Abstract
Objective
Radical hysterectomy with pelvic lymph node dissection is the treatment of choice for cervical cancer. All gynecologic oncologists should master this technique. The surgical procedure requires a wide dissection of the female pelvis. Performing radical hysterectomy without a thorough knowledge of the anatomy of the female pelvis can lead to serious complications. For novice surgeons to safely perform radical hysterectomy, mastering the 3-dimensional anatomy of the pelvis and aligning the dissection lines of radical hysterectomy to the female pelvic anatomy is crucial. Educational materials that demonstrate the anatomical relationship between dissection lines in radical hysterectomy and the surrounding pelvic structures are lacking. We aimed to create educational material to overcome these problems.
Methods
Laparoscopic nerve sparing, non-nerve sparing, and super-radical hysterectomies, exposing pivotal pelvic anatomical structures, were performed on a Thiel-embalmed cadaver.
Results
Nerve sparing, non-nerve sparing, and super-radical hysterectomies were laparoscopically performed in the right hemi-pelvis of the cadaver. We exposed the external and internal iliac vessels; obturator, sciatic, femoral, hypogastric, and pelvic splanchnic nerves and the pelvic nerve plexus; internal obturator, piriform, and coccygeal muscles; sacrospinous ligament; and ischial spine. Thus, we demonstrated where the dissection lines of the various radical hysterectomies are in a female pelvis.
Conclusion
Using a Thiel-embalmed cadaver, we demonstrated the relationship between the dissection lines of various radical hysterectomies and pivotal sidewall anatomical structures in a female pelvis. The anatomical detail shown in the video captured during this procedure may assist surgeons to safely perform various radical hysterectomies.
Keywords: Cadaver, Cervical Cancer, Education, Pelvis, Anatomy, Radical Hysterectomy
Synopsis
Performing a radical hysterectomy can produce serious complications. Educational materials demonstrating the dissection lines in relation to pelvic sidewall anatomy are lacking. This cadaveric study clearly demonstrates the relationship between various dissection lines and pivotal pelvic anatomical structures.
INTRODUCTION
The female pelvis is a complicated construction with the rectum, ureters, bladder, nerves, and blood vessels arranged in a bowl-shaped structure formed by the pelvic bones and muscles. Several potential spaces surround these structures [1]. Due to its complexity, novice gynecologic oncologists find comprehending the female pelvic anatomy challenging.
Nerve-sparing and non-nerve-sparing radical hysterectomies with pelvic lymph node dissection are the treatment of choice for cervical cancer, and all gynecologic oncologists must be proficient at performing them. More radical surgery—super-radical hysterectomy—may be required in recurrent cases [2]. These surgical procedures require extensive, wide dissections of the female pelvis and may lead to injury of the surrounding structures if knowledge of the pelvic anatomy is lacking. Therefore, educational material that demonstrates the relationship between the dissection lines of the various types of radical hysterectomy and surrounding anatomical structures is essential for novices.
In the clinical practice of radical hysterectomy, demonstrating the pelvic anatomical structures beyond the dissection lines is difficult because unnecessary dissection is detrimental to the patient. Several textbooks are helpful for gaining an understanding of the detailed pelvic anatomy [3,4], but they seldom demonstrate the relationship between the dissection lines of radical hysterectomy and surrounding pelvic anatomical structures. Furthermore, the number of patients with invasive cervical cancer is decreasing due to the widespread use of human papillomavirus vaccination [5], and surgery for cervical cancer is being de-escalated [6], creating fewer opportunities for novices to gain sufficient practice in the technique to master radical hysterectomy.
Because a Thiel-embalmed cadaver would create a more realistic visual and practical environment for clinicians [7], we used a Thiel-embalmed cadaver to perform various radical hysterectomies while exposing key pelvic structures, aiming to demonstrate dissection lines in nerve-sparing, non-nerve-sparing, and super-radical hysterectomy in relation to pivotal anatomical structures in the female pelvis.
Several studies have provided detailed, anatomy-based descriptions of the procedural steps involved in radical hysterectomy, aiming to ensure safe surgical and oncological outcomes [8,9]. As a result, educational resources focused on the procedure itself are already well established. Our objective is not to explain the radical hysterectomy procedure per se. Rather, our aim is to clarify the spatial relationships between the surgical field of radical hysterectomy and the lateral pelvic structures. We believe that this anatomical orientation will assist novice surgeons in developing a better spatial understanding of their operative environment within the pelvis. Such understanding can be particularly useful in managing unexpected events, such as bleeding around the cardinal ligament, by allowing for safe and precise responses that avoid injury to adjacent critical structures. Ultimately, we believe this approach will serve as a valuable educational tool for mastering radical hysterectomy safely.
MATERIALS AND METHODS
A Thiel-embalmed cadaver was placed in the lithotomy position, with 4 trocars placed around it (Fig. 1). Laparoscopic procedures were performed under a pressure of 10 mmHg in the pneumoperitoneum. The same surgical instruments used in an actual laparoscopic radical hysterectomy were used. The procedure was performed with the cadaver in the 10° Trendelenburg position; however, the assistant had to use their forceps to push up the dilated small intestine outside the pelvis throughout the surgery. As a result, all surgical procedures were performed using only the 2 forceps of the surgeon.
Fig. 1. Trocar placement. Although three 5-mm forceps were installed, the assistant’s forceps were used to elevate the small intestine. Therefore, the procedures were performed using the 2 forceps of the operator.
Nerve-sparing, non-nerve-sparing, and super-radical hysterectomies with pelvic lymphadenectomy were demonstrated in the right hemi-pelvis. While performing the procedures, the pivotal pelvic anatomical structures were exposed. These structures included the external and internal iliac blood vessels; obturator, sciatic, femoral, hypogastric, and pelvic splanchnic nerves; pelvic nerve plexus; internal obturator, piriform, and coccygeal muscles; sacrospinous ligament; and ischial spine. The relationship between the dissection lines of the various procedures and these anatomical structures was demonstrated.
Consent for the cadaver donation was based on the guidelines of the Japan Surgical Society and the Japanese Association of Anatomists. Consent to perform a normal autopsy, consent from the deceased person’s family, and consent to use the donated cadaver for clinical medical education and research were obtained according to the Act on Body Donation for Medical and Dental Education. Furthermore, approval to conduct this cadaveric study was obtained from the Institutional Review Board of Sapporo Medical University (IRB approval number: 6-1-36).
1. Definition of terminology
In the context of radical hysterectomy, certain anatomical terms specific to gynecologic surgery may be used, which are not always standardized across other surgical disciplines. Clear definitions of gynecology-specific anatomical terminology used in our descriptions are provided to ensure anatomical precision and interdisciplinary clarity [8,9,10,11].
Paravesical space
The paravesical space is a potential anatomical space located in the anterior portion of the pelvic cavity, between the bladder medially and the pelvic sidewall laterally. It is bounded:
• Medially by the bladder and the umbilical ligament,
• Laterally by the obturator internus muscle and the external iliac vessels,
• Posteriorly by the cardinal ligament, and
• Inferiorly by the levator ani muscle.
Pararectal space (Latzko’s space)
The pararectal space, specifically referred to as Latzko’s space, is a surgically defined avascular space located posterior to the cardinal ligament and medial to the internal iliac vessels. It is one of the 2 main pararectal compartments (Latzko’s and Okabayashi’s spaces) and plays an essential role in radical pelvic surgery.
Boundaries of Latzko’s space:
• Medially by the rectum and the uterosacral ligament,
• Laterally by the internal iliac artery and ureter,
• Anteriorly by the cardinal ligament,
• Posteriorly by the sacrum.
This space is developed to facilitate the identification of the internal iliac artery and its branches, and it is essential during lymphadenectomy and deep pelvic dissection. Unlike the Okabayashi space, which is located more medially, Latzko’s space allows lateral access to neurovascular structures and is often the first pararectal space opened during surgery.
Okabayashi pararectal space
The Okabayashi pararectal space is a surgically defined avascular plane located between the uretero-hypogastric nerve fascia and the rectum. It lies posterior to the rectum and lateral to the uterosacral ligament. This space is developed to allow posterior mobilization of the rectum, facilitating dissection of the uterosacral ligament and exposure of the pelvic autonomic nerve fibers. It is critical in nerve-sparing techniques and is considered a key landmark in deep pelvic dissection for advanced gynecologic malignancies.
Cardinal ligament
The cardinal ligament, also known as the transverse cervical ligament, is a thick condensation of the endopelvic fascia that extends from the lateral aspect of the cervix and upper vagina to the pelvic wall, anchoring these organs to the pelvic sidewall. It contains important vascular and neural structures, including the uterine artery and branches of the pelvic splanchnic nerves. During radical hysterectomy, the cardinal ligament is dissected and transected to ensure complete resection of paracervical tissues that may harbor tumor cells. Accurate identification of its lateral and medial borders is essential to achieve oncologic safety while preserving pelvic autonomic nerves when nerve-sparing approaches are employed.
Paravaginal space
The paravaginal space (Yabuki’s fourth space) refers to an anatomical plane located between the posterior layer of the vesicouterine ligament and the lateral vaginal wall. Proper identification and dissection of this space are essential for nerve-sparing radical hysterectomy. For a more detailed explanation, please refer to Step 4 below.
Anterior layer of the vesicouterine ligament
The anterior layer of the vesicouterine ligament is a fibrous connective tissue structure that extends from the anterior aspect of the cervix and upper vagina to the posterior wall of the bladder. It forms the ventral component of the vesicouterine ligament complex and is located anterior to the ureter.
It is encountered during radical hysterectomy when the bladder is mobilized caudally and laterally from the cervix. Dissection of the anterior layer is necessary to mobilize the ureter.
Posterior layer of the vesicouterine ligament
The posterior layer of the vesicouterine ligament is a fibrous structure that extends from the posterior aspect of the bladder to the anterior surface of the cervix and upper vagina. It contains vesical veins, lymphatic vessels, and connective tissue. This layer forms the dorsal component of the vesicouterine ligament, and its transection is necessary during radical hysterectomy to mobilize the bladder from the cervix.
Paracolpium
The paracolpium refers to the connective tissue complex that surrounds the lateral aspects of the vaginal wall, extending from the cervix to the pelvic sidewall. It comprises vascular, lymphatic, and neural structures embedded within loose connective tissue. Anatomically, the paracolpium includes the vaginal artery and vein, inferior vesical veins, pelvic nerve plexus, and associated lymphatics.
Inferior vesical vein
The inferior vesical vein is a venous branch that drains the lower portion of the urinary bladder. Its course can vary, but it typically traverses near the lateral aspect of the vaginal wall, along the levator ani muscle, often adjacent to the posterior layer of the vesicouterine ligament. In gynecologic oncology surgery, particularly during dissection of the paravesical or paravaginal spaces, identification and control of this vein are critical to minimize intraoperative bleeding. Notably, its anatomical recognition differs slightly among specialties [12,13,14,15].
RESULTS
The surgical procedure was performed laparoscopically using 8 steps, as described below and shown in Video S1.
Step 1: The paravesical and pararectal (Latzko) spaces were developed, and the cardinal ligament was exposed.
Step 2: The ureter and hypogastric nerve (uretero-hypogastric nerve fascia) were dissected from the peritoneum; that is, the Okabayashi rectal space was developed.
Step 3: Dissection between the fascia propria of the rectum and the uretero-hypogastric nerve fascia was performed down to the pelvic floor, and the rectum was mobilized. During this procedure, rectal branches from the pelvic nerve plexus were resected.
The rectum was suspended to the left abdominal wall, and the surgical field of the right pelvis was secured. Using this maneuver, the uretero-hypogastric nerve fascia was visible as a hammock-like structure behind the rectum. The ureter and hypogastric nerve were separated, and the pelvic splanchnic nerve was identified below the deep uterine vein. The pelvic nerve plexus consisted of the hypogastric and pelvic splanchnic nerves.
Step 4: After the ureter was mobilized by dissecting the anterior layer of the vesicouterine ligament, the paravaginal space was created. The development of the paravaginal space, also referred to as the “fourth space,” is a critical step in radical hysterectomy. Although the entry point of the paravaginal space has been clearly described in previous studies, the exit point remains somewhat ambiguous. Within the posterior layer of the vesicouterine ligament, venous return from the bladder drains into the deep uterine vein; therefore, these veins must be transected during radical hysterectomy to disconnect the bladder from the cardinal ligament. However, the inferior vesical vein, which courses dorsally through the posterior layer of the vesicouterine ligament and drains directly into the internal iliac vein, does not require resection. Consequently, the exit of the paravaginal space should be developed just above the inferior vesical vein, leading into the paravesical space. Caution is warranted, as some studies refer to the veins within the posterior layer of the vesicouterine ligament as the inferior vesical vein [12,13].
If the paravaginal space is developed too close to the lateral vaginal wall, there is a risk of injuring the inferior vesical vein, which can result in bleeding, or inadvertently involving the pelvic splanchnic nerves that innervate the bladder. Therefore, the inferior vesical vein should be regarded as a key anatomical landmark when developing the paravaginal space (Fig. 2).
Fig. 2. Paravaginal space. When the paravaginal space is correctly created, the posterior layer of the vesicouterine ligament is exposed outside the paravaginal space, with the branches of the pelvic nerve plexus that lead to the bladder inside the space. (A) The space immediately above the inferior vesical vein. The bottom of the paravaginal space should be created in this space. (B) The space between the inferior vesical vein and branches of the pelvic nerve plexus leading to the bladder. The bottom of the paravaginal space is created in this space, with the inferior vesical vein being sacrificed. (C) The space within the branches of the pelvic nerve plexus that leads to the bladder. The bottom of the paravaginal space is created in this space, with the pelvic nerve plexus being partially sacrificed.
CL, cardinal ligament; HGN, hypogastric nerve; PSN, pelvic splanchnic nerve.
Step 5: By expanding the space between the external iliac vessels and the psoas muscle, the obturator and L5 nerves were identified. This space was further developed, the S1 and S2 nerves were identified, and the sciatic nerve was exposed. The sciatic nerve was taped to the infrapiriform foramen.
The femoral nerve was identified on the lateral side of the psoas muscle. The anatomical positions of the pivotal pelvic nerves (the obturator, sciatic, and femoral nerves) were demonstrated.
Step 6: After identifying the pivotal nerves at the pelvic sidewall, nerve-sparing hysterectomy was resumed. The cardinal ligament and posterior layer of the vesicouterine ligament were transected, and the pelvic nerve plexus was completely exposed.
By transecting the uterine branches arising from the pelvic plexus, the portion of the pelvic plexus located cranial to the vaginal vessels can be separated from the uterus. The vaginal vessels traverse the pelvic plexus, effectively anchoring it to the lateral vaginal wall. Therefore, without transecting these vessels, mobilization of the pelvic plexus from the vaginal wall becomes technically challenging. To perform a nerve-sparing radical hysterectomy, it is essential to carefully transect the vaginal vessels traversing the pelvic plexus while avoiding nerve injury (Fig. 3) [8,9].
Fig. 3. Paracolpium. (A) The pelvic nerve plexus is anchored to the lateral vaginal wall by the vaginal vessels. (B) After separating the vaginal vessels, the pelvic nerve plexus can be bluntly dissected from the vaginal wall. (C) The relationship between the dissection line of the uterus and the pelvic nerve plexus.
HGN, hypogastric nerve; PSN, pelvic splanchnic nerve.
Step 7: The internal iliac vessels and their branches were transected, and the sciatic nerve and piriform and coccygeal muscles were exposed. The sacral anterior surface was dissected to confirm the S1–3 sacral foramina, thereby exposing the entire course of the sacral nerves to the infrapiriform foramen. At this stage, the pelvic splanchnic nerve was noted to originate from the sacral nerve. The internal obturator muscle was dissected, and the ischial spine was exposed. The sacrospinous ligament, which connects the ischial spine to the sacrum, was then exposed.
Step 8: The hypogastric and pelvic splanchnic nerves were transected, and non-nerve-sparing radical hysterectomy was performed. During this procedure, the dissection line of a super-radical hysterectomy was also demonstrated (Fig. 4), requiring dissection closer to the structures of the pelvic sidewall than nerve-sparing and non-nerve-sparing radical hysterectomies.
Fig. 4. Dissection line used for super-radical hysterectomy. The blue arrow indicates the dissection line of a super-radical hysterectomy. This procedure requires dissection closer to key anatomical structures of the pelvic sidewall than nerve-sparing and non-nerve-sparing radical hysterectomies.
HGN, hypogastric nerve; IIA, internal iliac artery; IIV, internal iliac vein; IS, ischial spine; PSN, pelvic splanchnic nerve; SSL, sacrospinous ligament.
DISCUSSION
This educational material is intended to demonstrate the relationship between the dissection lines of various radical hysterectomies and key anatomical structures in a female pelvis. The Video S1 is more informative when the following 4 points are considered.
(1) Pelvic splanchnic nerve: Nerve-sparing radical hysterectomy is a standard treatment. However, the course of the pelvic splanchnic nerves can be challenging for beginners to understand, as nerve-sparing radical hysterectomy is generally performed using the hypogastric nerve as the anatomical landmark. With this video, we demonstrate that the pelvic splanchnic nerve runs below the cardinal ligament, creating the possibility of injury to this nerve during lymph node dissection around the cardinal ligament. Understanding the anatomy of the pelvic splanchnic nerve may contribute to improving the quality of nerve-sparing radical hysterectomy.
(2) Paravaginal space: By developing the paravaginal space correctly, the posterior layer of the vesicouterine ligament and the pelvic nerve plexus are separated laterally and medially. When the paravaginal space is incorrectly created, the pelvic nerve plexus is partially separated from the vaginal wall as part of the posterior layer of the vesicouterine ligament (Fig. 2). This separation may lead to injury of the pelvic nerve plexus. In the video, we clearly demonstrate that the bottom of the paravaginal space should be the top edge of the inferior vesical vein.
(3) Vaginal vessels: The vaginal vessels anchor the pelvic nerve plexus to the lateral vaginal wall. Therefore, before the vaginal vessels are divided, the pelvic nerve plexus is located near the dissection line of the nerve-sparing radical hysterectomy [8,9]. Until the vaginal vessels are divided, the surgeon should consider that injury to the pelvic nerve plexus can easily occur.
These 3 points may be the cause of bladder function deteriorating postoperatively, even when nerve-sparing radical hysterectomy is performed. By focusing on these points, novice gynecologic oncologists can improve the quality of nerve-sparing radical hysterectomy.
(4) Relationship between the dissection lines and pelvic lateral structures of nerve-sparing, non-nerve-sparing, and super-radical hysterectomy.
In the video, the anatomy of pivotal lateral structures, such as the piriform muscle, coccygeal muscle, sacrospinous ligament, ischial spine, sacral nerve, and sciatic nerve, is demonstrated. For more radical surgeries, dissection lines closer to the pelvic sidewall are required. However, these lateral structures are rarely exposed in clinical practice, and misunderstanding of these critical structures can lead to serious complications, such as injury to the internal iliac vessels and sciatic nerve. The anatomical detail shown in this video should contribute to radical hysterectomies being safely performed.
For novice surgeons to obtain the surgical skills required for radical hysterectomies, mastering the 3-dimensional pelvic anatomy and aligning the dissection lines of radical hysterectomy in a female pelvis is crucial. This is difficult to grasp using only textbooks, lectures, and dry box training. In a Thiel-embalmed cadaver, the visibility, strain, and stiffness of the tissue are similar to those experienced during actual surgery and are regarded as a faithful representation of the soft tissue characteristics of patients. Using a Thiel-embalmed cadaver provides excellent and reproducible conditions for simulating surgical procedures [7].
This study has some limitations. First, only the anatomy of the right hemi-pelvis in a fresh cadaver was shown, and anatomical variations were not examined. Therefore, novice surgeons should comprehend the basic structures shown in this video and consider that variations in individual cases identified through preoperative imaging may be encountered. Second, the anatomical structures demonstrated in this video were identified based on gross findings without histological examination. Therefore, accurately distinguishing thin nerves from connective tissue was difficult. Finally, the effectiveness of this educational material for training novice gynecologic oncologists to safely master performing various radical hysterectomies has not been validated.
To conclude, using a Thiel-embalmed cadaver, we demonstrated the relationship between the dissection lines used in various radical hysterectomies and critical sidewall anatomical structures in a female pelvis.
ACKNOWLEDGEMENTS
We thank the staff of the Surgical Training Center, Sapporo Medical University, for technical assistance with preparing the cadaver.
Footnotes
Conflict of Interest: No potential conflict of interest relevant to this article was reported.
- Conceptualization:K.H., T.M., M.M., N.S., H.S., S.T.
- Data curation:K.H., T.M., M.M., N.S., H.S.
- Formal analysis:K.H., H.S.
- Funding acquisition:K.H., M.M., N.M., H.S.
- Investigation:K.H.
- Methodology:K.H., T.M., M.M., N.M.
- Project administration:K.H., M.M., N.M.
- Resources:K.H., T.M., N.M.
- Software:K.H., N.S., N.M.
- Supervision:S.T.
- Validation:K.H., N.S., H.S., S.T.
- Visualization:K.H., N.S., N.M., H.S.
- Writing - original draft:K.H.
- Writing - review & editing:T.M., M.M., N.S., N.M., H.S., S.T.
SUPPLEMENTARY MATERIALS
Laparoscopic demonstration of nerve-sparing, non-nerve-sparing, and super-radical hysterectomies in a Thiel-embalmed cadaver. The video illustrates stepwise development of several anatomical spaces, with exposure of the ureter, hypogastric and pelvic splanchnic nerves, pelvic plexus, and cardinal ligament. Key lateral structures—including the internal iliac vessels, obturator, sciatic, and femoral nerves, piriform and obturator muscles, sacrospinous ligament, and ischial spine—are demonstrated, clarifying the relationship between dissection lines and pivotal pelvic anatomy to support safe surgical practice.
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Associated Data
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Supplementary Materials
Laparoscopic demonstration of nerve-sparing, non-nerve-sparing, and super-radical hysterectomies in a Thiel-embalmed cadaver. The video illustrates stepwise development of several anatomical spaces, with exposure of the ureter, hypogastric and pelvic splanchnic nerves, pelvic plexus, and cardinal ligament. Key lateral structures—including the internal iliac vessels, obturator, sciatic, and femoral nerves, piriform and obturator muscles, sacrospinous ligament, and ischial spine—are demonstrated, clarifying the relationship between dissection lines and pivotal pelvic anatomy to support safe surgical practice.