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1 Department of Gynecology, National Cancer Center Hospital NICHIDOKU-IHO Vol. 51 No (2006) Nerve-sparing Radical Hysterectomy Tomoyasu Kato, M.D., Ph.D. Summary During nerve-sparing radical hysterectomy, the cardinal ligament is divided into two parts. The superficial vascular part that contains the uterine, vaginal, and inferior vesical vessels is dissected, while the deep neural part that contains the pelvic splanchnic nerves is preserved. The current surgical margin might compromise radicality. Recently, on the basis of operative findings as well as fresh cadaver studies, we have demonstrated that the pelvic splanchnic nerves arise from the dorsomedial portion of the neural part of the cardinal ligament. We have devised a new method of nerve-sparing radical hysterectomy. To increase radicality the nerve part of the cardinal ligament above the middle rectal artery is dissected, whereas to retain bladder function, the unilateral pelvic splanchnic nerves, pelvic plexus, and bladder branches are preserved. This operative method consists of four parts as follows. First, the mesoureter including the ureter is separated from the posterior leaf of the broad ligament; then the hypogastric nerves running along the rectum within the mesoureter are identified. Second, the nerve part of the cardinal ligament above the middle rectal artery is dissected to increase radicality at the pelvic sidewall. Third, for complete preservation of the pelvic plexus, the visceral stump of the cardinal ligament is mobilized ventrally above the hypogastric nerve before dissection of the uterosacral and rectovaginal ligaments. The hypogastric nerves enter the pelvic plexus at an ante-superior corner. Thus these nerves provide a good landmark for mobilization. When the tumor has deep myometrial or parametrial invasion, mobilization of the stump of the ligament should be avoided, so the pelvic plexus is partially preserved. Finally, to preserve the branches to the bladder, the fat pad around the lateral side of the vagina in the paravesical space is cleared to identify the running of bladder branches along the rectovaginal ligament. To maximize the preservation of bladder branches, rectovaginal ligaments are clamped with right-angle forceps. The anterior and posterior layers of the vesicouterine ligaments, together with some bladder branches, are dissected to maintain radicality. Between November 2001 and August 2004, 49 patients with stage IB to IVB cervical carcinoma underwent extended nerve-sparing radical hysterectomy. Ten patients received neoadjuvant chemotherapy, and 27 patients received adjuvant chemotherapy, but none received adjuvant pelvic radiation. Thirty-three patients with bilateral complete preservation of the pelvic plexus showed recovery of bladder function as rapidly as patients undergoing the conventional procedure. Further, 16 patients with partial unilateral preservation showed recovery to a residual urine volume of less than 50 ml at a median of 24 days postoperatively. None needed to perform self-catheterization. At the median follow-up period of 24 months, local recurrence alone was seen in two patients. None developed pelvic sidewall recurrence. Preoperative MRI findings of parametrial disease or lymph node involvement provide the key to deciding on the dissection line at the cardinal ligaments and pelvic plexus. These results suggest that partial preservation of the pelvic plexus on the side that has parametrial disease is sufficient to raise radicality and maintain voiding function. We propose a method of extended nerve-sparing radical hysterectomy for cervical cancer stage 2B disease.

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食道がん化学放射線療法後のsalvage手術

食道がん化学放射線療法後のsalvage手術 2006 2 17 52 Daly JM, et al. J Am Coll Surg 2000;190:562-573 Esophageal Cancer: Results of an American College of Surgeons Patient Care Evaluation Study Daly JM, et al. J Am Coll Surg 2000;190:562-573