Jpn J Clin Oncol 2003;33(11)589–591

Short Communication

A New Perspective on Nerve-sparing Radical Hysterectomy: Nerve

Topography and Over-preservation of the Cardinal Ligament
Tomoyasu Kato1, Gen Murakami2 and Yoshihiko Yabuki3
1Department of Gynecology, Cancer Institute Hospital, Tokyo, 2Department of Anatomy, Sapporo Medical University

School of Medicine, Sapporo and 3Department of Obstetrics and Gynecology, Ishikawa Prefectural Central Hospital,
Kanazawa, Japan
Received August 8, 2003; accepted September 21, 2003

Background: Nerve-sparing radical hysterectomy was established by Japanese gynecolo-

gists. They identified two parts of the cardinal ligament, namely the vascular part and the neural

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part, and postulated that the neural part contained the pelvic splanchnic nerves. However, our
fresh cadaver studies demonstrated that these nerves ran dorsomedially in contrast to the
classical concept. The aim of this study is to further validate this finding in clinical cases.
Methods: We examined the intraoperative biopsy specimens collected from the neural part of
the cardinal ligament in four patients with cervical carcinoma who underwent nerve-sparing
radical hysterectomy with dissection of the neural part.
Results: Careful dissections demonstrated that the pelvic splanchnic nerves arise from the
dorsomedial side of the neural part at the bottom of the pararectal space. The neural part was
composed of a connective tissue with focal positive staining by S-100 protein.
Conclusions: We propose that complete dissection of the cardinal ligament should be
performed during nerve-sparing hysterectomy to increase its radicality.

Key words: nerve-sparing radical hysterectomy – cardinal ligament – pelvic splanchnic nerves

INTRODUCTION of the critical issues for the surgical procedure, at least in

Although radical hysterectomy for early uterine cervical can-
cer has a long history, Japanese gynecologists (1,2) have made
great efforts to revise the classical Wertheim method (3) so as
to preserve pelvic autonomic nerves while maintaining a high
curability (the so-called Tokyo method). Japanese gynecolo-
gists focused their attention on the cardinal ligament of the
uterus rather than that of the parametrium. Once the pararectal
and paravesical spaces are developed, the cardinal ligament
appears clearly between the two spaces. Japanese gynecolo-
gists identified two parts in the cardinal ligament, i.e. the vas-
cular part and the ‘nerve’ part. They believed that the neural
part of the cardinal ligament contained the pelvic splanchnic
nerves. Today, the pelvic splanchnic nerves running along the
cardinal ligament are even shown in a figure prepared by a
Western gynecologist (Fig. 1a). Therefore, in the context of
nerve-sparing treatment, the cardinal ligament has become one
For reprints and all correspondence: Tomoyasu Kato, Department of
Gynecology, Cancer Institute Hospital, 1-37-1 Kami-Ikebukuro, Toshima-ku,
Tokyo, Japan. E-mail: tomoyasu.kato@jfcr.or.jp
Japan. It is only recently that nerve-sparing radical hysterec-
tomy has been introduced to Western (4) as well as to Asian
countries (5). Thus, it took a surprisingly long time for the
‘Tokyo method’ to gain acceptance elsewhere in the world. In
this paper, we take a new look at the ‘classical’ Tokyo method,
because there is the possibility that we can achieve better
radicality by correcting the current misunderstanding of nerve
topography that leads to over-preservation of the cardinal
ligament.
By dissection of fresh cadavers, we have demonstrated that
the neural part of the cardinal ligament is not likely to contain
the pelvic splanchnic nerves (Fig. 1b), but instead is composed
of a collagenous connective tissue similar to the transverse
cervical ligament (6). Therefore, we hypothesized that during
nerve-sparing radical hysterectomy the pelvic splanchnic
nerves are actually located in the medial wall of the pararectal
space and covered with rectal retractor or are located in the
floor of this space. We confirmed this hypothesis in recent
clinical cases.

© 2003 Foundation for Promotion of Cancer Research

590 A new nerve-sparing radical hysterectomy

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Figure 1. (a) Diagram of the pelvic autonomic nerves in radical hysterectomy. A transverse section through the pelvis shows the bladder, uterine cervix, and rectum.
The pelvic splanchnic nerves run from the lateral pelvic wall to towards the pelvic viscera. [Modification of Trimbos et al. (4).] (b) Anatomical representation of the
topographical anatomy around the cardinal ligament in a fresh cadaver dissection. Right pelvis viewed from the left side. The cardinal ligament (#) extends along
the lateromedial axis in contrast to pelvic splanchnic nerves from S3 or S4 (*) coming from the dorsomedial side. PV, paravesical space, Iia; internal iliac artery.

PATIENTS AND METHODS method has a great advantage over radical hysterectomy. An
adequate surgical margin is provided by the dorsal half of the
Between November 1, 2001 and August 31, 2002 four patients cardinal ligament, i.e. the neural part, which separates the
with stage Ib–IIb cervical carcinoma underwent radical hyste- vascular part from the pelvic splanchnic nerves. Therefore, the
rectomy with the dissection of the neural part of the cardinal nerves are well preserved despite the probable misunderstand-
ligament at the Cancer Institute Hospital, Tokyo. The median ing of their anatomy. However, the current surgical margin
age of the patients was 41 years (range 28–64 years). Intra- might compromise radicality.
operative biopsy specimens were collected from the neural
Trimbos et al. considered the lack of dissection of the most
part of the cardinal ligament in all cases.
lateral and distal part of the parametrium (including the neural
part of the cardinal ligament) as the major concern with the
RESULTS
After ligation and division of the vascular part of the cardinal
ligament, careful dissection demonstrated that the pelvic
splanchnic nerves arise from the dorsomedial side of the neural
part of the cardinal ligament at the bottom of the pararectal
space (Fig. 2). The pelvic splanchnic nerves run dorsomedially,
in contrast to the classical concept (Fig. 1a). The neural part of
the cardinal ligament was composed of connective tissue with
focal positive staining by S-100 protein (Fig. 2). The same his-
tological findings were obtained in the remaining three cases.

DISCUSSION
Which part of the pelvic autonomic nerves should gynecolo-
gists preserve? The answer seems to be both the pelvic plexus
and the entire course of its afferent and efferent nerves, i.e. the
branches of the hypogastric (sympathetic) nerve and the pelvic
splanchnic (parasympathetic) nerves running through from
the pelvis to the bladder, rectum and vagina. Actually, those
nerves seem to be well preserved when the Tokyo method is
performed with careful handling of the dorsal part of the
vesicouterine ligament. Thus, we agree that the Tokyo
Figure 2. Intraoperative photographs taken during radical hysterectomy dem-
onstrating the right splanchnic nerves arising from S3 (arrows), the right
visceral stump of the right vessel part of the cardinal ligament (white line) and
the neural part (black line). The splanchnic nerve runs dorsomedially through
the lower part of the cardinal ligament. Pathologic examination of a specimen
from the cut end of the neural part of the cardinal ligament shows connective
tissue with a few tiny nerve fibers (insert upper: HE, magnification ´4; insert
lower: S-100, magnification ´4).

Tokyo method in the case of stage II cervical cancer (4). How-
ever, Yabuki and colleagues obtained good results in stage II
cervical cancer, even when removal of the parametrium or car-
dinal ligament was restricted to the ventral or superficial side
of the deep uterine vein (7). The Tokyo method, i.e. the usual
nerve-sparing procedure, also provided good results (2,8).
Höckel et al. reported that pelvic side wall recurrence of cervi-
cal cancer showed the involvement of the perispinous adipose
tissue in 37% of cases (9). MRI demonstrates a distinct region
of perispinous adipose tissue, which is a triangular zone
between the mesorectum (lower border), the uterovaginal
venous plexus (upper border) and the obturator internus,
coccygeus and iliococcygeus muscles (lateral border). Accord-
ing to their cadaver study, this perispinous adipose tissue
corresponds to the neural part of the cardinal ligament and
the so-called ‘lateral ligament of the rectum’ (9). If complete
dissection of the cardinal ligament is accepted for nerve-
sparing hysterectomy, which is our proposal, greater radicality
would be obtained.
How should we handle or dissect the cardinal ligament and
does extended surgery have any new disadvantages? Division
of the neural part of the cardinal ligament should be performed
immediately along the lateral pelvic wall and it should never be
done at the medial part of the ligament, so that the floor or the
dorsal aspect of the pararectal space are kept intact to avoid
damage to the pudendal nerve and/or the nerves to the levator
ani. The neural part of the cardinal ligament observed in our
resected specimen (Fig. 2) may be part of these nerves. There
is a risk that non-preservation of the neural part of the cardinal
ligament may lead to too aggressive surgery such as complete
dissection of the pararectal space and/or the visceral stump of
the ligament. We usually perform gentle mobilization of the
visceral stump of the cardinal ligament, so that the pelvic
plexus and its visceral branches remain intact. To the best of
Jpn J Clin Oncol 2003;33(11) 591
our knowledge, the ideal method for dissecting the dorsal or
deep layer of the vesicouterine ligament has not yet been estab-
lished and it remains the ‘last problem’ for nerve-sparing radi-
cal hysterectomy. Even if aggressive dissection is performed at
the floor of the pararectal space, we do not recommend taping
the splanchnic nerves, because the tape might damage the
nerve fibers. Likewise, overdissection of the pelvic floor
should be avoided.
We believe that the Tokyo method will become better appre-
ciated around the world if the handling of lateral wall recur-
rence is improved, based on the actual anatomy as validated in
this report.
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