Avascular spaces in radical hysterectomy.pptx

Avascular spaces
in radical
hysterectomy
Dr Mohammad Masoom Parwez
Ignacio Zapardiel ,1 Marcello Ceccaroni,2 Lucas Minig ,3 Michael J Halaska,4 Shingo Fujii5
La Paz University Hospital, Madrid, Spain
29 December 2022

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

Introduction
4
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• Most common cancer in women worldwide is cervical cancer
• 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

• 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

• 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

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

AVASCULAR SPACES IN
THE FEMALE PELVIS
“
”20XX
10

• 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

Paravesical
spaces
12

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

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

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
16 20XX

Para-rectal
spaces
18

• 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

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
• 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

• 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

• 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

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

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
27 20XX

Avascular
spaces in vesico-
uterine ligament
29

• 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

• 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

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

• 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

• Exposure:
• Retract the bladder towards the symphysis pubis and subsequently 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

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

• 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

• 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

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

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

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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

Thank you for your patience
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Avascular spaces in radical hysterectomy.pptx

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