Around the world, cervical cancer is the most common malignancy, even though cervical cytological screening (the Pap smear) has reduced the incidence of this carcinoma in many regions. The current treatment of cervical cancer is based on establishing its anatomical distribution (staging) within the patient and then managing that distribution in accordance with the basic biological behaviour of the neoplasm itself (pathways of contiguous and lymphatic spread). Generally, for early tumours, Stages Ib and IIa, radical hysterectomy provides a cure, whereas for the more advanced stages of disease, radiation therapy, chemotherapy, and occasionally surgery, alone or in combination, are the treatment of choice.

Although abdominal hysterectomy was first described in 1895, not until Wertheim published his experience with 500 cases in 1912 did the operation become popular. Wertheim's high surgical mortality rate of 20 per cent was problematic, even for that era. Unfortunately, the less morbid alternative approach, radical vaginal hysterectomy, was, for technical reasons, applicable only to one-fifth of patients with cancer that would otherwise be surgically curable.

Ironically, the introduction of radium therapy, while improving the effectiveness of cervical cancer treatment, was a major setback in the evolution of radical hysterectomy. Although several centres in Europe and the United States continued to perform radical hysterectomies, most clinics at that time abandoned the surgical approach in deference to the newer, safer radium therapy. However, in 1944, Dr J. V. Meigs, in Boston, using more modern surgical and medical techniques, published details of 47 patients treated by combining radical hysterectomy with bilateral pelvic lymphadenectomy, in which he described curative results without the high operative mortality rates of previous series. This report reinstituted radical hysterectomy, but in combination with bilateral pelvic lymphadenectomy, as an effective treatment option for early stage (Ib, IIa) cervical carcinoma, as well as for other select pelvic malignancies, such as Stage II endometrial carcinoma and Stage I vaginal carcinoma confined to the upper vagina.

Radical hysterectomy is designed to be a curative surgical operation based on the Halstedian principle of radical en bloc dissection, whereby all the tissues adjacent to the cervix, including the paracervical and parametrial tissues, and upper vagina, are removed. Indeed, all tissues medial to the iliac vessels are incorporated in the dissection, and a bilateral pelvic lymphadenectomy is conducted along the iliac vessels and in the obturator space. In clinical circumstances where survival rates after treatment are equivalent, radical hysterectomy has advantages over radiotherapy, in that surgery preserves ovarian function, affords superior vaginal and sexual function, and permits a comprehensive surgical staging of the extent of disease.

Furthermore, surgery avoids the nuisances and complications of extensive radiotherapy, such as morbidity to the gastrointestinal and genitourinary tracts, as well as avoiding the potential of radiation-induced secondary malignancies. On the other hand, the radical hysterectomy procedure carries possible morbidity similar to that encountered with other major pelvic operations, but this acknowledged, if the operation is properly performed, it is safe and effective, and yields 5-year survival rates in excess of 90 per cent with Stage Ib carcinoma of the cervix.

Under general anaesthesia, with a three-way urinary catheter in place, pelvic examination is performed in search of clinical findings that would contraindicate surgery, such as obvious paravaginal or parametrial neoplasm. Assuming that no contraindication exists, the abdomen is opened through an infraumbilical midline incision (Fig. 1) 1487. Upon entering the peritoneum, normal saline is instilled into the abdomen and pelvis and is then recovered for histocytological evaluation.

A systematic exploration of the abdomen is begun, starting in the upper abdomen, where the visceral and peritoneal surfaces are inspected and palpated, in search of metastatic disease. Given the biological behaviour of cervical cancer, special attention is given to the para-aortic lymph nodes as a potential site of metastasis. Any suspicious findings should be removed for examination. If results are positive, the operation is generally contraindicated as under these circumstances surgery alone is not likely to be curative.

If no disease is detected in the upper abdomen, a self-retaining retractor is placed in the incision, and the bowel is packed away. The uterus is grasped by Kelly clamps across the insertion of the utero-ovarian ligament, fallopian tube, and round ligament. The round ligament is also clamped laterally, close to the inguinal ring, and is then divided in the centre, which in effect transects the broad ligament and enters the retroperitoneum. The anterior leaf of the broad ligament is further incised inferiorly and across the uterovesical fold, while the posterior leaf of the broad ligament is opened superiorly and lateral to the infundibulopelvic ligament; if need be, this incision can be extended still further lateral to the colon (Fig. 2) 1488. These peritoneal incisions allow the surgeon to dissect the bladder off the cervix and upper vagina and then to expose fully and to dissect the pelvic retroperitoneum inferiorly and posteriorly into the avascular paravesical and pararectal spaces. In so doing, a thorough exploration for advanced pelvic malignancy can be conducted. If any is found further surgery may be contraindicated. Although the condensation of tissue separating the paravesical and pararectal spaces and connecting the lateral cervix to the pelvic side-wall is commonly referred to as the ‘web’, in proper anatomical terms it is the cardinal ligament.

If the patient wants to retain ovarian function, the adnexa should be divided at the utero-ovarian ligament and, with the ureter directly visualized, the ovary with its vascular pedicle is mobilized by dissecting superiorly. This accomplished, the ovary can be pexed superiorly, high above the standard pelvic radiation field, a placement that often permits continued ovarian function, even if adjuvant radiation therapy to the pelvis becomes necessary. If the patient does not want to retain ovarian function, the vascular pedicle can be clamped, cut, and ligated (Fig. 3) 1489.

A pelvic lymphadenectomy, facilitated by haemostasis and marking the area of involvement with titanium surgical clips and electrocautery, is performed along the iliac vessels, starting from the mid common iliac artery and moving inferiorly. The dissection is taken into the obturator space, where the obturator nerve is identified beneath the external iliac vein. All lymph-bearing tissue between the obturator nerve and the obliterated hypogastric artery is removed (Fig. 4) 1490. As part of the lymphadenectomy, the uterine artery is identified at its origin from the internal iliac artery, where it is doubly clamped, cut, ligated or clipped, then dissected medially (Fig. 5) 1491. Using this systematic approach, a total bilateral pelvic lymphadenectomy is performed for prognostic, and possibly therapeutic advantages.

As part of the retroperitoneal dissection, the superior portion of the pelvic ureter is mobilized free of its peritoneal attachments, starting below the pelvic brim, moving inferiorly to the level where it intersects with the uterine artery, which has been transected and moved medially, and is then dissected over the ureter (‘water under the bridge’) (Fig. 6) 1492. The blood supply to the ureter is conserved.

In the Okabayashi modification of the radical hysterectomy, before the ureter is completely free of its inferior attachments, the rectovaginal septum is opened by incising the peritoneum to the cervix and dissecting the rectum from the upper two-third of the vagina. This separation allows complete exposure of the uterosacral ligaments; these are doubly clamped, cut, and suture ligated at their insertion lateral to the rectum (Fig. 7) 1493. This manoeuvre allows some mobilization of the uterus, releasing it anteriorly and permitting better visualization of the course of the ureter, as well as better surgical access to the specimen for the remainder of the case.

With the uterus mobilized and retracted anteriorly, the inferior ureter can be more readily dissected free of its attachments, beyond its intersection with the uterine artery, through its ‘tunnel’, to its final insertion into the bladder (Fig. 8) 1494. This delicate dissection is facilitated by the use of right-angle clamps and fine ligatures. At completion the ureter is completely mobilized, but not denuded, from the upper pelvis to its bladder entry, and lies in the lateral pelvis.

The ureter having been dissected free from the ultimate surgical specimen, the cardinal ligaments can now be, in a stepwise fashion, double clamped as far lateral as the vessels on the pelvic side-wall, cut, and suture ligated (Fig. 9) 1495. This transection is carried inferiomedially along the base of the cardinal ligament to the appropriate level where the vaginectomy is to occur.

At this point, the entire specimen has been surgically freed, with the exception of its attachment to the vagina. The vagina is transected at least 3 or 4 cm below the clinically evident disease so that negative surgical margins can be obtained (Fig. 10) 1496. Surgical stapling, using absorbable staples, is an expeditious alternative to traditional clamping and suturing as a technique actually to transect and to close the vagina. The vaginectomy being complete, the specimen, consisting of the uterus, cervix, upper vagina, parametrium, and paracervical tissues is passed off the field.

Because prolonged bladder dysfunction is inherent in the extensive pelvic dissection fundamental to radical hysterectomy, a suprapubic catheter is placed prior to closing the abdomen. Suprapubic catheters are generally more comfortable for patients than are transurethral catheters over the 2 to 6 weeks that bladder catheterization is needed for the return of normal voiding capability. In addition, bilateral, percutaneous, closed suction drains are placed into the lateral retroperitoneal areas inferiorly beneath the vaginal cuff to evacuate the sometimes large, but evanescent volumes of lymphatic fluids that pool after lymphadenectomy. The peritoneum is left open and a continuous mass closure is used for the abdominal incision (Fig. 11) 1497.

Although there is an incidence of morbidity with radical surgery of all types, there are specific problems associated with radical hysterectomy. Devascularization of the ureter can lead to fibrosis and fistula formation. To prevent this complication, the ureter should not be denuded of its longitudinal microvascular sheath during its dissection from the peritoneum. The pelvic veins are notorious for being clinically obscure, but when they are cut, they bleed profusely. Prolonged tamponade is often the only means of controlling the inaccessible haemorrhage that can result. The mean operative blood loss, even with properly performed radical hysterectomies, frequently exceeds 1000 ml. Injury to the obturator nerve affects the patient's ability to abduct her leg; thus, care in retraction and during lymphadenectomy is needed to reduce the chance of this neuropathy. Substantial lymphocysts can develop as a consequence of the lymphadenectomy, but are less common if percutaneous closed-suction catheters are left in situ until the drainage is minimal.

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