METHOD FOR NERVE-SPARING RADICAL HYSTERECTOMY IN TREATMENT OF PATIENTS WITH IA2-IIВ STAGE CERVICAL CANCER Russian patent published in 2023 - IPC A61B17/42 

FIELD: medicine.

SUBSTANCE: nerve-sparing radical hysterectomy is conducted in the treatment of patients with stage IA2-IIB cervical cancer, including bilateral iliac and obturator lymphadenectomy with removal of tissue and lymph nodes along the common external and internal iliac vessels from the bifurcation of the common iliac vessels to the Poupart’s ligament, in the region of the foramen obturatum and along the umbilical arteries on both sides, the paravesical and pararectal cellular spaces are opened on both sides with the identification of the main elements of the pelvic fascia: uterovesical/vaginal, cardinal and sacrouterine ligaments. The treatment is four-staged. At the first stage, the perivesical, pararectal cellular spaces of the pelvis are identified, the uterus is mobilized by opening the cellular spaces of the small pelvis and the localization of the nervous structures of the small pelvis is determined, the peritoneum is opened in the region of the uterovesical fold and along the round ligaments on both sides to the walls of the pelvis, round ligaments cross on both sides, using bipolar coagulation at the walls of the pelvis, and open the peritoneum above the parametric spaces, paravesical and pararectal cellular spaces are opened on both sides, at the same time, in the pararectal space between the mesoureter and internal iliac vessels, the lateral pararectal Latsko space is identified and the elements of the pelvic fascia: uterovesical/vesico-vaginal, cardinal and sacro-uterine ligaments, perform pelvic lymphadenectomy - the tissue and lymph nodes along the common, external and internal iliac vessels are removed from the bifurcation of the common iliac vessels to the Poupart’s ligament, in the region of the foramen obturatum and along the umbilical arteries on both sides. At the second stage, the Okabayashi spaces are identified, the hypogastric nerve is retained as part of the mesoureter, and the sacro-uterine ligaments are excised; the peritoneum of the broad ligament of the uterus and the ventral part of the adventitia of the ureter and, using monopolar coagulation, the medial pararectal space of Okabayashi are identified, the mesoureter is isolated in the embryonic avascular layer, the mesourethral plate is isolated from the level of the sacrum to the level of formation of the lower hypogastric plexus, then the mesourethral plate is retracted laterally to the pelvic wall, after which the sacro-uterine ligament is excised from the level of the sacrum using monopolar coagulation. At the third stage, the lower hypogastric plexus is identified, the cardinal ligament is excised, and between the paravesical and pararectal cellular spaces of the small pelvis, the fibrous-fatty layer is identified - the projection of the cardinal ligament and the lower hypogastric plexus, then, step by step, using a bipolar coagulation dissector, adipose tissue is crossed in small portions, as well as small vessels of the cardinal ligament, the uterine artery, as close as possible to the pelvic wall and as part of the cardinal ligament, the deep uterine vein is identified, which is crossed in the area of its confluence with the internal iliac vein, the superior cystic vein is ligated, after which, in stages, the tissues of the cardiac ligament, including the "roof of the tunnel "- the anterior part of the vesicouterine ligament, is taken to the uterus, thus opening the distal part of the ureter at the point of its confluence with the bladder, the uterine branches of the pelvic plexus are crossed, the pelvic splanchnic nerves emanating from the roots S2-S4 of the sacral plexus of the parasympathetic nervous system, is identified in the bottom of the pararectal fossa and traced to the pelvic plexus by moving the “working” swab in the anteroposterior direction from the sacrum to the cardinal ligament along the bottom and walls of the pararectal space. At the fourth stage, the posterior part of the vesicouterine ligament is excised, the vesicoureteral space - Yabuki space is determined, and for a clear visualization of the posterior part of the vesicouterine ligament and vesical branches of the pelvic plexus, the ureter and mesourethral tissues are displaced laterally and removed upward, the adipose tissue of the posterior parts of the vesicouterine ligament to the level of the vesical branches of the pelvic plexus are crossed, the mesoureter with the hypogastric nerve, the pelvic plexus and vesical branches are traced, after which a clamp is applied to the paravaginal tissues and the vagina is cut off at the level of the upper and middle thirds.

EFFECT: method allows for preserving the following autonomic nerve plexuses of the small pelvis within intrafascial cellular spaces: hypogastric nerves, S2-S4 pelvic splanchnic nerves, lower hypogastric or pelvic plexus, including cystic branches, which improves the functional results of surgical intervention.

1 cl, 2 dwg, 1 ex