Radical Hysterectomy or Total Mesometrial Resection—Two Anatomical Concepts for Surgical Treatment of Cancer of the Uterine Cervix

SIMPLE SUMMARY: Cancer of the uterine cervix is the fourth most common cancer and one of the main causes of death in women worldwide. For decades, a radical hysterectomy has been a standard surgical procedure of treatment for women with early-stage cancer of the uterine cervix. However, the disagreement regarding surgical anatomy terms during a radical hysterectomy still raises many controversies among authors, leading to different understandings while performing the procedure. Therefore, Michael Höckel proposed a different and unique surgical concept based on ontogenetic anatomy. The ontogenetic anatomy allows for predicting the potential extent of locoregional cancer spread, which is required to plan adequate surgical treatment. The surgical procedure based on this concept is called total mesometrial resection. The present article aims to describe and compare the anatomical and surgical basics of a radical hysterectomy and total mesometrial resection regarding surgical treatment of cancer of the uterine cervix. ABSTRACT: A radical hysterectomy is the standard method of surgical treatment for patients with early-stage cancer of the uterine cervix. It was first introduced more than 100 years ago. Since then, various and many different radical procedures, which diverge in terms of radicality, have been described. Inconsistencies are clearly seen in practical anatomy, which were defined as surgically created artifacts. Moreover, the disparity of the procedure is most notable regarding the terminology of pelvic connective tissues and spaces. Despite these controversies, the procedure is widely performed and implemented in the majority of guidelines for the surgical treatment of cancer of the uterine cervix. However, a different and unique concept of surgical treatment of cervical cancer has been reported. It is based on ontogenetic anatomy and maps any tissue in the mature organism according to its embryologic development. The clinical implementation of this theory in the context of early cervical cancer is total mesometrial resection. The present article aims to describe and compare the anatomical and surgical basics of a radical hysterectomy (type C1/C2) and total mesometrial resection. Discrepancies regarding the terminology, resection lines, and surgical planes of both procedures are highlighted in detail. The surgical anatomy of the pelvic autonomic nerves and its surgical dissection is also delineated. This is the first article that compares the discrepancy of classic anatomy and ontogenic anatomy regarding surgical treatment of cancer of the uterine cervix. Clinical data, oncological outcome, and neoadjuvant and adjuvant treatment regarding both procedures are not the topic of the present article.