This chapter should be cited as follows:
Sekiyama K, Mandai M, Glob Libr Women's Med
ISSN: 1756-2228; DOI 10.3843/GLOWM.422033

The Continuous Textbook of Women’s Medicine Series – Gynecology Module

Volume 13

Gynecological cancer

Volume Editors: Professor Hextan Ngan , Department of Obstetrics and Gynaecology, The University of Hong Kong, Hong Kong
Professor Karen Chan, Department of Obstetrics and Gynaecology, The University of Hong Kong, Hong Kong

Chapter

Okabayashi Radical Hysterectomy for the Treatment of Cervical Cancer

First published: February 2026

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INTRODUCTION

The history of surgical treatment for cervical cancer parallels the evolution of our understanding of pelvic anatomy in gynecology. In other words, the very concepts of pelvic anatomy in obstetrics and gynecology have developed hand in hand with the surgical techniques of radical hysterectomy. Therefore, a true understanding of the gynecologic anatomical terminology currently in use requires familiarity with knowledge of the historical development of radical hysterectomy. This chapter does not aim to cover the entire extensive history of the procedure but outlines the key steps that led to the present concepts of pelvic anatomy and surgical terminology.

The principle of treatment for cervical cancer i.e. complete removal of the lesion, was first proposed in the 17th century. Because simple hysterectomy was associated with an unacceptably high rate of local recurrence, modification of the procedure became necessary. From around 1880, a series of pathological reports revealed a high incidence of metastasis to the paracervical tissues and pelvic lymph nodes. Based on the surgical principles of breast cancer at the time, extensive resection of the paracervical tissue and pelvic lymph nodes – radical hysterectomy – was established as the standard around 1890. Ernst Wertheim, regarded as the pioneer of this surgical procedure, performed the first abdominal radical hysterectomy in Vienna in 1898 and reported detailed results in 500 cases in 1911.¹ His operative steps were illustrated in six drawings depicting transection of the round ligament, infundibulopelvic ligament, uterine artery and uterosacral ligament. In the Wertheim procedure, the ureter was exposed up to the ureterovesical junction, and the paracervical and paravaginal tissues were clamped and divided en bloc. Subsequently, the Wertheim procedure was improved, giving rise to the Latzko/Meigs procedure and the Okabayashi procedure. The Latzko/Meigs procedure (Piver class III), which forms the basis of radical hysterectomy in Western countries today, dissects and transects the cardinal ligament from the paracervical and paravaginal tissues.^2,3,4 In Japan, the Okabayashi procedure became the standard.⁵ This approach further subdivides the paracervical and paravaginal tissues into three components: the cardinal ligament, the dorsal layer of the vesicouterine ligament and the paracolpium/paravaginal tissue. Because the Latzko/Meigs approach does not recognize the dorsal layer of the vesicouterine ligament and the paracolpium/paravaginal tissue, the term ‘radical hysterectomy’ describes procedures that differ substantially among countries. When interpreting clinical trial results, it is important to verify how the resection margins for radical hysterectomy are defined in each study. Once the anatomical principles of the Okabayashi procedure (which divides the paracervical and paravaginal tissues into three components) are understood, the Wertheim and Latzko/Meigs techniques can be readily grasped as abbreviated forms. This chapter focuses on radical hysterectomy performed according to the Okabayashi method.

ANATOMICAL ORIENTATION

The principal steps involved in radical hysterectomy can be summarized as follows:

1. Development of pelvic ‘spaces’ around the cervix

2. Identification of the ‘ligaments’ (paracervical supporting structures) located between these ‘spaces’

3. Transection of the ‘ligaments’ at an appropriate distance from the cervix.

Two fundamental principles are inherent in this summary. First, dissection of the spaces must precede division of the ligaments. Only after two adjacent spaces are fully developed can the tissues requiring transection be clearly identified. Proper development of the pelvic spaces in the correct anatomical planes is the most critical maneuver in radical hysterectomy; inadequate dissection leads to uncertain margins and increased complications. Second, while development of the spaces is a procedure naturally determined by the surgical field, ideally yielding the same result regardless of the surgeon involved, transection of the ligaments must be determined by the surgeon according to the extent of disease. Consciously and clearly separating these two steps – space development and ligament transection – is the key to successful radical hysterectomy. This principle applies not only to radical hysterectomy but to all forms of hysterectomy: the more difficult the case, the more important it is to fully develop the anatomical spaces before determining the resection lines.

The principal pelvic spaces include the pararectal spaces, paravesical spaces, rectovaginal space, vesicovaginal space and Okabayashi paravaginal spaces.⁶ Further detailed descriptions of these spaces can be found in another chapter in this textbook.⁷ The ligaments to be divided include the cardinal ligament, uterosacral ligament, rectovaginal ligament, ventral and dorsal layers of the vesicouterine ligament, and the paracolpium/paravaginal tissue. Mastery of radical hysterectomy requires two key elements: acquiring the correct method for development of each space and understanding the anatomical components of each ligament. This chapter explains these anatomical structures and the key points of nerve-sparing techniques, following the steps of the Okabayashi procedure.

SURGICAL PROCEDURE^8,9,10,11

Development of the pararectal space (Latzko) (Video 1)

The medial plane serves as the key landmark. The rectum is retracted toward the contralateral cephalad side. If the rectum remains within the pouch of Douglas, the medial plane slackens and precise dissection is impossible. After transecting the round ligament, the anterior leaf of the broad ligament is incised along the lateral border of the infundibulopelvic ligament toward the cephalad side up to the level of the common iliac artery. By treating the infundibulopelvic ligament and posterior leaf of the broad ligament as a single plane and incising the loose connective tissue dorsally and craniocaudally, the ureter running along the posterior leaf of the broad ligament is exposed. Tracing the ureter cephalad reveals its crossing over the common iliac artery. The interstitial space between the ureter and the common and internal iliac arteries forms the entrance to the pararectal space (Latzko). Further dorsal dissection reveals the hypogastric nerve running parallel and 2–3 cm dorsal to the ureter; its lateral border defining the medial boundary of the pararectal space. The pararectal space is expanded along the hypogastric nerve in both the cranial and caudal directions. The dissection is then extended dorsal to the hypogastric nerve to enter the retrorectal space, thereby creating a horseshoe-shaped communication between the right and left pararectal spaces. Full development of the pararectal space exposes dorsally the presacral surface, laterally the internal iliac vessels surrounded by lymph-adipose tissue, and caudally the uterine artery and deep uterine vein also surrounded by lymph-adipose tissue. The pelvic splanchnic nerves run dorsal to the deep uterine vein. Development of the pararectal space reveals a continuous lymphatic pathway extending from the cervix to the cardinal ligament nodes (around the deep uterine vein), the internal iliac nodes (medial to the internal iliac artery and vein), and the presacral nodes (medial to the common iliac artery).

Development of the paravesical space (Video 1)

There are two approaches to development of the paravesical space:

Caudal approach

The dorsal aspect of the inguinal end of the transected round ligament is dissected, the external iliac vein is identified and dissected dorsally just medial to the caudal end of the external iliac vein. This naturally allows entry into the paravesical space along the lateral side of the obliterated umbilical artery. In conventional open surgery, this method is commonly used for the development of the paravesical space.

Cephalad approach

From the lateral wall of the previously developed pararectal space, the internal iliac artery is identified and the fat incised on its ventral side caudally to open the entrance to the paravesical space. With medial traction of the obliterated umbilical artery, the dissection is continued dorsocaudally through the loose connective tissue to expand the paravesical space. During this step, intentional division of lymphatic vessels running along the uterine artery and draining into the obturator and external iliac nodes facilitates entry to the precise paravesical space.

The levator ani forms the caudal boundary; the lateral wall shows the obturator internus muscle and the arcuate line of the ilium. Anastomotic veins between the deep uterine vein and obturator vein may cross the deep portion of the paravesical space and should be divided if present. Development of the paravesical space delineates the medial borders of the external iliac and obturator nodal basins and clarifies the cardinal ligament between the paravesical and pararectal spaces.

Pelvic lymphadenectomy (Video 1)

Although description of the detailed technique is beyond the scope of this chapter, understanding the anatomy surrounding the obturator nodes, most frequently identified as sentinel nodes in cervical cancer, is critical. Removal of these nodes together with the obturator vessels reveals the pelvic wall anatomy: the levator ani muscle forms the caudal wall, the obturator internus muscle the lateral wall, and the coccygeus muscle and sacral plexus the dorsal wall. The pudendal vessels, which are the caudal ends of the internal iliac vessels, run medial to the sacral plexus. The pudendal vessels and the sacral plexus both course dorsal to the coccygeus muscle. The coccygeus muscle is an essential anatomical landmark of the pelvic wall and provides a key clue for identifying the pelvic origin of the cardinal ligament. Therefore, complete retrieval of the obturator and internal iliac nodes clarifies the pelvic origin of the cardinal ligament. When performing sentinel lymph node biopsy only, caution is required as the pelvic origin of the cardinal ligament tends to become unclear.

Resection of the cardinal ligament (Video 1)

The cardinal ligament spans from the lateral cervix to the pelvic wall between the paravesical and pararectal spaces. Its components include visceral branches of the internal iliac vessels (uterine artery, superficial and deep uterine veins), associated lymph-adipose tissue, and the pelvic splanchnic nerves. In nerve-sparing surgery, the ventral vascular portion is divided sequentially – uterine artery, superficial uterine vein, deep uterine vein – while preserving the dorsal neural portion (pelvic splanchnic nerves). Multiple deep uterine veins, if present, are divided individually. Small branches of the middle rectal or inferior vesical arteries near the deep uterine vein may also require division. A middle rectal vein draining to the internal iliac vein along the dorsal medial wall of the paravesical space should be preserved when identified.

Development of the rectovaginal space and division of the uterosacral ligament (Video 2)

With the uterus retracted ventrally and the rectum cranially, incise the peritoneum of the pouch of Douglas to develop the rectovaginal space dorsal to the vaginal wall. The peritoneal incision should slightly overlap the rectal fat to facilitate smooth expansion of the entrance to the rectovaginal space. Development of the rectovaginal space reveals the uterosacral ligament between the rectovaginal space and the pararectal space. Fine nerve fibers running from the hypogastric nerve toward the uterine cervix attach closely onto the lateral surface of the uterosacral ligament. For nerve-sparing surgery, these fine nerve fibers are transected and the hypogastric nerve is mobilized laterally, exposing its course up to the vicinity of the deep uterine vein. The uterosacral ligament is then transected up to the deep uterine vein, ensuring the hypogastric nerve remains intact.

Development of the vesicovaginal space and division of the ventral layer of the vesicouterine ligament (Video 3)

With the uterus retracted cranially, incision of the vesicouterine peritoneum reveals the entrance to the vesicovaginal space, which extends ventral to the uterine cervix and vagina. Suspending the cut ends of the bilateral round ligaments and the incised edge of the bladder-side peritoneum toward the abdominal wall aids identification of the loose connective tissue of the vesicovaginal space to be incised. It is important to dissect continuously the loose connective tissue of the vesicovaginal space caudally and laterally. At the lateral margin of the vesicovaginal space, the ventral layer of the vesicouterine ligament is identified, forming the roof of the so-called ‘ureteral tunnel’. To expose the ureter up to the ureterovesical junction, two vessels crossing over the ureter within the ventral layer of the vesicouterine ligament must be divided. The surgical procedure involves first transecting the ureteral branch of the uterine artery, followed by the superior vesical vein crossing over the ureter at the entrance of the ureteral tunnel. Next the cervicovesical vessels crossing over the ureter 1–2 cm caudal to the superior vesical vein are transected. Once both the superior vesical vein and the cervicovesical vessels are divided, the remaining tissue covering the ureter contains few small vessels, allowing for monopolar incision. After completing the dissection of the ventral layer of the vesicouterine ligament, the ureter becomes entirely exposed, up to the ureterovesical junction, allowing for lateral mobilization of the ureter.

Mobilization of the ureter and development of the Okabayashi paravaginal space (Video 4)

After the ureter is exposed up to the ureterovesical junction, the surface of the paracervical tissue dorsal to the ureter is incised and the ureter is mobilized in the inguinal direction, exposing the paracervical tissue.

The Latzko/Meigs procedure dissects this paracervical tissue en bloc before vaginal incision. However, the Okabayashi method develops the Okabayashi paravaginal space to subdivide the paracervical tissue. The lateral compartment corresponds to the dorsal layer of the vesicouterine ligament, and the medial compartment to the paracolpium/paravaginal tissue. Multiple vesical veins draining to the deep uterine vein traverse the dorsal layer of the vesicouterine ligament, and vaginal veins draining into the deep uterine vein run within the paracolpium/paravaginal tissue. Careful dissection avoids injury to these vesical and vaginal veins when developing the Okabayashi paravaginal space. Before entering the Okabayashi paravaginal space, a firm membranous layer covering the ventral surface of the paracervical tissue is incised; this layer contains nerve fibers from the pelvic plexus to the ureter, but sacrificing them rarely causes severe voiding dysfunction. Once the firm membranous layer covering the ventral surface of the paracervical tissue is incised, adipose tissue surrounding the vesical and vaginal veins appears on its dorsal side. The entrance to the Okabayashi paravaginal space is recognized as a tissue gap just lateral to the ureterovesical junction and can be clearly identified only when the ventral layer of the vesicouterine ligament is completely dissected and the ureter is sufficiently mobilized. In most cases where the entrance of the Okabayashi paravaginal space cannot be identified, the causes are inadequate dissection of the ventral layer of the vesicouterine ligament, insufficient mobilization of the ureter, and failure to incise the firm membranous tissue covering the ventral surface of the paracervical tissue. The Okabayashi paravaginal space is developed toward the paravesical space. Removing the fatty tissue from the medial wall of the paravesical space beforehand makes the exit portion of the Okabayashi paravaginal space more clearly visible.

Division of the dorsal layer of the vesicouterine ligament (Video 4)

The paracervical tissue is separated into two compartments by the Okabayashi paravaginal space. The lateral compartment (the dorsal layer of the vesicouterine ligament) contains several inferior vesical veins draining to the deep uterine veins. Because the number of deep uterine and inferior vesical veins varies and inter-anastomoses are irregular, careful identification is essential. Development of the Okabayashi paravaginal space allows the cutting line of the dorsal layer of the vesicouterine ligament to follow naturally the bladder side, ensuring adequate resection margin around the cervix. The Okabayashi procedure was originally designed to treat Stage-IIB cervical cancer with parametrial invasion. In the modern era of advanced preoperative magnetic resonance imaging, it is now feasible to tailor the resection line of the dorsal layer of the vesicouterine ligament according to tumor extent.

Selective division of uterine branches of the pelvic (inferior hypogastric) plexus (Video 4)

After division of the inferior vesical veins and elevation of the cut end of the deep uterine vein, the pelvic plexus is exposed dorsal to the deep uterine vein. Bundles of the bladder branches of the pelvic plexus can be identified running along the dorsal aspect of the paracolpium/paravaginal tissue. A tissue gap between the bladder and uterine branches of the pelvic plexus is developed, allowing selective division of the uterine branches near the cervix. Adequate traction of the uterus cranially is essential for distinguishing the boundary between the bladder and uterine branches of the pelvic plexus. Because the Latzko/Meigs method does not expose the pelvic plexus, attempts at nerve preservation inevitably shift the resection line closer to the cervix, resulting in a less radical operation. In contrast, the nerve-sparing Okabayashi procedure divides the dorsal layer of the vesicouterine ligament on the bladder side, directly visualizes the pelvic plexus, and permits selective division of the uterine branches while mobilizing the bladder branches laterally, thereby maximizing oncologic radicality.

Division of the rectovaginal ligament, resection of the paracolpium/paravaginal tissue and vaginal incision (Video 4)

With the bladder branches of the pelvic plexus identified and preserved, the rectovaginal ligament is divided toward the planned line of paravaginal resection. This further mobilizes the bladder branches lateral to the paracolpium/paravaginal tissue. The paracolpium/paravaginal tissue is then divided without injuring the mobilized bladder branches. The division of the paracolpium/paravaginal tissue leads to the detachment of the uterus from all structures except the vagina. The vaginal wall is clamped to prevent tumor spillage and vaginal washing is performed. The vaginal wall is amputated to complete the radical hysterectomy. When cutting the 3 and 9 o’clock directions of the vaginal wall, attention should be paid not to cause thermal damage to the preserved bladder branches. When a nerve-sparing Okabayashi radical hysterectomy is completed with maximum curative intent, nothing remains at the lateral aspect of the vaginal stump except the preserved bladder branches from the pelvic plexus and the ureter. Confirming what remains in the surgical field after uterine removal makes the radicality of the surgery evident.

PRACTICE RECOMMENDATIONS

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