Retroperitoneal anatomyRetroperitoneal anatomyBy By

Dr. Khattab KAEODr. Khattab KAEO

Prof. & Head of Obstetrics and Gynaecology Prof. & Head of Obstetrics and Gynaecology Department Department

Faculty of Medicine, Al-Azhar University, Faculty of Medicine, Al-Azhar University, DamiettaDamietta

The subperitoneal area of the true pelvis is parti-

tioned into potential spaces by the various organs & their respective fascial

coverings and by the selective thickenings of the

endopelvic fascia into ligaments and septa.

Introduction

The retroperitoneal spacesThe retroperitoneal spacesThe paravesical space:The paravesical space: This is developed by dissect This is developed by dissect

ing between the ing between the external iliacexternal iliac vessels and the vessels and the anter. anter. division of the internal iliacdivision of the internal iliac artery (precisely, the artery (precisely, the superior vesical artery) lateral to the bladder. The superior vesical artery) lateral to the bladder. The uterine artery forms the posterior boundary of the uterine artery forms the posterior boundary of the space, while the levator ani muscles form its floor. space, while the levator ani muscles form its floor. First, expose the external iliac vessels near their First, expose the external iliac vessels near their entrance into the femoral canal by dividing the entrance into the femoral canal by dividing the round round ligamentligament near the deep inguinal ring. Note where the near the deep inguinal ring. Note where the circumflex iliac vein crosses the external iliac arterycircumflex iliac vein crosses the external iliac artery. . The anterior division of the internal iliac artery lies The anterior division of the internal iliac artery lies just medial. On the lateral side of the paravesical just medial. On the lateral side of the paravesical space lies the obturator fossa containing blood ves., space lies the obturator fossa containing blood ves., nerve and lymph nodes. Blunt dissection following nerve and lymph nodes. Blunt dissection following the inward pelvic slope can be continued to the the inward pelvic slope can be continued to the pelvic diaphragm. pelvic diaphragm. The space is limited superiorly by The space is limited superiorly by the lateral umbilical ligament. the lateral umbilical ligament.

Cardinal ligament

Cut round ligament

going through the deep inguinal ring

This is particularly useful in the following This is particularly useful in the following conditions (indications): conditions (indications):

1- Malignancy. 1- Malignancy.

2- Endometriosis. 2- Endometriosis.

3- Chronic PID. 3- Chronic PID.

4- Tubo-ovarian abscess. 4- Tubo-ovarian abscess.

5- Large or interligamentous liemyoma. 5- Large or interligamentous liemyoma.

6- Redsidual ovaries. 6- Redsidual ovaries.

7- Hypogastric artery ligation. 7- Hypogastric artery ligation.

Developing the retroperitoneal spacesDeveloping the retroperitoneal spaces

The pararectal space:The pararectal space: It is bound laterally by the It is bound laterally by the levator ani, medially by the rectal pillars, and levator ani, medially by the rectal pillars, and

posteriorly above the ischial spine by the posteriorly above the ischial spine by the anterolateral aspect of sacrum.anterolateral aspect of sacrum. Peripheral part of Peripheral part of

the cardinal ligament and the uterine artery the cardinal ligament and the uterine artery divides the paravesical & the para-rectal spaces.divides the paravesical & the para-rectal spaces.

To best develop the pararectal space, dissect To best develop the pararectal space, dissect between the first portion of the anterior division between the first portion of the anterior division

of the internal iliac artery laterally and the ureter of the internal iliac artery laterally and the ureter medially. The uterosacral ligament and the ureter medially. The uterosacral ligament and the ureter are located very near to each other between the are located very near to each other between the

rectovaginal and pararectal spaces. Remain close rectovaginal and pararectal spaces. Remain close to the rectum to avoid the internal iliac vein and to the rectum to avoid the internal iliac vein and

its side wall tributaries. its side wall tributaries.

The vesicovaginal space:The vesicovaginal space: Incise the Incise the vesicouterine peritoneal fold transversely. vesicouterine peritoneal fold transversely. Push the bladder down bluntly or by Push the bladder down bluntly or by sharp dissection. Moist gauze packing sharp dissection. Moist gauze packing usually controls any encountered slow usually controls any encountered slow venous bleeding. A common error is to venous bleeding. A common error is to dissect too close to the cervix and fail to dissect too close to the cervix and fail to get into the proper plane. Developing this get into the proper plane. Developing this space gives access to the vesicouterine space gives access to the vesicouterine ligament which contains the ureter as it ligament which contains the ureter as it passes to the bladder. passes to the bladder.

The rectovaginal space:The rectovaginal space: Incise the Incise the peritoneum between the insertion of the peritoneum between the insertion of the two uterosacral ligaments (the rectal two uterosacral ligaments (the rectal pillars contain the middle haemorrhoidal pillars contain the middle haemorrhoidal arteries). Bluntly dissect the vagina from arteries). Bluntly dissect the vagina from the rectum by sweeping the palm along the rectum by sweeping the palm along the posterior vaginal wall. For adherent the posterior vaginal wall. For adherent areas, sharp dissection against the areas, sharp dissection against the vagina is used. The vesicovaginal and vagina is used. The vesicovaginal and rectovaginal spaces may be rectovaginal spaces may be considerably altered. In such instances, considerably altered. In such instances, developing the paravesical and the developing the paravesical and the pararectal spaces first is very helpful. pararectal spaces first is very helpful.

The prevesical and presacral spaces:The prevesical and presacral spaces: The prevesical space can be developed The prevesical space can be developed by gently dissecting the areolar tissue by gently dissecting the areolar tissue immediately posterior to the symphysis immediately posterior to the symphysis pubis. The presacral space can be pubis. The presacral space can be developed by gently incising the over-developed by gently incising the over-lying parietal peritoneum. One may lying parietal peritoneum. One may place the sigmoid colon to the left. place the sigmoid colon to the left. Inside this space, encased in fat, is the Inside this space, encased in fat, is the sympathetic nerve plexus (the sympathetic nerve plexus (the presacral nerve) in addition to the presacral nerve) in addition to the middle sacral artery and vein. middle sacral artery and vein.

1988 FIGO SURGICAL staging:1988 FIGO SURGICAL staging:

Stage I: Tumour limited to the uterus. Stage I: Tumour limited to the uterus. Stage IA: Limited to the endometrium. Stage IA: Limited to the endometrium.

Stage IB: Invaded Stage IB: Invaded ½½ the myometrium. the myometrium.

Stage IC: Invaded >Stage IC: Invaded >½½ the myometrium the myometrium

Stage II: Extends to the cervix. Stage II: Extends to the cervix. Stage IIA: Endocervical glandular involvement Stage IIA: Endocervical glandular involvement

Stage IIB: Cervical stromal involvement. Stage IIB: Cervical stromal involvement.

Stage III: Spread to the pelvis. Stage III: Spread to the pelvis. Stage IIIA: Invasion of uterine serosa &/or adnexa or +ve peri-Stage IIIA: Invasion of uterine serosa &/or adnexa or +ve peri-

toneal cytology.toneal cytology.

Stage IIIB: Vaginal metastasis. Stage IIIB: Vaginal metastasis.

Stage IIIC: Pelvic or paraaortic LN metastasis. Stage IIIC: Pelvic or paraaortic LN metastasis.

Stage IV: Advanced pelvic or distant metastasis Stage IV: Advanced pelvic or distant metastasis Stage IVA: Bladder or bowel mucosa invasion.Stage IVA: Bladder or bowel mucosa invasion.

Stage IVB: Distant and/or inguinal LN metastasis. Stage IVB: Distant and/or inguinal LN metastasis.

CIS is often sharply demarcated

Histologic types: Histologic types: 90% of endometrial adeno-90% of endometrial adeno-carcinomas are of the carcinomas are of the endometrioidendometrioid type. type.

Degrees of differentiation:Degrees of differentiation: Poorly differentiated Poorly differentiated tumours are less responsive to adjuvant pro-tumours are less responsive to adjuvant pro-gestogen therapy than well-differentiated gestogen therapy than well-differentiated tumours. Also, they deeply invade the myo-tumours. Also, they deeply invade the myo-metrium early, while well-differentiated metrium early, while well-differentiated tumours tend to grow exophytically in the tumours tend to grow exophytically in the cavity. cavity.

G1: ≤5% of a non-squamous or non-morular G1: ≤5% of a non-squamous or non-morular solidsolid growth pattern. growth pattern.

G2: 6%-50% of a non-squamous or non-G2: 6%-50% of a non-squamous or non-morular morular solidsolid growth pattern. growth pattern.

G3: >50% of a non-squamous or non-morular G3: >50% of a non-squamous or non-morular solidsolid growth pattern. growth pattern.

10% uncommon types: clear cell, 10% uncommon types: clear cell, papillary serous, mucinous carcin-papillary serous, mucinous carcin-oma and undifferentiated tumours. oma and undifferentiated tumours. Clear cell adenocarcinomaClear cell adenocarcinoma is identi is identi cal to that of the cervix, vagina & cal to that of the cervix, vagina & ovary. It is a high-risk tumour; ovary. It is a high-risk tumour; early stages are comparable to G3 early stages are comparable to G3 endometrioid adenocarcinoma. endometrioid adenocarcinoma. Papillary serous carcinoma Papillary serous carcinoma tends tends to spread intra-abdominally, and is to spread intra-abdominally, and is refractory to most standard refractory to most standard therapytherapy

Lymphatic spread:Lymphatic spread: Lymphatic spread from Lymphatic spread from the mid and lower portions is similar to that the mid and lower portions is similar to that of the cervix. Fundal tumours spread of the cervix. Fundal tumours spread throughthrough the broad and infudibulopelvic ligaments to the broad and infudibulopelvic ligaments to the hypogastric, external iliac, common iliac the hypogastric, external iliac, common iliac & aortic nodes or through the round ligament & aortic nodes or through the round ligament to the superficial and deep lymph nodes. to the superficial and deep lymph nodes.

High risk endometrial adenocarcinoma: High risk endometrial adenocarcinoma: 1- >50% of the myometrial thickness is 1- >50% of the myometrial thickness is invadedinvaded

(stage IC), involvement of the cervix (stage (stage IC), involvement of the cervix (stage IIA, B) or adnexa (stage IIIA). IIA, B) or adnexa (stage IIIA).

2- Poorly differentiated (grade 3). 2- Poorly differentiated (grade 3). 3- Villoglandular type of endometrioid adeno-3- Villoglandular type of endometrioid adeno-

carcinoma if invaded the myometrium. carcinoma if invaded the myometrium.

4- The uncommon types. 4- The uncommon types.

Presentation:Presentation: Early growths are polyp- Early growths are polyp-oidal; surface ulceration and necrosis oidal; surface ulceration and necrosis peri-/post-menopausal peri-/post-menopausal bleedingbleeding. Because . Because this is this is ominousominous to both the patient & to both the patient & physician, delays in diagnosis are physician, delays in diagnosis are uncommon. uncommon.

Late cases may present with Late cases may present with intermittent pus-like discharge. intermittent pus-like discharge. Postmenopausal bleeding or bloody-Postmenopausal bleeding or bloody-mucoid discharge indicates cancer in the mucoid discharge indicates cancer in the genital tract in 50% of cases. genital tract in 50% of cases.

The uterus feels symmet The uterus feels symmet rically enlarged by the mass If affecting a rically enlarged by the mass If affecting a senile uterus, clinical enlargement may not senile uterus, clinical enlargement may not be produced.be produced.

Work-up:Work-up: History and examination: Most History and examination: Most patients are in their 60s & 70s. patients are in their 60s & 70s. Coexisting DM, hypertension & obesity. Coexisting DM, hypertension & obesity.

Endometrial biopsy for all wo Endometrial biopsy for all wo men >40 with IUB It is also indicated if men >40 with IUB It is also indicated if endometrialendometrial cells are noted on a Pap cells are noted on a Pap smear of a smear of a postpostmenopausal woman or menopausal woman or if if atypical glandularatypical glandular cells are noted on cells are noted on a smear of a a smear of a prepremenopausal woman. menopausal woman. Biopsy establishes the diagnosis with Biopsy establishes the diagnosis with high sensitivity and specificity. high sensitivity and specificity.

Ultrasonography could be re Ultrasonography could be re assuring if endometrial thickness is <3 assuring if endometrial thickness is <3 cm in a menopausal woman. cm in a menopausal woman.

Screening:Screening: Only worthwhile in highrisk popul: Only worthwhile in highrisk popul: white, obese, on estrogen or tamoxifen, nulli white, obese, on estrogen or tamoxifen, nulli para, with PCOS, granulosa cell tumour, per-para, with PCOS, granulosa cell tumour, per-sonal or family history of breast/ovarian/ colon sonal or family history of breast/ovarian/ colon cancer. Arrange 2-4 visits/year. Endo-metrial cancer. Arrange 2-4 visits/year. Endo-metrial sampling is done using Vabra aspira-tor sampling is done using Vabra aspira-tor (postsounding) which is diagnostic in 90-100% of (postsounding) which is diagnostic in 90-100% of cases +ve results cases +ve results additional endo cervical additional endo cervical sampling, but endometrial curettage is sampling, but endometrial curettage is unnecessary.unnecessary. If D & C is chosen: If D & C is chosen:

- At the end a polyp forceps is used to remove a polyp - At the end a polyp forceps is used to remove a polyp

- If 1 swipe of the curet produces obvious endometrial - If 1 swipe of the curet produces obvious endometrial carcinoma, further curettage is not necessary (may carcinoma, further curettage is not necessary (may disseminate tumour cells). disseminate tumour cells).

If there is hyperplasia, look for accompanying carcin-oma If there is hyperplasia, look for accompanying carcin-oma or ovarian tumour. or ovarian tumour.

The same work-up should be followed even if an obvious The same work-up should be followed even if an obvious cause of postmenopausal bleeding such as cervical cause of postmenopausal bleeding such as cervical polyp or vaginitis is present. polyp or vaginitis is present.

TreatmentTreatment Surgery:Surgery: TAH BSO is the mainstay treatment. TAH BSO is the mainstay treatment. Chemotherapy:Chemotherapy: Progestational therapy may Progestational therapy may respon- respon-

ses, but cures are unusual. ses, but cures are unusual. MPA: For CIS: 400 mg in 4 w in divided doses, then 400 MPA: For CIS: 400 mg in 4 w in divided doses, then 400

mg/month (5). mg/month (5). For carcinoma: 400 mg/day for a week, then 400 mg For carcinoma: 400 mg/day for a week, then 400 mg

3 times/w for 2 w before surgery with the same course 3 times/w for 2 w before surgery with the same course is given postoperatively if the tumour is ex-tended for is given postoperatively if the tumour is ex-tended for >1/3 of the myometrium. >1/3 of the myometrium.

Chemotherapy is attempted with distant metastasis. It Chemotherapy is attempted with distant metastasis. It includes cis-/ carbo-platin, doxorubicin & paclitaxil. includes cis-/ carbo-platin, doxorubicin & paclitaxil.

Radiotherapy: Radiotherapy: Stage IIB necessitates preoperative Stage IIB necessitates preoperative external external radiotherapyradiotherapy then TAH BSO. If the tumour is of then TAH BSO. If the tumour is of low risk, no further treatment is required. PORTEC low risk, no further treatment is required. PORTEC (Post (Post

Operative Radiation Therapy in Endometrial Carcinoma)Operative Radiation Therapy in Endometrial Carcinoma): External : External radiotherapy lowers the rate of local recurr-ence to 4% radiotherapy lowers the rate of local recurr-ence to 4% (Vs 14% in the no-radiotherapy group). However, the (Vs 14% in the no-radiotherapy group). However, the complication rate is 25% among the irradiated patients complication rate is 25% among the irradiated patients VsVs 6% in the no-radiotherapy group. 6% in the no-radiotherapy group. For stage Ia G1,2 no For stage Ia G1,2 no postoperative radiotherapy is required.postoperative radiotherapy is required. For stage Ib G1,2 For stage Ib G1,2 postoperative brachytherapy is required.postoperative brachytherapy is required. For stage Ic or G3 For stage Ic or G3 carcinomas, both are required. carcinomas, both are required.

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