This document discusses various avascular spaces in the female pelvis that are important for surgeons to understand when performing radical hysterectomies. It defines several key spaces, including the paravesical, pararectal, and paravaginal spaces. It describes the anatomical boundaries and surgical techniques for developing each space, which enables surgeons to perform radical hysterectomies while minimizing damage to surrounding structures. Understanding these pelvic spaces is crucial for safely conducting the dissection necessary during radical hysterectomies.

1. Avascular spaces
in radical
hysterectomy
Dr Mohammad Masoom Parwez
Ignacio Zapardiel ,1 Marcello Ceccaroni,2 Lucas Minig ,3 Michael J Halaska,4 Shingo Fujii5
La Paz University Hospital, Madrid, Spain
29 December 2022

2. Agenda
1 2 3 4 5
Introduction Methods Avascular
spaces in
female pelvis
Conclusion References
2 Journal club 2023

3. Abstract

4. Introduction
4

5. • Most common cancer in women worldwide is cervical cancer
• Incidence in developing countries is increasing, whereas in developed countries it is decreasing
• FIGO) 2018 stages IA, IB1-2, and IIA1), the standard treatment is radical hysterectomy with
lymph node assessment
• Advanced stage tumors, chemoradiotherapy is the standard of care
• Radical hysterectomy approach - first description by Ernst Wertheim in 1912
• Three major advances:
• Latzko (1919)
• Okabayashi (1921)
• Meigs (1944)
5 Presentation title 20XX

6. • Extensive knowledge of pelvic anatomy
• Pelvis is composed of several compartments composed of vessels, nerves and supportive tissue and,
avascular spaces
• Enable surgeons to perform the surgical steps necessary to decrease hemorrhage, as well as to
minimize damage to nerve supply to the pelvic organs (Figure 1
• Complications related to surgeon’s ability of proper dissection and identification of key anatomical
landmarks such as hemorrhage, lymphedema, and autonomic nerves injury
• Potential adverse outcomes related to parametrial resection include bladder, anorectal, and sexual
dysfunctions
• Nerve-sparing techniques were developed mainly by Japanese surgeons such as Yabuki, Sakuragi,
and Fujii; but also by several European surgeons such as Possover and Raspagliesi
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7. 7 Presentation title 20XX

8. • A study on urinary tract morbidity showed a lower rate of morbidity using type II or nerve-sparing
technique
• Several authors have described anatomical landmarks, structures, and spaces in order to set standards
for surgeons; however, the boundaries of pelvic avascular spaces remain elusive and definitions of such
spaces are often the subject of debate
• Aim of this review is to synthesize currently used anatomical landmarks in relation to surgical
spaces on the basis of recently introduced nomenclature of radical hysterectomy
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9. Methods
• Consensus process between authors was
completed from December 2019 to December
2020
• Computer-based comprehensive review of the
MEDLINE, Cochrane Central Register of
Controlled Trials (CENTRAL), PubMed,
EMBASE, and SciSearch databases, NCCN
and ESGO guidelines
• A manuscript of the definition of avascular
spaces, methods of dissection, and anatomical
limits was prepared
• All the avascular spaces of the pelvis
developed during radical hysterectomy, and
according to the literature search, were
considered and included in the manuscript

10. AVASCULAR SPACES IN
THE FEMALE PELVIS
20XX
10

11. • During embryological period, the female genital tract is developed between the urinary bladder and the
rectum
• Urinary bladder is located in the lower cervix/vagina with a space named the vesico-cervical/vaginal
space
• The rectum is located on the dorsal side of the vagina with a space named the rectovaginal space
• Between the pelvic side wall and the pelvic viscera, there are spaces of loose connective tissue known
as the paravesical, pararectal, and paravaginal spaces
11 Presentation title 20XX

12. Paravesical
spaces
12

13. Lateral Paravesical Space
• Divided into a medial and lateral paravesical space with respect to the obliterated umbilical artery and
the umbilical prevesical fascia
• Provides access to the distal aspect of the obturator vasculo-nervous structure and external iliac vessels
with their anastomotic network, also known as the corona mortis (Figure 2)
• Anatomical limits:
• laterally: the parietal pelvic fascia, external iliac vein and artery, and retro-inguinal Bogros’ space
• medially: the obliterated umbilical artery
• cranially: the lateral parametrium with the uterine artery and vein
• caudally: Bogros’ retroinguinal space and ischiopubic branches
• ventrally: the round ligament and peritoneum of the anterior leaf of the broad ligament
• dorsally: the pelvic floor
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14. 14 Presentation title 20XX

15. Lateral Paravesical Space
• Technique:
• transection of the round ligament at the level of the inguinal region
• the anterior and posterior peritoneal layers of the broad ligament are opened with a cranio-caudal
and dorso-ventral dissection and the ureter is identified
• obliterated umbilical artery is identified, following its course to the anterior abdominal wall
• lateral paravesical space is then developed by gentle medial traction of the umbilical artery together
with the fascial sheet of the lateral umbilical ligament
• Bluntly developing the loose connective tissue between umbilical artery and external iliac vessels
• This space can be developed to the level of pelvic floor, when that level of radicality is required,
observing right pelvic nodes and obturator nerve and vessels that enter in the obturator foramen, at
the level of pelvic wall
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16. Medial Paravesical Space
• Extended space of the lateral paravesical space to the medial side
• Connective tissue in the lateral umbilical ligament fascia sheet between the uterine artery and the
superior vesical artery is dissectable into the lateral paravesical space
• By the lateral traction of the umbilical ligament, the medial paravesical space is extended to the lateral
paravesical space
• Anatomical boundaries:
• laterally: the obliterated umbilical artery and lateral paravesical space
• medially: the umbilical prevesical fascia and paracolpos
• cranially: the lateral parametrium
• caudally: the bladder wall
• ventrally: the round ligament and peritoneum of the anterior leaf of the broad ligament
• dorsally: the pelvic floor
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17. 17 Presentation title 20XX

18. Para-rectal
spaces
18

19. • Defined as a loose connective tissue space surrounded by the rectal sidewall, the internal iliac blood
vessels and connective tissue segment containing the deep uterine vein, and nerve fibers of the lateral
parametrium
• Two different techniques to develop the pararectal space:
• One approach is a separation of the connective tissue between the rectum/ureter and the internal
iliac artery/vein by retracting medially on the rectum with the ureter - Latzko’s lateral pararectal
space
• Other approach is the separation of the connective tissue close to the rectal sidewall after
the division of the uterosacral ligament toward the base of the pelvis - Okabayashi’s medial
pararectal space
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20. 20 Presentation title 20XX

21. 21 Presentation title 20XX

22. Latzko’s Lateral Pararectal Space
• Anatomical boundaries
• laterally: parietal pelvic fascia, internal iliac artery, and piriformis muscle
• medially: the ureter and mesoureter with the hypogastric nerve
• cranially: the presacral fascia and sacral bone
• caudally: the lateral parametrium containing deep uterine vein and the pelvic splanchnic nerve
• ventrally: the peritoneal layer over the ureter, uterine artery, and superficial uterine vein
• dorsally: the pelvic floor
• Identification of the course of ureter at the level of pelvic brim, the peritoneum is incised
• Starting from the level of iliac vessels bifurcation, space is opened by blunt dissection of areolar tissue
between the rectal sidewall with ureter and the internal iliac artery
• Cobweb-like connective tissue is easily separated caudally over the internal iliac vein
• One may achieve an ideal approach to the pararectal space up to the level of parietal endopelvic fascia
covering the pelvic floor
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23. 23 Presentation title 20XX

24. Latzko’s Lateral Pararectal Space
• This step allows for the identification of the dorsal portions of coccygeal and piriformis muscles, and the
internal iliac lymph nodes
• In addition, on the rectal sidewall 2-3 cm dorsal to the ureter, a nerve bundle of the hypogastric nerve is
observed
• A key step during a radical hysterectomy, giving full access to the internal iliac (hypogastric) vessels,
visceral nerves, and lymph nodes
• More caudal dissection of the hypogastric nerve in the Latzko’s pararectal space allows the
identification of the middle rectal artery and the course of the deep uterine vein
• Constant anatomical landmark used to identify the plane dividing the parametrial pars vasculosa (deep
uterine vein) (ventrally and cranially) from the pars nervosa (pelvic splanchnic nerve that should be
preserved in all nerve-sparing surgeries)
• Medial caudal dissection of the pararectal space towards the concavity of the sacral bone provides
access to the retrorectal space, opening the so-called ‘holy plane of Heald’ in the midline
• During this step, sacral roots S2-S4 and pelvic splanchnic nerves are identified bilaterally
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25. Latzko’s Lateral Pararectal Space
• The so-called hypogastric fascia, composed of the presacral parietal pelvic fascia covering the muscles
and innervated by the parasympathetic pelvic splanchnic nerves originating at sacral roots S2-S4,
ultimately join with the inferior hypogastric plexus (or pelvic plexus) at the lower lateral cervix
• By the division and separation of the deep uterine vein toward the lower lateral cervix, the pelvic
splanchnic nerves are usually exposed
• This is done in order to preserve their fibers during the nerve-sparing radical hysterectomy
25 20XX

26. Okabayashi’s Medial Pararectal Space
• The space between the rectal sidewall and the pelvic connective tissue layer containing the ureter and
hypogastric nerve known as the mesoureter
• The mesoureter is the connective tissue bundle that emerges between Okabayashi’s pararectal space
(medially) and Latzko’s pararectal space (laterally)
• After isolation of the ureter in the mesoureter, the ureter is retracted toward the lateral pelvic side wall
• Plane development starts from the division of the uterosacral ligament
• The hypogastric nerve runs approximately 2-3 cm on the dorsal side of the ureter in the mesoureter
• In case of nerve sparing radical hysterectomy, the hypogastric nerve is isolated and preserved down to
the inferior hypogastric plexus at the lower lateral cervix
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27. Okabayashi’s Medial Pararectal Space
• Anatomical limits:
• laterally: the ureter, hypogastric nerve, mesoureter, and Latzko’s pararectal space
• medially: the visceral endopelvic rectal fascia (fascia propria recti), lateral ligaments of the rectum
(rectal wings, rectal pillars), and the rectal sidewall
• cranially: the sacral bone
• caudally: the blood vessels and connective tissue of the lateral parametrium
• ventrally: the peritoneal layer over the ureter
• dorsally: the pelvic floor
27 20XX

28. 28 Presentation title 20XX

29. Avascular spaces
in vesico-uterine
ligament
29

30. • Divided into the ventral layer
and dorsal layer by
Okabayashi
• Ventral layer is a connective
tissue layer covering the
ureter between the uterine
cervical fascia and the urinary
bladder
• The separation and division of
the ventral layer of the
vesicouterine ligament along
the ureter reveals the
connective tissue surface of
Okabayshi’s dorsal layer of
the vesicouterine ligament
30 20XX

31. • ventral layer contains the final
segment of the roof of the
ureteral tunnel and a
superficial connective tissue
layer covering the ureter
• dorsal layer may be defined
as connective tissue bundle
between the urinary bladder
and the lower-lateral cervix
that contains vesical veins
and branches of the
hypogastric plexus,
connecting the deep uterine
vein in the lateral
parametrium
31 20XX

32. Ureteral Tunnel Space
• Once the surgeon reaches the point where the ureter crosses under the uterine artery, focus should be
on the transection of the uterine artery from its origin at the internal iliac artery
• When the artery is visible and isolated, it should be cut
• Medial and upward traction on the medial pedicle of the uterine artery will allow for exposure of the
ureter as it enters the ventral layer of the vesicouterine ligament
• Of note, the superficial uterine vein is usually running parallel to the uterine artery
• In some patients, the uterine artery and vein may be clamped or coagulated as a bundle rather than
individually
• Then, the loose connective avascular space between the ureter and the ventral layer of the
vesicouterine ligament is appreciated - entrance of the ureter tunnel
• Dissection of the ureteral tunnel is one of the most important steps in a radical hysterectomy
32 Presentation title 20XX

33. Ureteral Tunnel Space
• Anatomic limits of the ureteral tunnel avascular space:
• laterally: medial side of the ureter
• medially: the uterine cervix and the lateral fornix of the vagina
• ventrally: the uterine artery
• caudally: a pair of artery and vein crossing over the ureter from the cervix to the urinary bladder
(named as cervico-vesical vessels)
• ventrally: the uterine artery and the superficial uterine vein
• dorsally: the dorsal layer of the vesicouterine ligament
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34. 34 Presentation title 20XX

35. Ureteral Tunnel Space
• Exposure:
• Retract the bladder towards the symphysis pubis and subsequently apply cephalad traction to the
uterus
• Ureter is then pulled medially or laterally in order to find the entrance of the ureter tunnel
• From here, the ventral layer of the vesicouterine ligament is separated
• Proceed gently along the medial side of the ureter not injuring a pair of artery and vein crossing over
the ureter from the cervix and urinary bladder
• separate and divide the anterior layer of the vesicouterine ligament to the portion where the ureter is
inserting into the urinary bladder
• Separating the loose connective tissue between the cervix and the medial side of the ureter, the
ureter itself is mobilized laterally enough to expose the connective tissue of the dorsal layer of the
vesicouterine ligament
35 Presentation title 20XX

36. Okabayashi’s Paravaginal Space
• Recognizing the surface of the dorsal layer
of the vesicouterine ligament, the ureter is
separated and retracted toward the inguinal
region
• The insertion of a broad L-shaped retractor
to hold the bladder above the line of the
separation is
useful
• On the lateral bladder side and just 1cm
lateral from the upper vaginal wall, entrance
of an avascular space named the
‘paravaginal space’ by Okabayashi is
appreciated
36 Presentation title 20XX

37. Okabayashi’s Paravaginal Space
• An avascular space filled with adipose tissue and extends into the
paravesical space
• Developed between the vaginal/cervical blood vessels (paracolpium) with
the bladder branch of the inferior hypogastric plexus and the medial side of
the dorsal layer of the vesicouterine ligament
• The caudal extension of the paravaginal space can expose the paracolpial
tissues on the upper vagina for the most appropriate length of the vaginal
cuff
• In order to obtain an appropriate length of the vaginal cuff, it is very
important to isolate and divide the dorsal layer of the vesicouterine
ligament at the level of Okabayashi’s paravaginal space
• When dissecting the posterior layer of the vesicouterine ligament, one
should keep in mind that there are vesical veins running from the urinary
bladder to the deep uterine vein. Injury to these veins may cause
considerable bleeding
37 Presentation title 20XX

38. Okabayashi’s Paravaginal Space
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39. 39 Presentation title 20XX

40. Okabayashi’s Paravaginal Space
• To obtain the appropriate length of vaginal cuff and to accomplish a nerve-sparing radical hysterectomy,
the development of Okabayashi’s paravaginal space is very important
• After complete division of the dorsal layer of the vesicouterine ligament, the bladder branch of the inferior
hypogastric plexus is revealed parallel and dorsal with the vaginal blood vessels (paracolpium)
• The rectovaginal ligament between the lower cervix and upper vagina and the rectum is divided by
the level of the appropriate vaginal cuff length
• Bladder branch is preserved on the divided rectal side of the rectovaginal ligament
• Ligation and division of the vaginal blood vessels (paracolpium) on the vaginal wall, the uterus is removed
• These are the brief steps for the nerve-sparing radical hysterectomy
40 Presentation title 20XX

41. Yabuki’s Fourth Space
• After separation of the ureter slightly from the connective tissue covering the ureter
• Yabuki developed a loose connective tissue space from the ventral layer of the vesicouterine ligament via
the mid-portion of the dorsal layer of the vesicouterine ligament into the paravesical space
• Surgical steps:
• opening and closing the tip of a Kelly’s forceps or any similar instrument creating the space by
excavating perpendicular to the areolar connective tissue, which is present between the ventral layer
of the vesicouterine ligament including the ureter and the mid-portion of the dorsal layer of the
vesicouterine ligament at approximately 2cm proximal to the entrance to the bladder
• Anatomical limits of Yabuki’s space:
• laterally: medial paravesical space
• medially: medial half of dorsal layer of the vesicouterine ligament that includes vaginal wall and
paracolpium
• cranially: the ureteral tunnel
• caudally: bladder wall
• ventrally: superficial leaf of the ventral layer of the vesicouterine ligament
• dorsally: paravesical space
41 Presentation title 20XX

42. 42 Presentation title 20XX

43. Yabuki’s Fourth Space
Surgical significance:
• May decrease bleeding while performing modified
radical hysterectomy or a modified technique of nerve-
sparing surgery
Nevertheless, the concept of Yabuki’s fourth space
is very difficult when opening Okabayashi’s paravaginal
space for radical hysterectomy
43 Presentation title 20XX

44. Conclusion
• A precise definition of the pelvic avascular spaces
will aid surgeons understanding of the anatomical
boundaries of the radical hysterectomy
• Ensures that surgeons are consistent in their
approach to the pelvic dissection, the structures
that need to be preserved, and those that should
be resected
• Facilitate the appropriate tailored radicality
depending on the risk factors of the disease
• Moreover, the knowledge of these spaces could
make pelvic surgery safer and more feasible for
other types of gynecological procedures
44

45. Thank you for your patience
45 Presentation title 20XX