A nerve-sparing radical hysterectomy: guidelines and feasibility in Western patients

We read with interest the paper by Trimbos et al. on nerve-sparing radical hysterectomy (RH) as a method of reducing the morbidity associated with this operation. In a questionnaire study on patients who had undergone a RH, we reported a high incidence of bowel, bladder, and psychosexual dysfunction at more than one year from surgery. In an effort to understand the etiology of the pelvic morbidity associated with RH, we postulated that the uterine supporting ligaments had a substantial nerve component and that the more lateral the division of these ligaments the greater the nerve damage. In our initial study using semiquantitative immunochemistry, we reported that these ligaments had a substantial nerve content and that the uterosacral ligaments had a significantly greater nerve content compared to the cardinal (lateral uterine/Mackendrodt) ligaments. We have also shown in a further study on nerve subtypes within the uterine supporting ligaments that sympathetic nerves represent the largest nerve subtype in the uterosacral ligaments and that both the uterosacral and cardinal ligaments contain sympathetic and parasympathetic nerve fibers. We would therefore argue that modifying surgical resection at RH to maintain cure and reduce morbidity is more likely to be achieved by less radical resection of the uterosacral ligaments, rather than the cardinal ligament. This contrasts with Trimbos et al. who argue that the potential reduced morbidity with nerve-sparing surgery is much more related to modified surgical resection of the lateral (cardinal) ligaments. The procedure described by the authors, and as depicted in Fig. 3 in their paper, will likely compromise surgical margins in the lateral tissues closest to the cervical cancer. It is, however, unlikely that any randomized trial would be undertaken to test the applicability and efficacy of these surgical concepts. It is gratifying, however, that gynecological oncologists are seriously reevaluating surgical practice to best serve their patients.