Avascular spaces in radical hysterectomy.pptx

anatomy of female pelvis, surgical avascular spaces

1. Avascular spaces in radical hysterectomy Dr Mohammad Masoom Parwez Ignacio Zapardiel , 1 Marcello Ceccaroni, 2 Lucas Minig , 3 Michael J Halaska, 4 Shingo Fujii 5 La Paz University Hospital, Madrid, Spain 29 December 2022

2. Agenda 1 2 3 4 5 Introduction Methods Avascular spaces in female pelvis Conclusion References 2 Journal club 2023

3. Abstract

4. Introduction 4

5. Most common cancer in women worldwide is cervical cance r Incidence in developing countries is increasing, whereas in developed countries it is decreasing FIGO) 2018 stages IA, IB1-2, and IIA1), the standard treatment is radical hysterectomy with lymph node assessment Advanced stage tumors, chemoradiotherapy is the standard of care Radical hysterectomy approach - first description by Ernst Wertheim in 1912 Three major advances: Latzko (1919) Okabayashi (1921) Meigs (1944) 5 Presentation title 20XX

6. Extensive knowledge of pelvic anatomy Pelvis is composed of several compartments composed of vessels, nerves and supportive tissue and, avascular spaces Enable surgeons to perform the surgical steps necessary to decrease hemorrhage, as well as to minimize damage to nerve supply to the pelvic organs ( Figure 1 Complications related to surgeon’s ability of proper dissection and identification of key anatomical landmarks such as hemorrhage, lymphedema, and autonomic nerves injury Potential adverse outcomes related to parametrial resection include bladder, anorectal, and sexual dysfunctions Nerve-sparing techniques were developed mainly by Japanese surgeons such as Yabuki , Sakuragi , and Fujii ; but also by several European surgeons such as Possover and Raspagliesi 6 Presentation title 20XX

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8. A study on urinary tract morbidity showed a lower rate of morbidity using type II or nerve-sparing technique Several authors have described anatomical landmarks, structures, and spaces in order to set standards for surgeons; however, the boundaries of pelvic avascular spaces remain elusive and definitions of such spaces are often the subject of debate Aim of this review is to synthesize currently used anatomical landmarks in relation to surgical spaces on the basis of recently introduced nomenclature of radical hysterectomy 8 20XX

9. Methods Consensus process between authors was completed from December 2019 to December 2020 Computer-based comprehensive review of the MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, EMBASE, and SciSearch databases, NCCN and ESGO guidelines A manuscript of the definition of avascular spaces, methods of dissection, and anatomical limits was prepared All the avascular spaces of the pelvis developed during radical hysterectomy, and according to the literature search, were considered and included in the manuscript

10. AVASCULAR SPACES IN THE FEMALE PELVIS “ ” 20XX 10

11. During embryological period, the female genital tract is developed between the urinary bladder and the rectum Urinary bladder is located in the lower cervix/vagina with a space named the vesico -cervical/vaginal space The rectum is located on the dorsal side of the vagina with a space named the rectovaginal space Between the pelvic side wall and the pelvic viscera, there are spaces of loose connective tissue known as the paravesical , pararectal, and paravaginal spaces 11 Presentation title 20XX

12. Paravesical spaces 12

13. Lateral Paravesical Space Divided into a medial and lateral paravesical space with respect to the obliterated umbilical artery and the umbilical prevesical fascia Provides access to the distal aspect of the obturator vasculo-nervous structure and external iliac vessels with their anastomotic network, also known as the corona mortis ( Figure 2 ) Anatomical limits: laterally: the parietal pelvic fascia, external iliac vein and artery, and retro-inguinal Bogros ’ space medially: the obliterated umbilical artery cranially: the lateral parametrium with the uterine artery and vein caudally: Bogros ’ retroinguinal space and ischiopubic branches ventrally: the round ligament and peritoneum of the anterior leaf of the broad ligament dorsally: the pelvic floor 13 20XX

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15. Lateral Paravesical Space Technique: transection of the round ligament at the level of the inguinal region the anterior and posterior peritoneal layers of the broad ligament are opened with a cranio-caudal and dorso -ventral dissection and the ureter is identified obliterated umbilical artery is identified, following its course to the anterior abdominal wall lateral paravesical space is then developed by gentle medial traction of the umbilical artery together with the fascial sheet of the lateral umbilical ligament Bluntly developing the loose connective tissue between umbilical artery and external iliac vessels This space can be developed to the level of pelvic floor, when that level of radicality is required, observing right pelvic nodes and obturator nerve and vessels that enter in the obturator foramen, at the level of pelvic wall 15 20XX

16. Medial Paravesical Space Extended space of the lateral paravesical space to the medial side Connective tissue in the lateral umbilical ligament fascia sheet between the uterine artery and the superior vesical artery is dissectable into the lateral paravesical space By the lateral traction of the umbilical ligament, the medial paravesical space is extended to the lateral paravesical space Anatomical boundaries: laterally: the obliterated umbilical artery and lateral paravesical space medially: the umbilical prevesical fascia and paracolpos cranially: the lateral parametrium caudally: the bladder wall ventrally: the round ligament and peritoneum of the anterior leaf of the broad ligament dorsally: the pelvic floor 16 20XX

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18. Para-rectal spaces 18

19. Defined as a loose connective tissue space surrounded by the rectal sidewall, the internal iliac blood vessels and connective tissue segment containing the deep uterine vein, and nerve fibers of the lateral parametrium Two different techniques to develop the pararectal space: One approach is a separation of the connective tissue between the rectum/ureter and the internal iliac artery/vein by retracting medially on the rectum with the ureter - Latzko’s lateral pararectal space Other approach is the separation of the connective tissue close to the rectal sidewall after the division of the uterosacral ligament toward the base of the pelvis - Okabayashi’s medial pararectal space 19 20XX

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22. Latzko’s Lateral Pararectal Space Anatomical boundaries laterally: parietal pelvic fascia, internal iliac artery, and piriformis muscle medially: the ureter and mesoureter with the hypogastric nerve cranially: the presacral fascia and sacral bone caudally: the lateral parametrium containing deep uterine vein and the pelvic splanchnic nerve ventrally: the peritoneal layer over the ureter, uterine artery, and superficial uterine vein dorsally: the pelvic floor Identification of the course of ureter at the level of pelvic brim, the peritoneum is incised Starting from the level of iliac vessels bifurcation, space is opened by blunt dissection of areolar tissue between the rectal sidewall with ureter and the internal iliac artery Cobweb-like connective tissue is easily separated caudally over the internal iliac vein One may achieve an ideal approach to the pararectal space up to the level of parietal endopelvic fascia covering the pelvic floor 22 20XX

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24. Latzko’s Lateral Pararectal Space This step allows for the identification of the dorsal portions of coccygeal and piriformis muscles, and the internal iliac lymph nodes In addition, on the rectal sidewall 2-3 cm dorsal to the ureter, a nerve bundle of the hypogastric nerve is observed A key step during a radical hysterectomy, giving full access to the internal iliac (hypogastric) vessels, visceral nerves, and lymph nodes More caudal dissection of the hypogastric nerve in the Latzko’s pararectal space allows the identification of the middle rectal artery and the course of the deep uterine vein Constant anatomical landmark used to identify the plane dividing the parametrial pars vasculosa (deep uterine vein) (ventrally and cranially) from the pars nervosa (pelvic splanchnic nerve that should be preserved in all nerve-sparing surgeries) Medial caudal dissection of the pararectal space towards the concavity of the sacral bone provides access to the retrorectal space , opening the so-called ‘ holy plane of Heald ’ in the midline During this step, sacral roots S2-S4 and pelvic splanchnic nerves are identified bilaterally 24 20XX

25. Latzko’s Lateral Pararectal Space The so-called hypogastric fascia, composed of the presacral parietal pelvic fascia covering the muscles and innervated by the parasympathetic pelvic splanchnic nerves originating at sacral roots S2-S4, ultimately join with the inferior hypogastric plexus (or pelvic plexus) at the lower lateral cervix By the division and separation of the deep uterine vein toward the lower lateral cervix, the pelvic splanchnic nerves are usually exposed This is done in order to preserve their fibers during the nerve-sparing radical hysterectomy 25 20XX

26. Okabayashi’s Medial Pararectal Space The space between the rectal sidewall and the pelvic connective tissue layer containing the ureter and hypogastric nerve known as the mesoureter The mesoureter is the connective tissue bundle that emerges between Okabayashi’s pararectal space (medially) and Latzko’s pararectal space (laterally) After isolation of the ureter in the mesoureter , the ureter is retracted toward the lateral pelvic side wall Plane development starts from the division of the uterosacral ligament The hypogastric nerve runs approximately 2-3 cm on the dorsal side of the ureter in the mesoureter In case of nerve sparing radical hysterectomy, the hypogastric nerve is isolated and preserved down to the inferior hypogastric plexus at the lower lateral cervix 26 20XX

27. Okabayashi’s Medial Pararectal Space Anatomical limits: laterally: the ureter, hypogastric nerve, mesoureter , and Latzko’s pararectal space medially: the visceral endopelvic rectal fascia (fascia propria recti), lateral ligaments of the rectum (rectal wings, rectal pillars), and the rectal sidewall cranially: the sacral bone caudally: the blood vessels and connective tissue of the lateral parametrium ventrally: the peritoneal layer over the ureter dorsally: the pelvic floor 27 20XX

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29. Avascular spaces in vesico -uterine ligament 29

30. Divided into the ventral layer and dorsal layer by Okabayashi Ventral layer is a connective tissue layer covering the ureter between the uterine cervical fascia and the urinary bladder The separation and division of the ventral layer of the vesicouterine ligament along the ureter reveals the connective tissue surface of Okabayshi’s dorsal layer of the vesicouterine ligament 30 20XX

31. ventral layer contains the final segment of the roof of the ureteral tunnel and a superficial connective tissue layer covering the ureter dorsal layer may be defined as connective tissue bundle between the urinary bladder and the lower-lateral cervix that contains vesical veins and branches of the hypogastric plexus , connecting the deep uterine vein in the lateral parametrium 31 20XX

32. Ureteral Tunnel Space Once the surgeon reaches the point where the ureter crosses under the uterine artery , focus should be on the transection of the uterine artery from its origin at the internal iliac artery When the artery is visible and isolated, it should be cut Medial and upward traction on the medial pedicle of the uterine artery will allow for exposure of the ureter as it enters the ventral layer of the vesicouterine ligament Of note, the superficial uterine vein is usually running parallel to the uterine artery In some patients, the uterine artery and vein may be clamped or coagulated as a bundle rather than individually Then, the loose connective avascular space between the ureter and the ventral layer of the vesicouterine ligament is appreciated - entrance of the ureter tunnel Dissection of the ureteral tunnel is one of the most important steps in a radical hysterectomy 32 Presentation title 20XX

33. Ureteral Tunnel Space Anatomic limits of the ureteral tunnel avascular space: laterally: medial side of the ureter medially: the uterine cervix and the lateral fornix of the vagina ventrally: the uterine artery caudally: a pair of artery and vein crossing over the ureter from the cervix to the urinary bladder (named as cervico -vesical vessels) ventrally: the uterine artery and the superficial uterine vein dorsally: the dorsal layer of the vesicouterine ligament 33 Presentation title 20XX

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35. Ureteral Tunnel Space Exposure : Retract the bladder towards the symphysis pubis and subsequentl y apply cephalad traction to the uterus Ureter is then pulled medially or laterally in order to find the entrance of the ureter tunnel From here, the ventral layer of the vesicouterine ligament is separated Proceed gently along the medial side of the ureter not injuring a pair of artery and vein crossing over the ureter from the cervix and urinary bladder separate and divide the anterior layer of the vesicouterine ligament to the portion where the ureter is inserting into the urinary bladder Separating the loose connective tissue between the cervix and the medial side of the ureter, the ureter itself is mobilized laterally enough to expose the connective tissue of the dorsal layer of the vesicouterine ligament 35 Presentation title 20XX

36. Okabayashi’s Paravaginal Space Recognizing the surface of the dorsal layer of the vesicouterine ligament, the ureter is separated and retracted toward the inguinal region The insertion of a broad L-shaped retractor to hold the bladder above the line of the separation is useful On the lateral bladder side and just 1cm lateral from the upper vaginal wall, entrance of an avascular space named the ‘paravaginal space’ by Okabayashi is appreciated 36 Presentation title 20XX

37. Okabayashi’s Paravaginal Space An avascular space filled with adipose tissue and extends into the paravesical space Developed between the vaginal/cervical blood vessels ( paracolpium ) with the bladder branch of the inferior hypogastric plexus and the medial side of the dorsal layer of the vesicouterine ligament The caudal extension of the paravaginal space can expose the paracolpial tissues on the upper vagina for the most appropriate length of the vaginal cuff In order to obtain an appropriate length of the vaginal cuff, it is very important to isolate and divide the dorsal layer of the vesicouterine ligament at the level of Okabayashi’s paravaginal space When dissecting the posterior layer of the vesicouterine ligament, one should keep in mind that there are vesical veins running from the urinary bladder to the deep uterine vein. Injury to these veins may cause considerable bleeding 37 Presentation title 20XX

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40. Okabayashi’s Paravaginal Space To obtain the appropriate length of vaginal cuff and to accomplish a nerve-sparing radical hysterectomy, the development of Okabayashi’s paravaginal space is very important After complete division of the dorsal layer of the vesicouterine ligament, the bladder branch of the inferior hypogastric plexus is revealed parallel and dorsal with the vaginal blood vessels ( paracolpium ) The rectovaginal ligament between the lower cervix and upper vagina and the rectum is divided by the level of the appropriate vaginal cuff length Bladder branch is preserved on the divided rectal side of the rectovaginal ligament Ligation and division of the vaginal blood vessels ( paracolpium ) on the vaginal wall, the uterus is removed These are the brief steps for the nerve-sparing radical hysterectomy 40 Presentation title 20XX

41. Yabuki’s Fourth Space After separation of the ureter slightly from the connective tissue covering the ureter Yabuki developed a loose connective tissue space from the ventral layer of the vesicouterine ligament via the mid-portion of the dorsal layer of the vesicouterine ligament into the paravesical space Surgical steps: opening and closing the tip of a Kelly’s forceps or any similar instrument creating the space by excavating perpendicular to the areolar connective tissue, which is present between the ventral layer of the vesicouterine ligament including the ureter and the mid-portion of the dorsal layer of the vesicouterine ligament at approximately 2cm proximal to the entrance to the bladder Anatomical limits of Yabuki’s space: laterally: medial paravesical space medially: medial half of dorsal layer of the vesicouterine ligament that includes vaginal wall and paracolpium cranially: the ureteral tunnel caudally: bladder wall ventrally: superficial leaf of the ventral layer of the vesicouterine ligament dorsally: paravesical space 41 Presentation title 20XX

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43. Yabuki’s Fourth Space Surgical significance: May decrease bleeding while performing modified radical hysterectomy or a modified technique of nerve-sparing surgery Nevertheless, the concept of Yabuki’s fourth space is very difficult when opening Okabayashi’s paravaginal space for radical hysterectomy 43 Presentation title 20XX

44. Conclusion A precise definition of the pelvic avascular spaces will aid surgeons understanding of the anatomical boundaries of the radical hysterectomy Ensures that surgeons are consistent in their approach to the pelvic dissection, the structures that need to be preserved, and those that should be resected Facilitate the appropriate tailored radicality depending on the risk factors of the disease Moreover, the knowledge of these spaces could make pelvic surgery safer and more feasible for other types of gynecological procedures 44

45. Thank you for your patience “ ” 45 Presentation title 20XX