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 to maintain the quality of life in this patient cohort.

We performed cross-sectional study of NSRH in 105 cases operated by the lead surgeon from January 2014 to December 2021.Patients of carcinoma cervix (up to stage IIA), endometrial carcinoma and carcinoma ovary (both upfront and interval setting) who underwent NSRH included in this study.We adopted our technique in all cases and observed perioperative outcomes in terms of bowel, bladder and sexual dysfunctions and quality of life issues using EORCTC QOL Ov28 module 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.

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.38 patients were not comfortable to disclose their sexual dysfunction.  (N=9) 8.7 %had bowel dysfunction in early postoperative period (upto 30 days). 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. On median follow-up of 30.2 months,3.8% (n= 4)  patients developed vesico vaginal fistula.All were carcinoma cervix patients who received radiation.

With nerve sparing hysterectomy with meticulous technique reduce the post-operative complications thereby increase both short-term and long-term quality of life patient scores.In our patients the post-op complications were much less compared to standard hysterectomy.None of our patients had persistent lower urinary tract symptoms to warrant urodynamic evaluation on follow up of 30 months.However,in our social circumstances most patients were hesitant to report about sexual dysfunction.

We considered NSRH is the standard of care for any hysterectomy for various cancers. Surgeon should take moral responsibility to adopt this technique in all cases. It maintains quality of life in terms of bowel, bladder and sexual dysfunction of the patient. Surgeon’s satisfaction would also definitely be high adapting the skill of performing NSRH.