of the uterine branch from the plexus. Fig. 11. Division of the uterine branch creates T- shaped nerve plane of the inferior hypogastric plexus. Fig. 12. Division of the rectovaginal ligament. Fig. 13. Division of the rectovaginal ligament and isolation of the paracolpium.

33 Fig. 14. Division of the paracolpium. Fig. 15. Amputation of the vagina. Fujii S, Gynecologic Oncology 2008

34 Trimbos JB, Int J Gynecol Cancer 2001

35 Class II vs Class III RH in Stage IB IIA Cx CA: A Prospective Randomized Study

36 Class II vs Class III RH in Stage IB IIA Cx CA: A Prospective Randomized Study Landoni F, Gynecologic Oncology, 2001

37 New classification system of radical hysterectomy A recto-uterine ligament; B space between the recto-uterine ligament and mesoureter (hypogastric plexus); C branches of the hypogastric plexus; D mesoureter; E ureter C1, C2 resection lines for types C1 and C2 radical hysterectomy. Cibula D, Gynecologic Oncology, 2011

38 Class II vs Class III RH in Stage IB IIA Cx CA: A Prospective Randomized Study Landoni F, Gynecologic Oncology, 2001

39 Class II vs Class III RH in Stage IB IIA Cx CA: A Prospective Randomized Study

40 Sexual Dysfunction The autonomic nerves from the inferior hypogastric plexus are important for neurogenic control of the blood vessels of the vaginal wall. These blood vessels are responsible for the neural control of vasocongestion and the lubrication response

41 Nerve-Sparing Approach Minimally Invasive Radical Hysterectomy: Meta-Analysis Bogani G, J Minim İnvaziv Gynecol, 2018