Radical Hysterectomy

NS=Not stated CLS=Capillary-like space

NS=Not stated CLS=Capillary-like space published relating to extracervical spread of microinvasive tumours, suggesting that the majority will be adequately managed by conization. Most gynaecologic oncologists would qualify this, depending on whether lymphovascular permeation was present. If it was, they might proceed to a radical hysterectomy and pelvic lymphadenectomy. As can be seen from the table, this practice is not based strictly on evidence. It should be noted that, according to current FIGO definitions, some of the tumours referred to in the table would now be staged beyond IA2 by virtue of their lateral dimensions; however, this serves further to confirm that radical hysterectomy is overtreatment in many cases. Practice will also vary depending on the woman's desire to retain fertility. Traditionally, stage IB1, IB2 and IIA tumours have been managed by radical hysterectomy and pelvic lymphadenectomy. Stage IIB, III and IV tumours are managed by radiotherapy, chemotherapy and surgery, either singly or in combination, and dependent upon the individual centre and the individual patient. Units vary on their policy for commencing radiotherapy depending on the number of lymph nodes involved.

An increasing number of young women are being diagnosed with invasive cervical cancer. This is probably a result of the cervical smear programme, which enables women to be detected both at an earlier stage in their malignancy and at an earlier age. The increasing number of young patients has made many wonder whether a less radical treatment than a radical hysterectomy and pelvic lymphadenectomy could be offered, while still maintaining a high cure rate and allowing preservation of fertility.

Daniel Dargent describes in Chapter 8 the radical vaginal hysterectomy. Expertise in this procedure is the prerequisite to having the skill required for a new technique he has described for removal of exophytic tumours—stages IA2 to IIA—which were unsuitable for treatment by conization; he called this procedure 'radical vaginal trachelectomy'. It involves removal of the cervix, parametrium and upper vagina via the vaginal route. Patients also undergo a pelvic lymphadenectomy performed laparoscopically prior to the trachelectomy (this operation is fully described by Plante and Roy in Chapter 9). This procedure requires considerable skill in both vaginal and laparoscopic techniques. Many gynaecological oncologists have recently acquired laparoscopic skills to complement their open surgical skills, but few have been trained to perform Schauta's radical vaginal hysterectomy. For these reasons, we have been involved in developing an abdominal approach to radical trachelectomy which is technically similar to a traditional radical hysterectomy, but still offers prospects for future fertility.

When considering more conservative surgery than has previously been the norm for a given condition, one has to consider both the pathology of the disease and its mode of metastasis. The spread of squamous cervical carcinoma is predominantly lateral; it may be continuous, where the tumour spreads in a confluent manner towards the pelvic side-wall, or discontinuous, with vessel or parametrial node involvement.

Vertical spread of cervical cancer is much less common than lateral spread. In Burghardt's series of 395 women (1991) there were no cases of vertical spread in any stage IB or IIA tumours. In the case of stage IIB tumours, there were 11 out of 220 cases (20%) of spread to the uterine corpus, while other workers quote figures of 26% (Mitani 1964) and 24% (Ferrari 1988). Age may be an important factor in spread to the uterine body. Balzer (1978) found that in women under the age of 50 the vertical spread of stage IIB tumours was 9.5%, whereas in women over 50 years old the figure rose to 32%.

Anatomical considerations

Fertility

To retain fertility without the need for assisted conception techniques, a woman must retain her ovaries, fallopian tubes, uterus, a residuum of cervix with a patent cervical os and a functioning vagina. With the use of assisted conception and ovum donation techniques, a woman requires as an absolute minimum to have retained her uterus and enough cervix to retain a cervical cerclage suture.

Vascular considerations

The uterus is supplied by three pairs of arteries: the uterine, ovarian and vaginal arteries, the latter two via collaterals. Viability of the uterus can certainly be maintained in the absence of uterine arteries, but probably only if there is no interruption of the ovarian or vaginal arterial supply. At the Society of Gynaecologic Oncologists Meeting in New Orleans in February 1996, the membership in an interactive session were asked to vote on how many vessels they felt were required for uterine preservation: the majority felt that the uterus required three of its six supplying vessels to remain viable. Interestingly, we now know that uterine viability may be maintained by the ovarian arteries alone, as demonstrated in 7 cases of radical abdominal trachelectomy already undertaken.

Oncological considerations

Any form of radical surgery for treatment of cervical carcinoma requires the removal of at least the cervix, some of or all the parametrium and upper vagina coupled with pelvic lymphadenectomy. The extent of parametrial resection required is still a subject of controversy (Hagen et al 2000). Pelvic lymphadenectomy should involve removal of the paracervical obturator, internal, external and common iliac nodes and possibly also the para-aortic nodes. A full description of Dargent's vaginal technique is given in Chapter 9. Laparoscopic lymphadenectomy techniques are described in Chapter 16.

Operative procedure

Figure 1 demonstrates the tumour requiring to be removed and the vascular supply to the uterus. In our technique for performing a radical abdominal trachelectomy, the abdomen is opened in standard fashion, through either a midline incision or a modified Cherney's incision, and the operation proceeds initially like a standard radical abdominal hysterectomy. The dissection commences by dividing the round ligaments, opening the broad ligament, paravesical and pararectal spaces (Figure 2). The external iliac, common iliac, internal iliac and obturator nodes are removed (Figure 3). The ureter is dissected from its entry into the pelvis until it runs under the uterine artery. The dissection of the anterior division of the internal iliac artery into the superior vesical and uterine vessels is continued with skeletonization of these vessels (Figure 4). The uterine artery is further dissected out alongside the uterine body to produce a completely skeletonized vessel. Bulldog clamps are applied and the vessel is divided approximately 4 cm from its origin at the internal iliac artery. A solution of heparin is instilled into the vessel (Figure 5). The ureteric tunnels are then opened and dissected and the bladder deflected anteriorly. The rectovaginal septum is opened to the level of the pelvic floor. The uterosacral ligaments are divided close to the sacrum and the vagina and parametrium are then incised. The uterus, cervix, upper third of vagina and parametrium are then swung superiorly, still attached to the ovarian pedicle (Figure 6). This allows excision of the cervix, parametrium and upper vagina. A small residuum of cervix is left as the site for inserting a cervical cerclage suture. Frozen section histological examination is performed on tissue from the upper surface of the cervix, to ensure adequate resection margins, and also from the lymph nodes. If the cervix demonstrates inadequate resection margins or the pelvic lymph nodes contain tumour, the procedure is abandoned and a full radical hysterectomy performed

Current research is investigating whether the uterus supplied only by the ovarian arteries can be assessed for viability intraoperatively by pulse oximetry. If the uterus proves to be viable supplied by the ovarian arteries alone then no further action will be required. If, however, uterine perfusion appears compromised, the divided uterine arteries will be anastomosed (Figure 7). A cervical cerclage suture is inserted in the residuum of the cervix to ensure competence in any future pregnancy and the body of the uterus is sutured to the upper edge of the vagina. The abdomen is then closed in the standard fashion.

Future developments

It would appear that the uterus is probably viable in most cases supplied only by the ovarian arteries and drained by the ovarian veins (as per the findings of Dr L Ungars).

Vagin Spread

Figure 1

The area to be removed during the procedure

Round Ligament Pregnancy

Figure 2

The round ligaments are divided and the broad ligament opened onto the pelvic sidewall

In those cases where uterine arterial anastomosis may be required, we have tested a number of methods. The 3-M Precise Microvascular Anastomotic Device (3M, Leicestershire, UK) is easy to use but does not allow for vessel expansion during pregnancy and is therefore not suitable. We have used 6-0 Prolene and 70 PDS sutures (both Ethicon Endosurgery, Edinburgh, UK) in a porcine model and shown both to be effective in suturing the vessels. Flow characteristics as determined by Doppler flow studies were normal throughout pregnancy and the sows delivered normal litters in terms of both size and numbers of piglets. The vessels had normal calibre and appearance at post-mortem. 7-0 PDS was technically the easier material to use. Operating magnifying loops are required. Bulldog clamps (Vascu-Statt: Scanlon International, USA) are

Lymphadenectomy For Ovarian Cancer

Figure 3

The internal iliac and uterine arteries are skeletonized

Pelvic Lymphadenectomy Ovarian Cancer

Figure 4

The uterine artery is divided close to its origin following application of haemoclips or ligation (see inset)

applied to the uterine arteries which are irrigated with heparin. Three sutures are inserted outside to inside and then inside to outside with care to include the full thickness of the vessel wall. The Bulldog clamps are then removed and, using a Yankauer (Sherwood Medical, Tullamore, Eire) suction cannula, any bleeding points are identified. The clamps are then reapplied and further sutures placed at any bleeding points. A total of 5 or 6 sutures per vessel is usually required to achieve a dry result.

Criticism of our procedure is not oncological, since our operation, in terms of clearance, is virtually the same as a radical hysterectomy and, we believe, has equal capacity to deliver clearance of tumour. Either a

Radical Hysterectomy

Figure 5

The ureteric tunnel is opened. Bleeding can be profuse at this point and the application of haemoclips may be helpful

Figure 5

The ureteric tunnel is opened. Bleeding can be profuse at this point and the application of haemoclips may be helpful

Figure 6

The vagina has been incised and the uterus is shown here, swung superiorly with the ovaries and uterine tubes attached. Arterial supply at this point is via the ovarian vessels alone proportion of or all the parametrium can be removed, depending upon the tumour being excised. Rather, criticism must be related to possible increased intraoperative and postoperative morbidity associated with a procedure which takes longer than a standard radical hysterectomy, and involves reanastomosis of vessels. If the anastomosis fails or becomes blocked, and the uterus does not appear to be well perfused, then a hysterectomy would be required. Microvascular surgeons, however, quote success rates in excess of 99% for suturing vessels 2.5-3 mm in diameter, i.e. vessels of similar size to the uterine artery. If failure does occur, it is expected to do so at the time of surgery, not in the immediate postoperative phase. As noted

Diagrammatic representation of the end result. The uterine arteries have been anastomosed and the residuum of the cervix sutured to the vagina

Figure 7

Diagrammatic representation of the end result. The uterine arteries have been anastomosed and the residuum of the cervix sutured to the vagina above, it is likely that uterine arterial anastomosis is not required in the majority of cases with the uterus supplied and drained via the ovarian vessels alone. The authors are currently researching a novel method for determining uterine viability and its relationship to the number of reanastomosed vessels.

One of the authors (LU) has performed the operation in 7 cases: one patient subsequently underwent a hysterectomy owing to an abnormal Papanicolaou smear result (the histology in this case was negative); the remaining six are well, all having regular periods, with no documented pregnancies. One patient was probably pregnant but had a miscarriage prior to ultrasound confirmation; the remaining patients have not as yet tried for pregnancy.

In summary, radical abdominal hysterectomy offers an oncologically sound procedure with a good chance of cure, but fertility is not preserved. It is this operation which is most commonly performed and has the best follow-up data. Radical vaginal trachelectomy requires advanced vaginal and laparoscopic surgical skills. It has, however, been proved that fertility follows such surgery, and so far the long-term survival data look impressive. Radical abdominal trachelectomy appears to be oncologically sound, and is perhaps more accessible in technical terms than radical vaginal trachelectomy. Fertility and long-term survival rates, despite limited follow-up data, we believe should be similar to those in radical abdominal hysterectomy.

Bibliography

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