Clinical characteristics of phenotypes of fecal incontinence.

PURPOSE: Fecal incontinence (FI) is common, but its etiology is complex with large knowledge gaps. Several phenotypes of FI are known, but the phenotype is often not decisive in the chosen therapy. In this study we aimed to assess the association of the clinical characteristics of patients with FI and the various phenotypes, in order to establish a targeted clinical treatment decision tree. METHODS: We retrospectively studied the charts of patients with FI, who visited our institute from January 2018 until December 2020. Patients were divided into the following groups: passive fecal loss, urge incontinence, combined fecal incontinence with predominantly passive fecal loss, and combined fecal incontinence with predominantly urge incontinence. We compared the characteristics between the passive and urge incontinence groups, the passive  and combined mainly passive groups, and the urge and combined mainly urge groups. RESULTS: Patients with passive incintinence were older, more often had a flaccid anus with presence of a mucosal prolapse, and had a lower resting pressure on anorectal manometry. Patients with urge incontinence were younger and more often had a history of birth trauma. The combined groups showed characteristics of both of the main types of FI. CONCLUSION: Differentiating into phenotypes of FI can be clinically meaningful. The patient history and clinical judgement of the consulting specialist, rather than the physical characteristics, seem to be decisive in the categorization. Additional diagnostic testing can be helpful in complicated cases, but should not be used routinely.

Non-dynamic graciloplasty is an effective treatment for patients with passive fecal incontinence.

BACKGROUND: Fecal incontinence is a multifactorial problem and its etiology is complex. Various therapies are available and different success rates have been described. The aim of this study was to assess the effectiveness and safety of non-dynamic graciloplasty in patients with passive fecal incontinence. METHODS: We retrospectively studied charts of patients with fecal incontinence treated with graciloplasty at our institution from November 2015 until June 2018. Patients were included according to the following criteria: (1) presence of predominantly passive fecal incontinence and (2) presence of a lax perineal body. Primary outcome was the effectiveness, defined as a significant reduction or absence of the complaints of passive fecal incontinence at 3, 6 and 12 months after surgery. Second, we studied the safety of the procedure evaluating the complications within 30 days after surgery. RESULTS: Thirty-one patients met the inclusion criteria. Twenty-six of them, in addition to passive incontinence as the main symptom, had some degree of fecal urgency. The median age at the first visit to the outpatient clinic was 64.0 years (IQR 52-68). Most patients were female (n = 29, 94%). At 3 months after graciloplasty, 71% (22 of 31) of patients were successfully treated for their passive fecal incontinence. At 6 months, the success rate of the graciloplasty increased to 77%. At 12 months among the patients who were still seen in the clinic, the success rate was 58% (18/31). Two patients cancelled follow-up visits after 3 months, because of failure to control symptoms in 1 case. After 6 months, 9 patients were given the choice to do telephone follow-up only. Of these 11 patients without in-person follow-up, 10 were contacted 1 year after surgery and in 7 of them, the graciloplasty was effective in controlling their passive fecal incontinence for an overall success rate of 80% (25/31). Of the 26 patients with mixed passive and urge incontinence, 6 (23%) still complained of urge incontinence at 1 year. Of these patients with persistent urge incontinence, 6 underwent sacral nerve stimulation which was successful in 4. Two serious complications occurred within 30 days. A rectal perforation requiring temporary colostomy and a recto-vaginal fistula which was successfully repaired. CONCLUSION: Non-dynamic graciloplasty is an effective treatment for passive fecal incontinence. Differentiation based on subtypes of fecal incontinence might be important for a pattern-specific approach to treatment. More research is necessary to determine the right indications for more invasive treatments of fecal incontinence.

LIM-only protein FHL2 attenuates inflammation in vascular smooth muscle cells through inhibition of the NFκB pathway.

Despite the advent of new-generation drug-eluting stents, in-stent restenosis remains a significant problem in patients with coronary artery disease. In- stent restenosis is defined as the gradual re-narrowing of a stented coronary artery lesion due to arterial damage with subsequent local inflammation of the vessel wall and excessive growth of the vascular smooth muscle cells (vSMCs). Four-and-a-half LIM-domain protein 2 (FHL2) is a scaffold protein involved in regulating vSMC function and inflammation. Previously we have demonstrated that FHL2 prevents vSMC proliferation in a murine carotid artery ligation model. However, the effect of FHL2 on the inflammatory response of the vSMCs is not investigated. Therefore, we studied the inflammatory response in the vessel wall of FHL2-deficient (-KO) mice after carotid artery ligation. We found that circulating cytokines and local macrophage infiltration in the ligated carotid vessels were increased in FHL2-KO mice after carotid artery ligation. Moreover, FHL2-KO vSMCs showed increased secretion of cytokines such as SDF-1α and RANTES, and enhanced activation of the NFκB pathway. Finally, we found that blocking the NFκB signalling pathway abrogated this pro-inflammatory state in FHL2-KO vSMCs. Taken together, our results demonstrate that FHL2 decreases the inflammatory response of vSMCs through inhibition of the NFkB-signalling pathway.

Nikolay Ivanovich Pirogov (1810-1881): Anatomical research to develop surgery.

The 19th century Russian surgeon Nikolay Ivanovich Pirogov believed passionately in the importance of anatomy for surgeons. His interest in anatomy began as a medical student in Moscow. After graduating in 1828 Pirogov entered the postgraduate German-Baltic University of Dorpat (now Tartu in the Republic of Estonia) where he studied anatomy and surgery. After completing his study, he remained to research the consequences of ligation of the aorta in a series of animal experiments, which formed the core of his doctoral thesis. He wanted to determine the feasibility of aortic ligation as a treatment for patients with an aneurysm of the aorta or iliac artery. He discovered that success was only likely when the aorta was ligated between the two mesenteric arteries and the ligature gradually tightened, an approach surgically difficult in humans. Pirogov then spent 2 years at the Charité Hospital in Berlin before returning to Russia. In 1841, he was appointed Professor of Applied Anatomy and Surgery at the Imperial Medico-Surgical Academy in Saint Petersburg. He instituted the teaching of microscopy and histology to the medical curriculum and in 1846 formed the Institute for Applied Anatomy within the academy, where in addition to teaching medical students future teachers of anatomy in Russia were trained. Pirogov published extensively on anatomy, including several anatomical atlases, the most notable his three-dimensional atlas of topographical anatomy published in four volumes between 1852 and 1859. Today Pirogov's contributions to anatomy are remembered in a number of anatomical structures named after him. Clin. Anat., 33:714-730, 2020. © 2019 Wiley Periodicals, Inc.

The anatomy of the perineal body in relation to abdominoperineal excision for low rectal cancer.

AIM: Dissection of the perineal body (PB) during abdominoperineal excision (APE) for low rectal cancer is often difficult due to the lack of a natural plane of dissection. Understanding the PB and its relation to the anorectum is essential to permit safe dissection during the perineal phase of the operation and avoid damage to the anorectum and urogenital organs. This study describes the anatomy and histology of the PB relevant to APE. METHOD: Six human adult cadaver pelvic exenteration specimens (three male, three female) from the Leeds GIFT Research Tissue Programme were studied. Paraffin-embedded mega-blocks were produced and serially sectioned at 50- and 250-µm intervals. Sections were stained by immunohistochemistry to show collagen, elastin and smooth muscle. RESULTS: The PB was cylindrically shaped in the male specimens and wedge-shaped in the female ones. Although centrally located between the anal and urogenital triangles, it was nearly completely formed by muscle fibres derived from the rectal muscularis propria. Thick bundles of smooth muscle, mostly arising from the longitudinal muscle, inserted into the PB and levator ani muscle (LAM). The recto-urethralis muscle originated from the PB and separated the anterolateral PB from the urogenital organs. CONCLUSION: Smooth muscle fibres derived from the rectal muscularis propria extend into the PB and LAM and appear to fix the anorectum. Dissection of the PB during APE is safe only when the smooth muscle fibres that extend into the PB are divided.

Deficiency or inhibition of lysophosphatidic acid receptor 1 protects against hyperoxia-induced lung injury in neonatal rats.

AIM: Blocking of lysophosphatidic acid (LPA) receptor (LPAR) 1 may be a novel therapeutic option for bronchopulmonary dysplasia (BPD) by preventing the LPAR1-mediated adverse effects of its ligand (LPA), consisting of lung inflammation, pulmonary arterial hypertension (PAH) and fibrosis. METHODS: In Wistar rats with experimental BPD, induced by continuous exposure to 100% oxygen for 10 days, we determined the beneficial effects of LPAR1 deficiency in neonatal rats with a missense mutation in cytoplasmic helix 8 of LPAR1 and of LPAR1 and -3 blocking with Ki16425. Parameters investigated included survival, lung and heart histopathology, fibrin and collagen deposition, vascular leakage and differential mRNA expression in the lungs of key genes involved in LPA signalling and BPD pathogenesis. RESULTS: LPAR1-mutant rats were protected against experimental BPD and mortality with reduced alveolar septal thickness, lung inflammation (reduced influx of macrophages and neutrophils, and CINC1 expression) and collagen III deposition. However, LPAR1-mutant rats were not protected against alveolar enlargement, increased medial wall thickness of small arterioles, fibrin deposition and vascular alveolar leakage. Treatment of experimental BPD with Ki16425 confirmed the data observed in LPAR1-mutant rats, but did not reduce the pulmonary influx of neutrophils, CINC1 expression and mortality in rats with experimental BPD. In addition, Ki16425 treatment protected against PAH and right ventricular hypertrophy. CONCLUSION: LPAR1 deficiency attenuates pulmonary injury by reducing pulmonary inflammation and fibrosis, thereby reducing mortality, but does not affect alveolar and vascular development and, unlike Ki16425 treatment, does not prevent PAH in neonatal rats with experimental BPD.

Understanding the surgical pitfalls in total mesorectal excision: Investigating the histology of the perirectal fascia and the pelvic autonomic nerves.

AIM: Excellent understanding of fasciae and nerves surrounding the rectum is necessary for total mesorectal excision (TME). However, fasciae anterolateral to the rectum and surrounding the low rectum are still poorly understood. We studied the perirectal fascia enfolding the extraperitoneally located part of the rectum in en-bloc cadaveric specimens and the University Medical Center Utrecht (UMCU) pelvic dataset, and describe implications for TME. METHODS: Four donated human adult cadaveric specimens (two males, two females) were obtained through the Leeds GIFT Research Tissue Programme. Paraffin-embedded blocks were produced and serially sectioned at 50 and 250 µm intervals. Whole mount sections were stained with haematoxylin & eosin, Masson's trichrome and Millers' elastin. Additionally, the UMCU pelvic dataset including digitalised cryosections of a female pelvis in three axes was studied. RESULTS: The mid and lower rectum were surrounded by a multi-layered perirectal fascia, of which the mesorectal fascia (MRF) and parietal fascia bordered the 'holy plane'. There was no extra constant fascia forming a potential surgical plane. Nerves ran laterally to the MRF. More caudally, the mesorectal fat strongly reduced and the MRF approached the rectal muscularis propria. The MRF had a variable appearance in terms of thickness and completeness, most prominently at the anterolateral lower rectum. CONCLUSION: Dissection onto the MRF allows nerve preservation in TME. Rectal surgeons are challenged in doing so as the MRF varies in thickness and shows gaps, most prominently at the anterolateral lower rectum. At this site, the risk of entering the mesorectum is great and may result in an incomplete specimen.

Whole mount microscopic sections reveal that Denonvilliers' fascia is one entity and adherent to the mesorectal fascia; implications for the anterior plane in total mesorectal excision?

BACKGROUND: Excellent anatomical knowledge of the rectum and surrounding structures is essential for total mesorectal excision (TME). Denonviliers' fascia (DVF) has been frequently studied, though the optimal anterior plane in TME is still disputed. The relationship of the lateral edges of DVF to the autonomic nerves and mesorectal fascia is unclear. We studied whole mout microscopic sections of en-bloc cadaveric pelvic exenteration and describe implications for TME. METHODS: Four donated human adult cadaveric specimens (two males, two females) were obtained from the Leeds GIFT Research Tissue Programme. Paraffin-embedded mega blocks were produced and serially sectioned at 50 and 250 µm intervals. Sections were stained with haematoxylin & eosin, Masson's trichrome and Millers' elastin. Additionally, a series of eleven human fetal specimens (embryonic age of 9-20 weeks) were studied. RESULTS: DVF consisted of multiple fascial condensations of collagen and smooth muscle fibres and was indistinguishable from the anterior mesorectal fascia and the prostatic fascia or posterior vaginal wall. The lateral edges of DVF appeared fan-shaped and the most posterior part was continuous with the mesorectal fascia. Fasciae were not identified in fetal specimens. CONCLUSION: DVF is adherent to and continuous with the mesorectal fascia. Optimal surgical dissection during TME should be carried out anterior to DVF to ensure radical removal, particularly for anterior tumours. Autonomic nerves are at risk, but can be preserved by closely following the mesorectal fascia along the anterolateral mesorectum. The lack of evident fasciae in fetal specimens suggested that these might be formed in later developmental stages.

Development of major aorto-pulmonary collateral arteries in vegf120/120 isoform mouse embryos with tetralogy of fallot.

The degree of right ventricular outflow tract obstruction, pulmonary stenosis (PS) and the development of major aorto-pulmonary collateral arteries (MAPCAs) in patients with tetralogy of Fallot (TOF) is related to clinical outcome. Vegf120/120 mutant mouse embryos develop TOF with various degrees of PS, comparable to humans. We aimed to study the ontogeny of the development of MAPCAs in this mouse model. The development of the right ventricular outflow tract, pulmonary arteries, and ductus arteriosus (DA) and formation of MAPCAs were studied in both wild type as well as Vegf120/120 mice from embryonic day 10.5 until day 19.5. Of the 49 Vegf120/120 embryos, 35 embryos (71%) had ventral displacement of the outflow tract and a subaortic ventricular septal defect. A time-related development in severity of PS to pulmonary atresia (PA) was observed. From embryonic day 12.5, hypoplasia of the DA was seen in 13 (37%) and absent DA in 12 (37%) of these embryos. The 3 (6%) embryos with PA and absent DA developed MAPCAs, after day 15.5. In all, the MAPCAs arose from both subclavian arteries, running posterior in the thoracic cavity, along the vagal nerve. The MAPCAs connected the pulmonary arteries at the site of the hilus. A time-related development of PS to PA can lead, in combination with absent DA, to the development of MAPCAs later in embryonic life as an alternative route for pulmonary perfusion in this mouse model. This finding contributes to a better understanding of the consecutive morphological changes in the development toward MAPCAs in humans.

Lymphatic drainage pathways from the cervix uteri: implications for radical hysterectomy?

OBJECTIVE: Radical hysterectomy with pelvic lymphadenectomy is the treatment of choice for early-stage cervical cancer. Wertheim's original technique has been often modified, mainly in the extent of parametrectomy. Okabayashi's technique is considered as the most radical variant regarding removal of the ventral parametrium and paracolpal tissues. Surgical outcome concerning recurrence and survival is good, but morbidity is high due to autonomic nerve damage. While the autonomic network has been studied extensively, the lymphatic system is less understood. This study describes the lymphatic drainage pathways of the cervix uteri and specifically the presence of lymphatics in the vesico-uterine ligament (VUL). METHODS: A developmental series of 10 human female fetal pelves was studied. Paraffin embedded blocks were sliced in transverse sections of 8 or 10 µm. Analysis was performed by staining with antibodies against LYVE-1 (lymphatic endothelium), S100 (Schwann cells), alpha-Smooth Muscle Actin (smooth muscle cells) and CD68 (macrophages). The results were three-dimensionally represented. RESULTS: Two major pathways drained the cervix uteri: a supra-ureteral pathway, running in the cardinal ligament superior to the ureter, and a dorsal pathway, running in the utero-sacral ligament towards the rectal pillars. No lymph vessels draining the cervix uteri were detected in the VUL. In the paracolpal parametrium lymph vessels draining the upper vagina fused with those from the bladder. CONCLUSIONS: The VUL does not contain lymphatics from the cervix uteri. Hence, the favorable survival outcomes of the Okabayashi technique cannot be explained by radical removal of lymphatic pathways in the ventrocaudal parametrium.

Toward a highly-detailed 3D pelvic model: approaching an ultra-specific level for surgical simulation and anatomical education.

The surgical anatomy of the pelvis is highly complex. Anorectal and urogenital dysfunctions occur frequently after pelvic oncological surgery and are mainly caused by surgical damage of the autonomic nerves. A highly-detailed 3D pelvic model could increase the anatomical knowledge and form a solid basis for a surgical simulation system. Currently, pelvic surgeons still rely on the preoperative interpretation of 2D diagnostic images. With a 3D simulation system, pelvic surgeons could simulate and train different scenes to enhance their preoperative knowledge and improve surgical outcome. To substantially enrich pelvic surgery and anatomical education, such a system must provide insight into the relation between the autonomic network, the lymphatic system, and endopelvic fasciae. Besides CT and MR images, Visible Human Datasets (VHDs) are widely used for 3D modeling, due to the high degree of anatomical detail represented in the cryosectional images. However, key surgical structures cannot be fully identified using VHDs and radiologic imaging techniques alone. Several unsolved anatomical problems must be elucidated as well. Therefore, adequate analysis on a microscopic level is inevitable. The development of a comprehensive anatomical atlas of the pelvis is no straightforward task. Such an endeavor involves several anatomical and technical challenges. This article surveys all existing 3D pelvic models, focusing on the level of anatomical detail. The use of VHDs in the 3D reconstruction of a highly-detailed pelvic model and the accompanying anatomical challenges will be discussed.

Accuracy of fluoroscopy in the treatment of intra-articular thumb metacarpal fractures.

The purpose of this study was to determine the accuracy of fluoroscopic imaging during closed reduction and percutaneous fixation of intra-articular thumb metacarpal fractures. Closed reduction and percutaneous fixation was assessed in eight simulated intra-articular thumb metacarpal fractures, using fluoroscopy and digital radiographs. Displacement and fracture step-off were measured during fluoroscopy, on plain radiographs, and by direct visualization after careful dissection. Displacement on fluoroscopy was 0.8 (SD 1.0) mm and 1.2 (SD 1.4) with radiographic imaging. Direct visualization showed displacement of 0.9 (SD 1.2) mm. Intra-articular step-off on fluoroscopy was 0.8 (SD 1.0) mm and 0.8 (SD 0.8) with radiographic imaging. Direct visualization showed an intra-articular step-off of 0.8 (SD 1.2) mm. Statistical analysis showed excellent compatibility between fluoroscopy and direct visualization. Fluoroscopic visualization during surgery provides an adequate assessment of articular step-off and displacement in comparison with radiographs and direct visualization.

The MiniArc sling for female stress urinary incontinence: clinical results after 1-year follow-up.

INTRODUCTION AND HYPOTHESIS: The objective of this study was the assessment of the efficiency of the MiniArc for curing stress urinary incontinence. METHODS: Seventy-seven patients, operated on from March 2008 to November 2009, were evaluated in this study. One-year post-operative data are presented. All patients suffered from predominant stress urinary incontinence. After 1 year, response was 74%. Evaluation was performed using a questionnaire consisting of the EuroQol-5 Dimensions, the Patient Global Impression of Improvement, the Incontinence Impact Questionnaire, the Urinary Distress Inventory, the Prolapse/Urinary Incontinence Sexual Questionnaire, short form, and the Defecation Distress Inventory. RESULTS: One year after surgery, 68% of the patients stated an improvement in their incontinence status, while only 44% stated to be completely dry. CONCLUSION: The 1-year follow-up suggests that the MiniArc is less effective in the treatment of stress urinary incontinence than the TVT.

Origin of presacral local recurrence after rectal cancer treatment.

BACKGROUND: The objective of this study was to obtain detailed anatomical information about the lateral lymph nodes, in order to determine whether they might play a role in presacral local recurrence of rectal cancer after total mesorectal excision without lateral lymph node dissection. METHODS: Ten serially sectioned human fetal pelvises were studied at high magnification and a three-dimensional reconstruction of the fetal pelvis was made. RESULTS: Examination of the histological sections and the three-dimensional reconstruction showed that lateral lymph node tissue comprises a major proportion of the pelvic tissue volume. There were no lymph nodes located in the presacral area. Connections between the mesorectal and extramesorectal lymph node system were found in all fetal pelvises, located below the peritoneal reflection on the anterolateral side of the fetal rectum. At this site middle rectal vessels passed to and from the mesorectum, and branches of the autonomic nervous system bridge to innervate the rectal wall. CONCLUSION: The findings of this study support the hypothesis that tumour recurrence might arise from lateral lymph nodes.

Vaginal blood flow after radical hysterectomy with and without nerve sparing. A preliminary report.

Radical hysterectomy with pelvic lymphadenectomy (RHL) for cervical cancer causes damage to the autonomic nerves, which are responsible for increased vaginal blood flow during sexual arousal. The aim of the study of which we now report preliminary data was to determine whether a nerve-sparing technique leads to an objectively less disturbed vaginal blood flow response during sexual stimulation. Photoplethysmographic assessment of vaginal pulse amplitude (VPA) during sexual stimulation by erotic films was performed. Subjective sexual arousal was assessed after each stimulus. Thirteen women after conventional RHL, 10 women after nerve-sparing RHL, and 14 healthy premenopausal women participated. Data were collected between January and August 2006. The main outcome measure was the logarithmically transformed mean VPA. To detect statistically significant differences in mean VPA levels between the three groups, a univariate analysis of variance was used. Mean VPA differed between the three groups (P= 0.014). The conventional group had a lower vaginal blood flow response than the control group (P= 0.016), which tended also to be lower than that of the nerve-sparing group (P= 0.097). These differences were critically dependent on baseline vaginal blood flow differences between the groups. The conventional group follows a vaginal blood flow pattern similar to postmenopausal women. Conventional RHL is associated with an overall disturbed vaginal blood flow response compared with healthy controls. Because it is not observed to the same extent after nerve-sparing RHL, it seems that the nerve-sparing technique leads to a better overall vaginal blood flow caused by less denervation of the vagina.

Decellularization of rat aortic valve allografts reduces leaflet destruction and extracellular matrix remodeling.

OBJECTIVES: Decellularization of aortic valve allografts in advance of transplantation is a promising approach to overcome immune-induced early graft failure. In this study the effects of in vitro cell extraction on extracellular matrix molecules and in vivo remodeling of decellularized aortic valves were investigated in a heterotopic aortic valve rat implantation model. METHODS: Rat aortic valve conduits were decellularized by a 2-step detergent-enzymatic extraction method involving sodium dodecyl sulfate in combination with RNase and DNase. Cellular and acellular allogeneic (2x, n = 4) and syngeneic valve grafts (2x, n = 3) were grafted infrarenally into the descending aorta for 21 days. Immunohistochemical techniques were used to study extracellular matrix constitution (elastin, collagen, fibronectin, and chondroitin sulfate) and cellular infiltration. RESULTS: The decellularization procedure resulted in a complete loss of all cellular structures from the entire valve conduit with minimal damage to the extracellular matrix. All transplanted cellular allografts became deformed, swollen, and acellular with major changes in extracellular matrix structure. The transplanted decellularized allografts, however, retained normal preserved valve leaflets comparable to transplanted cellular and acellular syngeneic grafts. With the exception of cellular syngeneic grafts, all other grafts showed retrovalvular thrombi. CONCLUSIONS: Damage to the valves caused by decellularization technique is much less than the damage caused by the recipient's immune response. In vitro removal of viable cells in (cryopreserved) homografts may decrease graft failure. Seeding with autologous or major histocompatibility complex-matched donor endothelial cells will be necessary to diminish damage induced by an absent blood-tissue barrier.

Nerve sparing radical hysterectomy: latest developments and historical perspective.

Autonomic nerve damage during surgery is thought to play a crucial role in the aetiology of bladder dysfunction, sexual dysfunction and colorectal motility disorders which are seen in patients after radical hysterectomy. In order to prevent these complications, Japanese gynaecologists introduced a surgical technique with preservation of the pelvic autonomic nerves in the 1960s. In the 1980s the first English paper was published. Since then several surgical approaches have been described, i.e. liposuction, electrical stimulation to locate nerves intra-operatively and laparoscopically assisted techniques. Recently, more attention is being paid to the importance of sparing the sympathetic hypogastric nerve. All authors report results on small cohorts of patients. The incidence of urinary dysfunction seems very low after nerve sparing. Sparing the autonomic nerves during radical hysterectomy seems feasible and safe in both Japanese and Western patients. Literature review does not provide strong clues for a compromised radicality and cure due to nerve sparing. Future larger clinical trials will have to decide whether the technique of nerve sparing radical hysterectomy could be implemented as a standard treatment for cervical cancer patients.

[Nerve sparing radical hysterectomy in the case of cervical cancer]. / Zenuwsparende radicale hysterectomie bij cervixcarcinoom.

Autonomous pelvic nerves are essential for bladder and rectum function as well as sexuality. These nerves are usually permanent damaged during radical oncological surgery and this results in urological, sexual and proctological morbidity. Japanese surgeons have paved the way for surgical approaches to dissect these nerves during surgery and leave them intact. At the Department of Gynaecology of the Leiden University Medical Center, the Netherlands, a new surgical technique has been developed to spare the autonomous pelvic nerves during radical hysterectomy. In this procedure the lateral parts of the sacro-uterine ligament, through which the N. hypogastricus passes bilaterally, are left intact. The initial results of this nerve-sparing surgical technique during radical hysterectomy seem to be promising. The operation was easy to perform, with almost no extra blood loss and an extra operating time of just 10-15 minutes. Postoperative recovery of the bladder function occurred after a mean period of 9 days.