Classification of Radical Hysterectomy

1. Piver-Rutledge-Smith Classification (1974) - Historical Standard

2. Querleu-Morrow (Q-M) Classification (2008, Updated 2011 & 2017) - Current Standard

Type A - Minimum Paracervix Resection (Limited Radical Hysterectomy)

• Ureter visualized after opening the ureteric tunnel, but not mobilized from its bed
• Paracervix transected medial to the ureter but lateral to the cervix
• Uterine artery, uterosacral, and cardinal ligaments are NOT cut at a distance from the uterus
• Vesicovaginal ligament is not transected
• Vaginal resection < 10 mm from the cervix
• Equivalent to Piver Class I-II (closer to simple hysterectomy)

Type B - Transection of Paracervix at the Ureter (Partial Radical Hysterectomy)

• Ureters are unroofed and displaced laterally (but NOT fully mobilized below)
• Paracervix transected at the level of the ureteric tunnel
• Partial resection of uterosacral peritoneal fold and vesicouterine ligaments
• Vesicovaginal ligament is NOT transected
• At least 10 mm of vagina from cervix/tumor resected
• Two subtypes:
  • B1 - Without removal of lateral paracervical lymph nodes
  • B2 - With additional removal of lateral paracervical lymph nodes
• Roughly equivalent to Piver Class II (modified radical)

Type C - Complete Ureteral Mobilization and Full Parametrial Resection (Classic Radical Hysterectomy)

• Ureters are completely mobilized from the ureteric tunnel
• Uterosacral ligament transected at the rectum
• Cardinal ligament transected at the internal iliac vessels
• Vesicouterine ligament fully divided at the bladder
• Upper 15-20 mm of vagina resected

• C1 - With preservation of autonomic nerves (nerve-sparing) - see detailed steps below
• C2 - Without preservation of autonomic nerves (complete parametrial resection); branches of the inferior hypogastric plexus are sacrificed
• Roughly equivalent to Piver Class III (Meigs radical hysterectomy)

Type D - Extended Radical (Laterally Extended) Hysterectomy

• Identical ureteral dissection and ventral/dorsal parametrial resection as Type C2
• Additional: internal iliac artery and vein ligated and removed together with all their branches (gluteal, internal pudendal, obturator vessels)
• Performed for lateral pelvic sidewall disease
• Two subtypes:
  • D1 - Removal of the entire paracervix at the pelvic sidewall including the internal iliac vessel system
  • D2 (LEER - Laterally Extended Endopelvic Resection) - Removal of paracervix with the adjacent fascia or muscle (levator ani, piriformis) or vessels at the pelvic wall
• Roughly equivalent to Piver Class IV-V

Comparison Table: Piver-Rutledge vs. Querleu-Morrow

3. Other Classification Systems

Rutledge Classification (Modified, 1987)

Morrow-Curtin Classification

Type C1 - Nerve-Sparing Radical Hysterectomy: Detailed Surgical Steps

Rationale and Goal

1. The superior hypogastric plexus and hypogastric nerves (sympathetic)
2. The inferior hypogastric plexus / pelvic plexus and its bladder branches (parasympathetic + sympathetic)

Step-by-Step Technique

Preliminary Steps (same as any radical hysterectomy)

1. Patient positioning - Dorsal lithotomy with Trendelenburg
2. Incision - Pfannenstiel (Maylard or Cherney for wider exposure) or midline
3. Pelvic space development - Open paravesical and pararectal spaces bilaterally to delineate the parametrium; identify the pelvic sidewall structures

Phase 1 - Identification of the Hypogastric Nerves (Sympathetic System)

1. Sacral promontory dissection - Peritoneum over the sacral promontory is incised and the superior hypogastric plexus is identified as a plexiform bundle anterior to the sacrum at L5-S1 level
2. Hypogastric nerve tracing - Follow the two hypogastric nerves bilaterally as they descend inferolaterally, running dorsal to the ureteral mesentery and medial to the ureter, along the medial leaf of the posterior broad ligament
3. Gently develop the plane between the hypogastric nerve and the uterosacral/rectouterine ligaments by blunt dissection - this is the "mesoureter-hypogastric nerve" interval

Phase 2 - Ureteral Mobilization and Ventral Parametrium

1. Unroofing the ureteric tunnel - Identify and open the ureteric tunnel fully; the ureter is mobilized from its bed and displaced laterally (this is the same as in C2)
2. Uterine artery ligation - Divided at its origin from the internal iliac artery
3. Ventral parametrium (vesicouterine ligament):
   • In C1: The cranial part is removed but the caudal part (below the ureter) is preserved, as it contains the bladder branches of the inferior hypogastric plexus. The dissection does NOT extend below the course of the ureter
   • In C2 (for comparison): Both cranial and caudal parts are removed
4. Deep uterine vein and the bladder venous plexus (running within the vesicovaginal ligament) are elevated as a single vascular plane toward the midline by sharp dissection - this exposes the inferior hypogastric plexus and its nerve branches

Phase 3 - Identification and Preservation of the Inferior Hypogastric Plexus

1. Exposing the pelvic plexus - The inferior hypogastric plexus is visualized lateral to the vagina in the paracolpium. It has a cross-shaped ("+") configuration, formed by:
   • Medial uterine/vaginal branches (to be sacrificed)
   • Lateral/cranial branches from the hypogastric nerve (to be preserved)
   • Bladder branches running ventrally (the critical ones to preserve)
   • Rectal branches
2. Fujii space development (optional but useful for visualization) - The space between the bladder branch and the medial branches is carefully developed, transforming the plexus from a "+" or "X" shape to a "Y" shape, isolating the bladder branch
3. Selective nerve transection - All nerve branches directed to the uterus and vagina are divided, but the bladder branches of the inferior hypogastric plexus are preserved intact

Phase 4 - Dorsal Parametrium (Rectouterine/Uterosacral Ligament)

1. Rectovaginal space development - Enter the rectovaginal space and develop it laterally
2. Uterosacral ligament - In C1, the sagittal dissection of the hypogastric nerves from the rectouterine and rectovaginal ligaments is performed. The uterosacral ligament is cut at the rectum (same as C2), BUT the nerve fibers running parallel to the ligament are carefully separated and preserved
3. The caudal limit of the rectouterine ligament resection is formed by the tangential plane of the vaginal cuff resection - the nerves below this level are left intact

Phase 5 - Lateral Parametrium

1. Cardinal ligament - Divided at the internal iliac vessels (same lateral extent as C2)
2. The key difference from C2 is in the longitudinal (deep/vertical) dimension - the resection does NOT extend below the course of the ureter on the ventral side, where the bladder branches of the hypogastric plexus travel

Phase 6 - Vaginal Resection and Completion

1. Vaginal cuff - Upper 15-20 mm of vagina is circumferentially incised (same as C2)
2. Specimen removal - Uterus, cervix, bilateral parametria, and upper vaginal cuff are removed en bloc
3. Vaginal closure - Angles secured, vault closed with interrupted or running sutures
4. Hemostasis and peritoneal closure (if applicable)

Phase 7 - Pelvic Lymphadenectomy (concurrent)

1. Bilateral pelvic lymph node dissection (external iliac, internal iliac, obturator) is performed - the extent of lymphadenectomy is classified separately in the Q-M system

Key Anatomical Landmarks for Nerve Identification

Functional Benefits of C1 vs. C2

• Faster recovery of bladder function with reduced bladder hypotonia/atony
• Less colorectal dysmotility (constipation)
• Improved sexual function - less reduction in vaginal lubrication and congestion
• A meta-analysis confirmed no worsening of oncologic prognosis with C1 compared to C2
• In the 2017 Q-M update, C1 is now the recommended default for type C cases; C2 is reserved only when anatomic constraints prevent nerve preservation