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Avascular spaces in radical hysterectomy
  1. Ignacio Zapardiel1,
  2. Marcello Ceccaroni2,
  3. Lucas Minig3,
  4. Michael J Halaska4 and
  5. Shingo Fujii5
  1. 1 Gynecologic Oncology Unit, La Paz University Hospital, Madrid, Spain
  2. 2 Department of Obstetrics & Gynecology, IRCCS Sacro Cuore-Don Calabria Hospital, Negrar (Verona), Italy
  3. 3 Gynecologic Oncology Unit, IMED Hospitales, Valencia, Spain
  4. 4 Department of Obstetrics and Gynaecology, 3rd Medical Faculty, Charles University, Prague, Czech Republic
  5. 5 Department of Gynecology and Obstetrics, Kyoto University, Kyoto, Japan
  1. Correspondence to Dr Ignacio Zapardiel, Gynecologic Oncology Unit, La Paz University Hospital, Madrid, Spain; ignaciozapardiel{at}


The most common cancer in women worldwide is cervical cancer. For early-stage disease the standard treatment is radical hysterectomy. One of the main issues faced by surgeons performing a radical hysterectomy is the wide variation in the terminology used to define the procedure and the nomenclature used to describe the anatomical spaces critical to the success of the surgery. The aim of this review was to synthesize currently used anatomical landmarks with relation to surgical avascular spaces for the performance of radical hysterectomy.

A computer-based comprehensive review of the MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase, and SciSearch databases, as well as National Comprehensive Cancer Network and European Society of Gynaecological Oncology guidelines, was performed. With all relevant data collected, and previous anatomical studies during surgeries and on cadavers performed by authors, a manuscript of the definition of avascular spaces, methods of dissection, and anatomical limits was prepared.

Avascular pelvic spaces developed during radical hysterectomy, such as the paravesical, pararectal, ureter tunnel, and paravaginal, were considered and included in the manuscript. A clear definition of avascular spaces may aid a better understanding of the anatomical aspects of the radical hysterectomy. It could improve surgeon knowledge of the structures that need to be preserved and those that need to be resected during a radical hysterectomy. Additionally, the detailed exposure of anatomical boundaries will facilitate the appropriate tailored radicality depending on the risk factors of the disease. Moreover, knowledge of these spaces could make pelvic surgery safer and easier for other types of gynecological and non-gynecological procedures.

  • surgical procedures, operative
  • surgical oncology
  • cervical cancer

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  • Contributors IZ and SF: Conceptualization, Methodology, Validation, Investigation, Writing – Original Draft, Writing – Review and Editing, Visualization, Final approval. MC, LM, and MJH: Conceptualization, Investigation, Writing – Review and Editing, Visualization, Final approval.

  • Funding The work has been supported by Cooperation project Maternal and Childhood Care (No. 207035) from 3rd Medical Faculty, Charles University.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.