I know that my task for today is to talk about the parametrectomy. Before I go there, I would like just to mention a few aspects which I consider important. One of them is what defines radical hysterectomy, because it's a little bit confusing in some older classification systems. The parametrectomy was also combined with radicality of vaginal excision, or even resection of other organs, like fibro-rattlage classification, also included resection of the bladder. What I want to emphasize is that the extent of vaginal resection is not defined by the type of radical hysterectomy. As an example, an endocervical tumor which is large does not require a bigger extent of the vaginal resection, while if you have a small tumor on the surface, and with also involvement of upper vagina, then the extent will be larger, even in a lower type of parametrectomy. So why am I speaking about it? Because each procedure should be really properly defined before the surgery, and this is an example how we define our procedure. So what you can find on operation schedule, that first it's a surgical approach, second is the procedure on an exa, what to do, an exectomy, and ovarian transposition, what's the plan, lymph node staging. We typically do, in all our cervical patients, sentinel lymph node and frozen section, and we do it exactly for the purpose of intraoperative detection of larger metastases. So then we have two options, either SLN negative or SLN positive. So both options are then defined in the description. And then for us, type of procedure, because the same classification and similar principles apply to radical parametrectomy, radical esterectomy, and radical trachelectomy. So what is the type of procedure on the uterus, and then type of parametrectomy. And from the whole field, we will focus only on the type of parametrectomy today. For our purpose, we should be aware that parametria, after the dissection of the spaces, which are, you know, spaces are not existing, but we do it, we do it by dissection. And we dissect the so-called spaces, which are more or less vascular spaces, which can be dissected either blindly or with just a little bit of bleeding control. So after the dissection, we can very well differentiate three parts of the parametria on both sides of the uterus. And I find this approach very important for any radical surgery in the pelvis. Even if you operate a stuck tumor, it can be ovarian cancer, sometimes infiltrated into parametria, it can be a situation in severe endometriosis, it can be the patient after radiotherapy, which all these conditions make the anatomy much more difficult. And the way out is not just to try with your clamps, but always try to follow first stable anatomical structures like vessels, ureters, cervix, of course, and then try to dissect these spaces. And for the resection of the parametria, the former classification systems before Keller-Lamoureux always defines the horizontal aspect. So the aspect between the cervix and pelvic sidewalls, while current edition of Keller-Lamoureux recognizes also that there are two aspects, one is horizontal, but the other one is vertical, which is for the consequences, especially for the damage of the nerves, much more important than the horizontal one. So this Keller-Lamoureux classification I find very useful, I understand that it's still not generally used, but if you search the literature, the majority of authors within the last 5-10 years used this classification. And since it is really detailed, and it describes the extent of the resection on each part of the parametria, even if you call your hysterectomy whatever, okabayashi or whatever, it should be able for you to translate it into Keller-Lamoureux classification. So say, okay, I do nerve sparing, which in my hands corresponds to C1 in the ventral, C1 in the lateral, C2 in the dorsal parametrium. It also helps you, it allows you to define side different extent, so it might be that you have your tumor infiltration or tumor localization on one side, and you do more radical procedure on one side and less radical procedure on the other side, and everything should be possible for you to describe using Keller-Lamoureux classification. So just, you know, I also do not, although I'm co-author of the second and the third edition of this, I also do not agree, just between us, with everything what is written there. It's a kind of agreement between all authors and the previous group who developed the classification. I also don't see, you know, too much difference between type A and simple hysterectomy, but obviously, you know, it reflects current practice. So for me, what is fundamental is to differentiate type B, type C1, which corresponds to nerve sparing, and one C2, which is more radical than C1, I would simplify it like this. And if I am to, I have my pictures, and these pictures are pretty old. I've been using them since maybe 2004, and they are still valid. Still the principle is the same, and the principle is the same. And, you know, what I find very, very nice is that we have this, you know, nomenclature, and we use certain dissection and technique of parametrectomy, which is in this department. So like five people do hear a radical hysterectomy, and I know that it doesn't matter who does the procedure, type B, type C1, type C2 is always the same extent. And sometimes what I see at different departments is that usually, you know, they do like one type of radical hysterectomy. It can be sometimes, you know, less radical, sometimes very radical. And it's difficult for them to adopt for different types. And this is very much related to the dissection. Because once you do, and I will show you later, once you do less dissection in the pelvis, if you do not open the spaces, if you do not dissect individually these parts of the parametria, then you cannot do too much radical procedure, and it allows you to do always the same. And those who do radical dissection, then of course, it tends to you to remove everything. So, you know, in my opinion, there should be really the plan behind your strategy. So as I can only tell you that at our department, our strategy is that in small tumors, we do type B radical hysterectomy. And in large tumors, because we do not give any adjuvant treatment to patients, irrespective of the size of the tumor, if lymph nodes are negative. So even if the tumor is seven centimeter and lymph nodes are negative, we do not give them any adjuvant treatment, but we do more radical hysterectomy. So our aim is really to remove the parametria, because, and this is quite important, is to understand the reason why the parametria is receptive. And this reason has been changed in the history. In the past, the main reason was to remove completely the tumor, so achieve free margins, because imaging was not used, and by palpation, you know, we are... David, go ahead. Yes. And using just physical examination, our ability to stage the tumor is very poor. So that's why, you know, they invented radical hysterectomy. So nowadays, when we use either MRI or X-ray ultrasound, we know whether parametria are infiltrated. So the main reason for parametrectomy is to really remove the parametria, to remove also parametrial lymph nodes, which can be positive, because parametrial lymph nodes lie between the cervix and your pelvic, pelvic side lymph nodes. so they can be positive even if pelvic lymph nodes are negative. So back to the classification very briefly, how I translate this classification in my daily routine. For type B radical hysterectomy, the main anatomical landmark is the urethra. So your surgical line follows the urethra and it allows you to resect a little bit of lateral parametrium, no ventral parametrium, and corresponding part of the dorsal parametrium. While in a horizontal aspect, the surgical line for C1 and C2 lies really at the pelvic side wall. Here is the medial aspect of internal iliac vein. So there is no reason why to spare this tissue. There is just a fatty tissue and some lymphatic nodes and lymphatic channels, otherwise no nerves. But the vertical limit difference, the aim of C1 is to preserve because here we look at the lateral para-rectal space. So here is urethra, common and extended iliac vessels. This is the uterine artery, lateral parametrium, and the resection of the lateral parametrium in C1 preserve the caudal half of the lateral parametrium because those stripes here are nerves. I have hypogastric splinting nerves, and here those white strips are hypogastric plexus. So this bottom part, which is below the urethra and which is in the bottom part of the lateral parametria should be spared. In the dorsal parametrium, we don't have any anatomic landmark in the dorsal parametrium. So it's corresponding to what we resect laterally in time. We just simply cut about one and a half centimeters. But it's possible really here in this case, you see that the rectum is completely dissected from the dorsal parametrium. So it depends what type of radical hysterectomy we do. And now, you know, I just would like to, on a short videos, on a short films, to demonstrate how different can be the resection of individual parts of the parametrium. Once again, it depends on the dissection which precedes such a dissection. So on the lateral parametrium, this corresponds to type B, which is above the urethra. This corresponds to type C1, because this is at the level of one of the, you know, big veins in the lateral parametrium. And I'm sorry, so I have to go back a little bit. So once again, type B, lateral parametrium, the same lateral parametrium, type C1, and a complete resection more horizontally alongside internally that vein, type C2. So the radicality, the extent of the resection is very different. Eventually, type C1, which corresponds to about one and a half, two centimeters resection above the urethra, but it also, if you dissect it from the bladder, you can resect even more if the tumor is large. Sometimes we operate patient with eight centimeter tumor, where we really aim to resect the parametria. So we go eventually to the dorsal wall of the bladder. And dorsally type B, which doesn't require the dissection of the uterus sacral ligament and the hypogastric plexus, because you keep your dissection above the level where the urethra was positioned. For site type C1, you need to dissect the hypogastric nerve plexus from the ligament. So then you can resect a little bit more of the ligament. And in site type C2, you can completely resect the dorsal parametrium. Of course, the price is that you sacrifice also hypogastric plexus with certain consequences, especially for function of the urinary bladder. And now my main message, how to gain access to the parametrium, because a lot of people, if we in the past been discussing these types of radical hysterectomy, they say ventral parametria, they do not exist. There is a bladder ventrally from the cervix. And well, that's not true, of course. The bladder is essentially, but laterally to the bladder, there are massive structures of the parametria. And everything depends on the dissection. So if you don't dissect the paracervical space and parabasical space and the bladder from the ventral parametria, then you don't see ventral parametria. But this applies also for the lateral parametria. If you don't open completely pararectal and parabasical space, you don't see lateral parametria. And another point, of course, which is key for the type of radical hysterectomy is a ureteral dissection. One important message, an important trick for nerve sparing type. Nerves, those main nerves, hypogastric plexus, the hypogastric plexus follows the ureter and follows the ureter below the ureter. So if you want to spare these nerves, you have to spare the tissue, which is below the ureter, all the way down to the bladder. So dorsally, laterally, but also ventrally. So what I sometimes see on teaching videos is that people delicately dissect hypogastric plexus dorsally, and then they cut everything laterally on the lateral parametria. And then they take the whole bench of tissue, which is lateral to the cervix, together with hypogastric plexus. So it's a continuous structure, which runs laterally. You see, it's laterally, not to the cervix. It's rather lateral to the proximal vagina. But this is the key message for the nerve sparing, to spare this tissue. And I'm not saying that it's always easy. If you have different cases, there can be cases which tend to bleed less and tend to bleed more. There can be really a big tumor, there can be fibrosis after previous surgery or whatever. So to spare the nerve is a tricky operation. And sometimes it's only possible that you do less radical procedure. You simply type B, radical hysterectomy, which means that you end up your dissection here at the level of the urethra. You don't go any more laterally or vertically. And here on this case, I like to show you how dissection influences your radicality of your hysterectomy. So this is, you know, one patient, but on the left side and on the right side, we did difference dissection before we resect the part. So on the left side, what we did is we completely open, unroof urethra, open the lateral parametrium. So one part is here and the second part is here, and we dissect the urethra from the vagina, from the cervix and from the lateral parametrium. So this is for me a typical dissection for type B radical hysterectomy. What such a dissection allows is this one. So it's about two centimeters per section dorsally. And then laterally, this small piece of tissue, which lies medially to the urethra. No more. This is because for bigger resection, you will have to dissect your urethra completely, and you will have to open the spaces, paravesical and pararectal more. But once you stop here, this is what you can do. And on the other side, the spaces were completely opened and the urethra was completely dissected, even from the ventral parametrium. This is Follet Balloon, just to demonstrate on the lateral parametria where the bladder wall lies. And of course, it's a super radical possibility, super radical extent. But on the same patient, just to demonstrate the difference that this, you see that completely open paravesical space, completely open pararectal space, completely dissected urethra. And here you have the size of the parametria you can dissect. So it's completely different. And of course, you need to have your own strategy and your own institute. I saw all possibilities. So there are many institutions which would never perform such a radical hysterectomy, even in bulky tumors, because they send all tumors larger than three centimeters to chemoradiation. And they use adjuvant treatment according to GOG criteria to everybody who has tumor bigger than two centimeters combined with LVSI. So they always did just type B radical hysterectomy. And there are other institutions like one, I spent some time, they, even if they plan to do small radical hysterectomy, they always end up in such a big radical one. So there is a lot of heterogeneity in a daily routine practice. So this was all from myself, what I wanted to share with you. And I would be happy to answer your questions or if you want first to demonstrate the case and then to discuss.

parametrectomy

radical hysterectomy

cervical cancer

tumor size

nerve sparing

imaging techniques