Total mesometrial resection: high resolution nerve-sparing radical hysterectomy based on developmentally defined surgical anatomy.

Total mesometrial resection (TMMR) is characterized by: i). the en bloc resection of the uterus, proximal vagina, and mesometrium as a developmentally defined entity; ii). transection of the rectouterine dense subperitoneal connective tissue above the level of the exposed inferior hypogastric plexus; and iii). extended pelvic/periaortic lymph node dissection preserving the superior hypogastric plexus. Since July 1998 we have studied prospectively the outcome in patients treated with TMMR for cervical carcinoma FIGO stages IB, IIA, and selected IIB. By July 2002, 71 patients with cervical cancer stages pT1b1 (n = 48), pT1b2 (n = 8), pT2a (n = 3), pT2b (n = 12) had undergone TMMR without adjuvant radiation. Fifty-four percent of the patients exhibited histopathologic high risk factors. At a median observation period of 30 months (9-57 months) two patients relapsed locally, two patients developed pelvic and distant recurrences and two patients only distant recurrences. Three patients died from their disease. Grade 1 and 2 complications occurred in 20 patients, no patient had grade 3 or 4 complications. No severe long-term impairment of pelvic visceral functions related to autonomic nerve damage was detected. Based on these preliminary results, we believe TMMR achieves a promising therapeutic index by providing a high probability of locoregional control at minimal short and long-term morbidity.