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| Japanese Journal of Clinical Oncology | Pages |
Letter
Japanese nerve preserving techniques in surgery for cancer of the uterine cervix
To the Editor:
Operative techniques for primary rectal cancer in Japan combine preservation of the pelvic autonomic nerves with radical tumor resection to ensure optimal local tumor control with minimal bladder and sexual dysfunction. In the past I have been involved in a prospective study that was undertaken in The Netherlands to evaluate morbidity and functional outcome of the nerve-preserving technique, which was performed by Moriya of the National Cancer Center Hospital, Tokyo. The study proved this technique to be feasible and successful in Dutch patients (1).
The first-choice treatment of the International Federation of Gynecology and Obstetrics (FIGO) stage I and IIa cervical cancer is radical hysterectomy. In The Netherlands, the surgical procedure is based upon Japanese work: a modification of the Okabayashi method is performed (2). The pelvic autonomic nerves are not identified and preserved during the procedure. Inspired by the nerve-preserving techniques performed by Moriya in rectal cancer surgery, we carried out an anatomical study (3) to determine the location of the autonomic nerves relative to crucial tissues during the radical hysterectomy operation as it is currently performed at the Leiden University Medical Center (supervisors: G.G. Kenter and J.B. Trimbos, Leiden University Medical Center). The nerves appeared to be closely related to crucial surgical structures and damage to the autonomic nerves seemed inevitable. A technique through which the autonomic nerves could be preserved during radical hysterectomy seemed an attractive option to lower morbidity after the operation.
Dr Moriya subsequently took the initiative for my fellowship of the Foundation for Promotion of Cancer Research to enable me to study techniques of nerve preservation in radical hysterectomy as performed in Japan. I stayed in Tokyo from April 1 to 29, 1999. The concept of the identification and preservation of the pelvic autonomic nerves appears to have been introduced by Kobayashi, a gynecologist working at the University of Tokyo in the 1960s. He published an extensive description of his technique in Japanese. The surgeons at the National Cancer Center Hospital subsequently developed their nerve-preserving technique for rectal cancer. In the 1980s, Sakamoto, an apprentice of Kobayashi, published an English paper on radical hysterectomy called the `Tokyo method', which included identification and preservation of the autonomic nerves (4).
I was introduced to Professor Kuwabara, Head of the Department of Obstetrics and Gynecology at Juntendo University, and to Dr Hasumi, Head of the Department of Gynecology of the Cancer Institute Hospital, who enabled me to study their nerve-preserving techniques in radical hysterectomy.
The pelvic autonomic nerves of clinical importance in the radical hysterectomy procedure include the hypogastric nerves, the pelvic nerve (also called `pelvic splanchnic nerves') and the pelvic plexus (also called `inferior hypogastric plexus') and its end branches. These nerves are the pathway for efferent and afferent sympathetic and parasympathetic autonomic nerves and some sensory nerves supplying the rectum, uterus, vagina, vestibular bulbs and the clitoris, bladder and urethra. Nerve preservation in combination with radical hysterectomy is performed for FIGO stage Ib cervical carcinoma. In surgically staged II tumors, with invasion of the parametrium, the nerves cannot be preserved and are taken out with the specimen.
Three important steps in the identification and preservation of the nerves can be recognized. The hypogastric nerve can be palpated under the ureter, in the layer that borders the pararectal space on the rectal side. The nerve is isolated and preserved before the sacrouterine and rectovaginal ligaments are divided. After development of the cardinal ligament, the nervous part of it is identified. It is posterior to the vascular part and contains the pelvic nerve. The cardinal ligament is cut above the level of the pelvic nerve. During the subsequent dissection of the rectovaginal ligament, care is taken not to damage the pelvic plexus. In this way, all crucial pelvic autonomic nerves are preserved. Radicality does not seem to be compromised: the lymphadenectomy is carried out in a standard fashion, with `en bloc' removal of lymphoid tissue. The operation time is about 4 h, with about 1 l of blood loss. Urinary function after operation has improved significantly in both institutions since the introduction of the nerve-preserving technique.
Professor Kuwabara recently developed a modification of the `Tokyo method', preserving the end branches of the pelvic plexus in the vesicouterine ligament which supply the bladder. In patients undergoing his new technique, the bladder residue was down to 50 ml significantly faster, and detrusor compliance was significantly less disturbed.
In conclusion, nerve-preserving radical hysterectomy has been successfully performed in Japan for many years, dating back from a first publication by Kobayashi in 1961. Nerve-preserving radical hysterectomy seems to be a superior surgical procedure: the incidence of postoperative urinary dysfunction seems lowered, and radicality is not compromised. The question remains of whether this technique could be adopted with Western patients. A higher incidence of obesity and atherosclerosis probably make the procedure more difficult to perform. A prospective study on the feasibility and functional results, i.e. urinary function and also sexual function, of the Japanese nerve-preserving radical hysterectomy in Western patients seems warranted.
My fellowship of the Japanese Foundation for the Promotion of Cancer Research has been very rewarding and hopefully will lead to further cooperation between the Japanese and the Dutch in the future. My stay in Japan has been of great importance to the Department of Gynecology of Leiden University Medical Center.
References
Cornelis P. Maas
Fellow of the Foundation for Promotion of Cancer Research, Department of Gynecology, Leiden University Medical Center, Leiden, The Netherlands
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Copyright© 1999 Foundation for Promotion of Cancer Research.
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