Nerve-preserving techniques for radical hysterectomy

Aims. Postoperative bladder dysfunction of varying severity is common after radical hysterectomy due to damage to the pelvic autonomic nerves during surgical resection. Pelvic autonomic nerve damage occurs at two main sites: the fibrous tissue at the lateral aspect of the uterosacral ligament (FLUSL) and the posterior layer of the vesicouterine ligament (PLVUL). In this article, we classify the main sites of pelvic autonomic nerve damage based on previous reports and our own experience, outline the problems with current nerve-preserving techniques, and describe an improved nerve-preserving technique that we have developed. Results. We present urodynamic data for 25 patients who underwent radical hysterectomy using the nerve-preserving technique we described previously and preliminary results for four patients treated by the latest technique. To avoid pelvic autonomic nerve damage, injury to the FLUSL and PLVUL should be minimized. For the FLUSL, we have obtained relatively good bladder function with the cardinal ligament pull-through technique. However, a new method is needed for management of the PLVUL, since the only way to minimize nerve damage at this site currently is to limit the extent of PLVUL resection.