Modern classification of radical hysterectomy should be based on the following principles:

The classification system described in this chapter was first published by Querleu and Morrow in 2008 [52], and later extended into a 3D model [11]. Five types of the procedure (A, B, C1, C2, D) correspond to other common historical types of radical hysterectomy (Table 33.1). The new classification system has some exceptional aspects to it: (a) recognizes the size and type of parametria resection as the crucial and sole parameter for classification, (b) includes new type of nerve sparing procedure, (c) uses stable anatomical landmarks for description of surgical resection margins, (d) identifies surgical landmarks in three planes—frontal, sagittal and transverse.

Type A corresponds to the extrafascial hysterectomy, the main principle of which is pericervical tissue removal up to the attachment of vaginal fornices. The ureter does not need to be identified or dissected in the parametrium, parametria are not resected and autonomic nerves remain fully preserved.

Type B corresponds mostly to the modified radical hysterectomy. Ureter is the major resection margin ventrally and laterally (Fig. 33.4). It must be identified in the parametrium, its course is unroofed, dissected from the cervix and displaced laterally, but not dissected from the lateral or ventral parametria. Such extent of distal ureteral dissection enables the resection of only a small initial part of the ventral and lateral parametria. Identification of autonomic nerves is not required, and the hypogastric plexus remains hidden in a deeper part of the parametria, thus remaining fully preserved.

There are significant differences, particularly in the vertical (deep parametrial) dimension, between type C1, which corresponds to the nerve-sparing procedure, and type C2, which aims for a complete parametrial resection. In type C1 the ureter is unroofed, dissected from the cervix and lateral parametria, but only partially from the ventral parametria, while type C2 requires complete dissection of the ureter from the ventral parametria up to the urinary bladder wall. Laterally, resection margins in a transverse plane are identical for both types, formed by the medial aspect of the internal iliac vein (Fig. 33.4). In type C1 the deep parametrial resection margin on the lateral parametria is formed by the deep uterine vein (vaginal vein), which is a large vein located about 1–2 cm below the uterine artery and vein (Fig. 33.3). As such the caudal part of the lateral parametria containing the splanchnic nerves is preserved. In type C2 the resection line continues alongside the medial aspect of the internal iliac vessels up to the sacral bone (Fig. 33.3). Such deep resection allows for greater mobility of the lateral parametria, facilitating its complete removal. Ventrally, in type C1 a partial dissection of the ureter from the ventral parametria allows for limited resection in a sagittal plane of 1–2 cm of the ventral parametria (Fig. 33.5). Even more important is a vertical resection margin on the ventral parametria, which must be at the level of ureter to preserve bladder branches of the hypogastric plexus localized below the course of the ureter [29, 30]. In type C2, a complete dissection of the ureter from the ventral parametria is required, which allows for complete resection of the ventral parametria up to the urinary bladder wall (Fig. 33.5). Bladder branches of the hypogastric plexus are sacrificed. Dorsally, type C1 requires separation of two parts of the dorsal parametria: the medial part, which is composed by the recto-uterine and recto-vaginal ligaments, and the lateral laminar structure, which contains the hypogastric plexus, also called the mesoureter (Fig. 33.6). Main branches of the hypogastric plexus are preserved on the lateral part (mesoureter), while recto-uterine and recto-vaginal ligaments can be resected at the level of its rectal attachment. Type C2 aims to a complete resection of the dorsal parametria deeply below the rectal attachment, so that separation of major branches of the hypogastric plexus is not needed and these nerves are sacrificed (Fig. 33.6).

Type D differs from type C2 only in a lateral extent of the lateral parametria resection. Ureteral dissection and resection of both dorsal and ventral parametria is identical to type C2. Laterally, however, it requires ligation and removal of internal iliac artery and vein, together with their branches, including gluteal, internal pudendal and obturator vessels. Lateral resection line is formed by the lumbosacral nerve plexus, piriformis muscle and obturator internal muscle.

Round ligament is identified at the beginning of the procedure, cut through and the retroperitoneum is broadly exposed above the external iliac vessels. Paravesical and lateral pararectal spaces are opened by blind dissection and the lateral parametrium remains revealed between these two spaces. Umbilical ligament is dissected from the ventral parametria and preserved. The origin of the uterine artery is identified on the medial aspect of internal iliac artery; at this point it is interrupted, usually together with the uterine vein, localized below the artery. Now the lateral parametrium can be dissected from the pelvic side wall—lateral resection margin is formed by the medial aspect of internal iliac vein—caudal margin depends on the type of radical hysterectomy, formed by the deep uterine vein in type C1, while dissection continues up to the sacral bone in type C2. Type D requires ligation and resection of both internal iliac vessels.

Ureter is identified on the posterior leaf of broad ligament; it is sharply mobilized up to its entrance to lateral parametria. Mobilization of the distal ureter requires caudal dissection of the urinary bladder from the cervix and proximal vagina. Ureteral tunnel in the lateral parametrium is blindly opened; parametria resected above the ureter and the ureter is completely mobilized from the cervix and ventrally from the upper vagina. Such dissection of distal ureter is adequate for type B, while type C1 requires complete mobilization of the ureter from lateral parametria, whereas for type C2 additional complete dissection from ventral parametria up to its entrance into the urinary bladder is necessary.

The extent of urinary bladder caudal dissection is determined by the projected size of vaginal cuff removal. The extent of ventral parametrial resection depends on the type of radical hysterectomy: ventral parametria are not resected in type B, while about 2 cm of proximal part located above the ureter is removed in type C1. In type C2 and D after the ureter has been fully dissected, ventral parametrium is resected completely at the bladder wall.

The rectovaginal peritoneal flap is cut and rectum is caudally dissected from the vagina and lateral parametria. Dorsal parametria are resected in the extent of 1–2 cm in type B. Type C1 requires separation of two parts of the dorsal parametria—hypogastric plexus is preserved in laterally separated part (mesoureter) while sacrouterine and sacrovaginal ligaments can be resected at the level of its attachment into the rectum. Separation of two parts of the dorsal parametrium is not required for type C2 or D as dorsal parametria are completely resected and hypogastric plexus is inevitably sacrificed.

Finally the paracolpium is interrupted in transverse plane at the level of intended vaginal resection, the vagina is resected and vaginal cuff sutured, preferably by submucosal closure which allows for further complete visualization of the upper vagina during the follow-up.