Hypothesis / aims of study
Nerve Sparing Radical Hysterectomy (NSRH) is desirable in all cases of hysterectomy to avoid bowel, bladder and sexual dysfunction which are as high as 40% in literature. Meticulous anatomical knowledge of pelvic nerves, course of ureters, vessels, vessels plexus, various pelvic spaces and over all the skill of the surgeon are pivotal for this technically challenging surgery.
Study design, materials and methods
We performed NSRH in our 105 cases of carcinoma cervix (up to stage IIA), endometrial carcinoma and carcinoma ovary (both upfront and interval setting). We adopted our technique in all cases and observed perioperative outcomes in terms of bowel bladder and sexual dysfunctions and quality of life issues by asking questioners on follow-up.
Standard operative steps are followed till the ligation of uterine artery and superficial uterine vein. The next zone of dissection is crucial, and we termed it as ‘Red Alert Zone’ of pelvis. We were careful in the following area to safeguard the Hypogastric and pelvic Splanchnic nerves during the division of uterosacral and rectovaginal ligament, during the division of deep uterine vein in cardinal ligament, division of Vessels plexus in vesicouterine ligament, vaginal blood vessels in paracolpos area and during bladder mobilization from the anterior wall of the vagina.
Results
We performed 105 cases of NSRH. This includes 45 ca cervix (up to stage IIA), 28 cases of ca endometrium and 32 cases of carcinoma ovary. The mean operative time for NSRH alone was 120 minutes (90 min to 150 minutes). The mean blood loss was 200±50 ml as compared to 450±50 ml with our previous conventional technique. In a multivariate analysis, we found that obese patients (BMI >30), and post chemotherapy desmoplastic changes were associated with longer operative time. We followed ERAS protocol for all patients, underwent NSRH. We removed Ryle’s tube in the evening of the day of surgery. In the following day, we removed Foley’s catheter. Urinary retention was noted in 4.76% (N=5). We observed obese and diabetic patients having the tendency for urinary retention more. We used EORTC Ov28 questionnaire to assess sexual dysfunction at around 8 weeks.28.5% (n-30) patients were sexually inactive and 5.7% (n=6) reported vaginal dryness during sexual activity. There was no post-operative mortality. Intraoperative complications included bladder injury 2.9% (n=3), ureteric injury 3.8% (n=4) which occurred in post NACT ovarian cancer patients.
Interpretation of results
Nerve Sparing Hysterectomy is essential to sustain quality of life after Radical Hysterectomy, Sexual Dysfunction is usually 13-37% after pelvic surgery. The limited data suggests that NSRH can have some impact in improving female sexual life. Bowel bladder dysfunction reported as 20-40%. Development of new diagnostic test and perfect surgical techniques can spare genital nerves and vaginal and clitoral blood supply to preserve female sexual function and bowel bladder dysfunctions like ours technique. The detailed anatomical knowledge of pelvic nerves helps in meticulous dissection for NSRH and hence improving perioperative quality of life. Defining different pelvic zones, delineating of all anatomical structures, like our technique, need to be implemented in routine practice for expected outcomes.