Radical Hysterectomy 

Updated: Sep 20, 2019
Author: Jori S Carter, MD, MS; Chief Editor: Warner K Huh, MD 

Overview

History of the Procedure

Clark performed the first radical hysterectomy for cervical cancer at Johns Hopkins Hospital in 1895. In 1898, Wertheim, a Viennese physician, developed the radical total hysterectomy with removal of the pelvic lymph nodes and the parametrium. In 1905, Wertheim reported the outcomes of his first 270 patients. The operative mortality rate was 18%, and the major morbidity rate was 31%.

In 1901, Schauta described the radical vaginal hysterectomy and reported a lower operative mortality rate than the abdominal approach. In the late 20th century, radiation therapy became the favored approach because of the high mortality and morbidity of the surgical approach.

In 1944, Meigs repopularized the surgical approach when he developed a modified Wertheim operation with removal of all pelvic nodes (the Wertheim-Clark plus Taussig operation). Meigs reported a survival rate of 75% for patients with stage I disease and demonstrated an operative mortality rate of 1% when these procedures were performed by a specially trained gynecologist. Throughout the remainder of the 20th century, various modifications have been made for this radical procedure, especially in light of improvements in the areas of anesthesia, intensive care, antibiotics, and blood product transfusion science. Finally, the concurrent decrease in the incidence of invasive cervical cancer, the most common rationale for this procedure, has declined over the past several decades and has led to more conservative procedures (ie, conization for early-stage disease) or nonsurgical modalities (ie, radiotherapy).[1]

Problem

Radical hysterectomy was initially developed as a surgical treatment for cervical cancer due to the absence of other modalities for treatment. Squamous cell carcinoma and adenocarcinoma are the most common variants that arise in the cervix. The uterine cervix comprises the distal third of the uterus. The cervix projects into the vagina and continues up to the lower uterine segment. The portion of the cervix exposed to the vagina is most commonly covered with squamous epithelium. The squamous epithelium transitions to columnar epithelium at the squamocolumnar junction, which is also known as the transformation zone. It is this vulnerable area of the cervix, where columnar cells are actively undergoing metaplastic change to squamous epithelium, in which the majority of cervical malignancies occur.

Epidemiology

Frequency

In 2009, there were 12,357 cervical cancer cases in the United States, and 3,909 women died from the disease.[2] The death rate from cervical cancer has decreased dramatically since the American Cancer Society recommended the use of the Papanicolaou test (Pap test) for cervical cancer screening in the mid 1940s. Over the next 40 years, the death rate from cervical cancer decreased by more than 70% because preinvasive lesions and cervical cancers were detected at an earlier stage.

Worldwide, cervical cancer is the third most common cancer in women. More than 85% of the global burden occurs in developing countries.[3] The lack of a screening cytology program (ie, Pap test) has resulted in this significant problem in the area of women's health. Thus, the most effective strategy of prevention of this malignancy due to the detection of a preinvasive phase is negated and most cases of cervical cancer are not diagnosed until they are advanced in stage and the patient becomes symptomatic.

Etiology

Multiple factors have been associated with the development of cervical cancer. This malignancy most commonly arises at the squamocolumnar junction, where cells are most actively undergoing metaplastic change from columnar epithelium to squamous epithelium.

Infection with human papillomavirus (HPV) is detected in more than 99% of cervical cancers. Although more than 70 different subtypes of HPV have been identified, women infected with high-risk subtypes have an increased risk of developing dysplasia and a subsequent malignancy. The most common high-risk subtypes are HPV-16 and HPV-18, which account for 70% of cervical cancers in the United States.[4] The E6 protein product of these high-risk HPVs binds to the tumor suppressor protein p53, which is thought to disrupt the p53-dependent control of the cell cycle.[5] The E7 protein causes an inactivation of the tumor suppressor retinoblastoma gene (Rb) via its interaction with the Rb protein, whose normal function is seen with the negative control of cell growth.[6]

Risk factors associated with HPV infection include multiple sexual partners, history of other sexually transmitted infections, high parity, immunosuppression, and cigarette smoking.[7]

Cigarette smoking has been associated with an increased severity of dysplasia and squamous cell carcinoma in women with underlying HPV infection.[8] Nicotine, co-nicotine, hydrocarbons, and tars, carcinogenic breakdown products of cigarette smoke, have been seen concentrated in cervical secretions.[9]

The effect of oral contraceptive use on the risk of cervical cancer is controversial because it is difficult separate sexual behavior from contraceptive use in studies. However, several studies have demonstrated that long-term oral contraceptive use resulted in an increased incidence of cervical cancer.[7, 10, 11] To adequately demonstrate an association, such studies must control for sexual behavior and for the interval of last cervical screening in all study groups. Finally, there are no proven benefits from the cessation of oral contraceptives in the clinical management of cervical dysplasia.

Immunosuppression, either induced or acquired (eg, from HIV infection), is a risk factor for the development of significant preinvasive disease for cervical cancer.[12] In the era of organ transplantation and chronic diseases that require systemic immunosuppression, there exists a cohort of patients with increased risk for the development of cervical cancer.

Sexually transmitted diseases, such as those caused by Chlamydia trachomatis, Neisseria gonorrhoeae, herpes simplex virus, and Trichomonas vaginalis, may be associated with preinvasive disease of the cervix and ultimately a risk for malignancy.[13] With the evidence of HPV as an etiologic agent, such diseases may represent more than a co-infective process, and, in fact, they may be a cofactor in the ability for the establishment of the viral infection via disruption of epithelial integrity.

Pathophysiology

Squamous cell carcinoma is the most common histologic variant of cervical cancer. HPV is now known to be definitively associated with cervical carcinogenesis and its precancerous precursors, low-grade squamous intraepithelial lesions (LSIL) and high-grade squamous intraepithelial lesions (HSIL). The molecular basis for the malignant potential of these viruses has been determined in the dysregulation of the cell cycle by the viral oncogenes E6 and E7.[14]

The progression rate of mild dysplasia to a severe dysplasia or worse is approximately 1% per year; high-grade lesions (moderate and severe dysplasia) have demonstrated a progression to a worsening lesion in approximately 16-36% of cases. Therefore, the treatment strategy for a high-grade lesion usually involves removal of the lesion, but a colposcopically confirmed low-grade lesion can be conservatively managed. The progression time to an invasive malignancy is variable and can span a period of 1 year to several decades.

Adenocarcinoma, the second most common histologic type of cervical cancer, arises from the subcolumnar reserve cells of the columnar endocervical epithelium. A strong association has been demonstrated between cervical adenocarcinoma and HPV-18. The overall incidence for this variant has increased and is associated with women younger than 35 years. Approximately 15% will exhibit no visible lesion due to its endocervical point of origin. Adenocarcinoma in situ of the cervix is strongly associated with an underlying squamous dysplastic lesion and/or cancer in more than 50% of cases, thus making this a high-risk cytologic finding.

Other histologic findings of malignancy involving the cervix include minimal-deviation adenocarcinoma, papillary villoglandular adenocarcinoma, endometrioid adenocarcinoma, serous adenocarcinoma, mesonephric adenocarcinoma, glassy cell carcinoma, adenoid basal carcinoma, basal cell carcinoma, verrucous carcinoma, clear cell adenocarcinoma, adenosquamous carcinoma, adenoid cystic carcinoma, adenoid basal epithelioma, and neuroendocrine tumors.[15] Rarely, cervical lesions result from direct invasion by advanced endometrial, vaginal, bladder, urethra, or colon cancers.

Presentation

Patients with early-stage cervical cancer are relatively asymptomatic; these cases are usually detected via cytologic screening. With the advancement of the disease, signs and symptoms of abnormal bleeding and vaginal discharge may occur. Postcoital bleeding may be the first reported sign in sexually active women; in women who are not sexually active, cervical cancer may not produce clinical manifestations, such as postmenopausal or abnormal uterine bleeding, until the malignancy is in an advanced stage.

As tumors enlarge and outgrow their blood supply, they may become necrotic and produce a malodorous discharge. Larger tumors may cause size-related symptoms such as urinary frequency or retention, rectal pressure, constipation, neurologic symptoms (ie, sciatic pain due to local extension), lower extremity pain, and swelling. Urinary or fecal incontinence due to a local tumor eroding into the bowel or bladder may be the symptom that prompts patients to seek care. Symptomatic anemia may be encountered due to persistent bleeding of the cervical lesion.

The most common sign of cervical cancer is a grossly visible lesion upon a vaginal speculum examination. An exophytic or ulcerative lesion may be obvious during the clinical examination, but an endocervical lesion may remain occult and demonstrate a normal-appearing ectocervical mucosa in the presence of a firm, enlarged cervix. With microinvasive cervical cancer, colposcopic evaluation may provide the means of detection. Colposcopic detection of atypical vessels that demonstrate irregular distribution, unusual caliber, and acute angles are associated with an early invasive tumor of the ectocervix. Presence of any ulcerative or erosive lesion warrants a histologic evaluation by biopsy despite a normal cytologic (Pap test) antecedent result.

The size of the cervix is most accurately determined via a rectal examination, which can also determine the involvement of the adjacent parametrial tissue and/or pelvic side wall. Endocervical lesions expanding or prolapsing through the cervical os can be mistaken for cervical or prolapsing leiomyomata. Biopsy of any abnormally firm or grossly abnormal lesions of the cervix should be undertaken.

The remainder of the physical examination for a patient suspected of a diagnosis of cervical cancer should include a careful evaluation of the vagina, vulva, and rectum for the presence of locally advanced disease. In addition, surveillance of the inguinal, femoral, and supraclavicular lymph nodes by careful palpation should be performed in search of overt evidence of advanced distal disease.

Indications

Radical hysterectomy is indicated for patients with International Federation of Gynecology and Obstetrics (FIGO) stage IA2-IIA cervical cancer who are medically fit enough to tolerate an aggressive surgical approach and wish to avoid the long-term adverse effects of radiation therapy. Prospective randomized trials have validated equal curative rates from radical surgery and radiotherapy (overall survival similar at 83%).[16]

Increased complication rates are noted with combined radical therapies (ie, requirement for adjuvant radiotherapy). However, adjuvant radiotherapy is recommended after radical hysterectomy if there is parametrial involvement, positive surgical margins, or pelvic lymph node metastases, and it should be considered if there is a combination of lymphovascular space invasion, tumor size greater than 2 cm, and deep invasion.[17, 18]

Currently, with stage IB disease, approximately 54% of patients with tumors 4 cm or less in size (stage IB1) and 84% with tumors greater than 4 cm (stage IB2) will require postoperative adjuvant radiotherapy. Recent encouraging data for improved outcomes with combined chemoradiation therapy and the increased morbidity noted with the combined surgical and adjuvant radiotherapy has brought into question the role of radical surgery with stage IB2 and stage IIA. However, a review of survival in 4,885 women with stage IB1-IIA cervical cancer in the Surveillance, Epidemiology, and End Results database showed that radical hysterectomy is superior to primary radiation for the treatment of cervical cancer lesions smaller than 6 cm, and especially for those smaller than 4 cm.[19]

Young patients who desire ovarian preservation and retention of a functional, nonirradiated vagina are ideal candidates for this procedure. Patients who have relative or absolute contraindications to radiation therapy, such as a pelvic kidney or a history of pelvic abscess or pelvic irradiation, should be afforded surgical treatment. In the setting of recurrence, radical hysterectomy has been performed for very small, centrally recurrent or persistent cancers after radiation therapy. Radical hysterectomy is also indicated for other disease processes that involve the cervix (eg, primary upper vaginal carcinoma, endometrial cancer with involvement of the lower uterine segment or cervix).

Relevant Anatomy

Knowledge of the relevant anatomy of the pelvis is important. Radical hysterectomy includes removal of the uterus with parametrial and paracervical tissue, proximal vagina, and proximal uterosacral ligaments. The uterine artery is transected at its origin, lateral to the ureter. In order to complete this dissection, the ureter is unroofed from the paracervical tunnel until the point of entry into the bladder. In order to resect the parametrial and paracervical tissue and unroof the ureter, the paravesical and pararectal spaces must be developed. The pertinent boundaries are the paravesical space and the pararectal space.

The paravesical space is bordered as follows:

  • Medially by the obliterated umbilical artery

  • Laterally by the obturator internus muscle

  • Posteriorly by the cardinal ligament

  • Anteriorly by the pubic symphysis

The pararectal space is bordered as follows:

  • Medially by the rectum

  • Laterally by the hypogastric artery (the internal iliac artery)

  • Posteriorly by the sacrum

  • Anteriorly by the cardinal ligament

The pelvic lymphadenectomy is performed in a systematic fashion. The anatomy of this procedure involves removal of all nodal tissue and skeletonization of all vessels from the mid portion of the common iliac vessels and the internal and external iliac vessels to the level of the circumflex iliac vein distally, from the mid portion of the psoas muscle laterally to the ureter medially, with preservation of the genitofemoral nerve on the psoas muscle. The nodal tissue in the obturator fossa is removed from above the obturator nerve to the external iliac vein superiorly and laterally to the pelvic sidewall. Care must be taken in the obturator fossa to avoid injury to the obturator nerve or to an accessory obturator vein, which is present in approximately 20% of patients.

Contraindications

Contraindications to radical hysterectomy include patients who are medically infirm and those who refuse surgical treatment. Because between one third and two thirds of surgical patients require transfusion, radiation therapy should be considered for patients whose religious or personal beliefs prohibit blood product transfusion. As with any other surgery, careful preoperative risk assessment must be performed. A relative contraindication concerns the possible requirements for adjuvant radiotherapy (ie, stage IB2/IIA or intraoperative findings of locally advanced disease with overt parametrial involvement or grossly positive pelvic or para-aortic lymph nodes).

 

Workup

Laboratory Studies

CBC results can identify patients who are anemic secondary to bleeding from the primary tumor. Preoperative management of anemia is indicated because the average blood loss from an abdominal radical hysterectomy is 500-1000 mL. Some reports indicate a negative association between anemia and outcome in patients with cervical cancer. Whether correction of anemia before and during therapy improves survival rates and the progression-free interval is unclear.

Serum chemistries are helpful in determining renal function and nutritional status before surgery. An abnormal serum creatinine level may be an indication of ureteral obstruction due to advanced disease, which is a contraindication to surgical management. Low total body protein stores, low albumin level, and uncontrolled hyperglycemia should raise concern regarding the likelihood of successful wound healing after surgery.

Preoperative arterial blood gas and pulmonary function tests may be beneficial in risk assessment and in establishing a baseline before surgery in patients with significant pulmonary risk factors. Patients deemed high risk by pulmonary criteria might be better served by radiation therapy.

Urinalysis results may indicate preoperative urinary tract infection, which must be treated to avoid possible postoperative febrile morbidity. Additionally, gross or microscopic hematuria may reflect an advanced stage of disease due to bladder or ureter involvement.

Cone biopsy of the cervix is essential for the surgical planning for microscopic disease management. It is critical to establish the depth and width of invasion to delineate microscopic stage IA1, IA2, and IB1 in order to execute the correct surgical procedure (extrafascial hysterectomy, modified radical hysterectomy, and type III radical hysterectomy, respectively).

Imaging Studies

Chest radiographs help identify effusions or intraparenchymal lesions consistent with distal metastatic disease.

Historically, intravenous pyelography (IVP) has been used to identify hydroureter and hydronephrosis, which are indicative of stage III disease. Computed tomography (CT) scanning is now widely used in the preoperative evaluation and planning due to its ability to evaluate the above abnormalities and possible determination of significant lymphadenopathy. However, according to guidelines published by the International Federation of Gynecology and Obstetrics (FIGO), only information that could have been obtained by intravenous pyelography, barium enema, and a clinical examination should be used for the clinical staging of cervical cancer.

A barium enema can be of assistance in evaluating patients for disease outside the cervix; however, similar information may be obtained from CT scanning and proctoscopy.

Bipedal lymphangiography was one of the studies originally allowed in the FIGO staging scheme to look for advanced disease in the lymphatics of the pelvis and paraaortic region. Few radiology departments still offer or are proficient at this procedure.

CT scanning has been used as an adjunct to clinical staging because of its ability to simultaneously evaluate the urinary tract for obstruction and determine if the liver, bone, and lymph nodes contain metastatic disease. CT findings may also be helpful in delineating anatomic variances that alter surgical management, such as ureteral duplication or the presence of a pelvic kidney. CT scanning, lymphangiography, and MRI are equally accurate (~84%) in detecting paraaortic metastasis.[20] CT scanning is limited because it can only detect nodes larger than 1 cm. Nodes that are not pathologically enlarged but which contain microscopic tumor cannot be detected on CT scans. Additionally, lymph nodes may be enlarged because of inflammation related to tumor necrosis and may not contain metastatic disease.

While CT scanning and MRI are equal in their ability to detect pathologically enlarged lymph nodes, MRI is better at discriminating tumor-containing tissue from non–tumor-containing tissue. This is beneficial when evaluating the patient for factors that may militate against a radical hysterectomy. The patient may be evaluated for tumor size, depth of stromal invasion, and vaginal or parametrial extension as well as nodal involvement.[21, 22] MRI is particularly useful in evaluating pregnant patients diagnosed with cervical cancer because MRI has not been found to be detrimental to the fetus. An optimal treatment plan can be developed based on these findings.

Because tumors take up glucose at a higher rate than healthy tissues, positron emission tomography (PET) scanning, which uses a radionuclide-labeled glucose analogue, has been increasingly used for the evaluation of metastatic disease.[23] Rose and colleagues found a 75% positive predictive value and a 92% negative predictive value for PET scanning of the pelvic and para-aortic nodes before lymphadenectomy.[24] Thus, PET may be better able to delineate the presence of subclinical metastatic disease than a preoperative CT or intraoperative evaluation of high-risk regions that includes lymph nodes and parametrial tissue. PET scanning, or PET integrated with CT, has also proved valuable for assessing treatment response after completion of concurrent chemoradiation, documented recurrent cervical cancer, and unexplained elevation of tumor markers post treatment.[25]

Diagnostic Procedures

Physical examination

The physical examination should evaluate the primary lesion and potential sites of metastatic disease, such as the left supraclavicular fossa, lungs, groin, and abdomen. Close inspection of the distal vagina, vulva, urethra, and rectum is warranted to rule out locally advanced disease. Unilateral leg edema may be indicative of disease extending to the sidewall, which causes lymphatic or venous obstruction.

The size of the primary lesion and the presence of vaginal or parametrial extension are particularly important for determining the clinical stage and treatment modality. The ideal setting for a thorough evaluation of these areas is an examination under anesthesia.

Cystoscopy and proctoscopy

Although the ability to detect disease outside the cervix with a stage I tumor is low with these procedures, an evaluation under anesthesia may provide the physician with a better understanding of the clinical disease status and stage. The cervix and vagina can be visualized and palpated, as can the uterosacral ligaments and parametria, via rectovaginal examination.

Cystoscopy may reveal cancer that extends through the bladder mucosa directly from the primary lesion. Bullous edema of the bladder does not elevate the stage of disease based on FIGO clinical staging criteria, but it may alert the physician to the presence of lymphatic obstruction of nearby tissue by tumor.

Proctoscopy is performed to evaluate for tumor extension into the rectal mucosa.

Colposcopy

Colposcopy is indicated for patients with abnormal Pap smear results in order to search for the etiology of the abnormal result when no gross lesion has been visualized.

Ectocervical carcinomas are traditionally associated with abnormal vessels that vary in their caliber and have acute angles in their distribution. Endocervical lesions may occur in the presence of a normal-appearing ectocervix, and, therefore, the colposcopic appearance may be normal.

If an abnormal Pap smear result cannot be explained by a colposcopically detected lesion, then evaluation of the endocervical canal by endocervical curettage should be considered.

Cone biopsy

Cervical cone biopsy may be indicated if microinvasion is thought possible and the diagnostic biopsy is not deep enough to determine the depth of the lesion.

Cone biopsy is also indicated for the following situations:

  • Evaluation of a discrepancy between Pap smear results and colposcopically directed biopsies

  • Inability to visualize the entire lesion during colposcopy

  • Inability to visualize the entire transformation zone at colposcopy

  • Detection of dysplastic cells from endocervical curettage

Histologic Findings

The most common histologic type of cervical cancer is squamous cell carcinoma, which comprises approximately 85% of all cervical carcinomas. The remainder are usually adenocarcinomas (endocervical or mucinous). More rare epithelial subtypes include adenosquamous, glassy cell, adenoid cystic, adenoid basal, small cell, carcinoid, and undifferentiated.

Staging

FIGO criteria for staging of cervical cancer are based on clinical findings. The FIGO classification of cervical cancer is below.[26]

Stage I: Cervical carcinoma is confined to the cervix.

Stage IA: Invasive carcinoma is diagnosed only by microscopy, with deepest stromal invasion of less than or equal to 5 mm and largest horizontal of spread less than or equal to 7 mm; substages are as follows:

  • Stage IA1: Stromal invasion less than or equal to 3 mm in depth and horizontal spread less than or equal to 7 mm

  • Stage IA2: Stromal invasion greater than 3 mm but less than or equal to 5 mm in depth and horizontal spread less than or equal to 7 mm

Stage IB: Clinically visible lesion is confined to the cervix or a microscopic lesion is greater than substage IA2; substages are as follows:

  • Stage IB1: Clinically visible lesion less than or equal to4 cm in greatest dimension

  • Stage IB2: Clinically visible lesion greater than 4 cm in greatest dimension

Stage II: Cervical carcinoma invades beyond the uterus but not to the pelvic sidewall or to the lower third of the vagina.

Stage IIA: There is no parametrial involvement; substages are as follows:

  • Stage IIA1: Clinically visible lesion less than or equal to 4 cm in greatest dimension

  • Stage IIA2: Clinically visible lesion greater than 4 cm in greatest dimension

Stage IIB: There is parametrial involvement.

Stage III: Cervical carcinoma extends out to the pelvic sidewall, and/or involves the distal third of the vagina, or causes hydronephrosis or a nonfunctioning kidney.

Stage IIIA: Cervical carcinoma involves the lower third of the vagina without extension to the pelvic wall.

Stage IIIB: Cervical carcinoma extends out to the pelvic sidewall or causes hydronephrosis or a nonfunctioning kidney.

Stage IV: Tumor extends beyond the true pelvis or involves the mucosa of the bladder or rectum.

Stage IVA: Direct extension is to adjacent organs.

Stage IVB: Distant metastasis is present (including peritoneal spread; involvement of supraclavicular, mediastinal, or para-aortic lymph nodes; lung; liver; or bone).

 

Treatment

Medical Therapy

For patients with stage IB lesions, equal cure rates may be obtained with surgery or radiation therapy. Radiation therapy consisting of pelvic teletherapy in combination with brachytherapy has traditionally been reserved for patients who are medically infirm and those with contraindications to surgery.[27, 28]

Adverse effects of radiation therapy can continue to manifest years after treatment has been completed. Adverse effects include vaginal atrophy, fibrosis, stenosis, and agglutination, which can severely affect sexual function; bladder dysfunction secondary to long-term effects, such as decreased pliability of the bladder; and acute bowel effects such as diarrhea. Over the long term, small bowel obstruction, small bowel fistula formation, rectal stricture, and rectovaginal fistula are risks.

Approximately 54% of stage IB1 and 84% of stage IB2 will require postoperative adjuvant radiotherapy. The combination of two sequential radical therapies is notable for an increased complication rate. Additionally, the promising outcomes with an initial treatment of chemoradiation have brought into question radical surgery for stage IB2 and stage IIA. On the other hand, in patients with stage IIIB disease, chemoradiation followed by radical hysterectomy has been found to have an acceptable rate of complications and a survival outcome similar to that of chemoradiotherapy.[29]

Cisplatin-based neoadjuvant chemotherapy followed by radical hysterectomy for patients with FIGO stage IIB cervical cancer appears to have comparable survival outcomes relative to concurrent chemotherapy alone, according to a retrospective study (2003-2012) of 621 Chinese patients.[30] Of 285 women who received neoadjuvant chemotherapy/radical hysterectomy, 221 (77.6%) achieved a complete or partial response, with significantly higher disease-free and overall survival rates compared to those who did not have a treatment response and also with comparable overall survival rates to those who received concurrent chemoradiotherapy. In addition, there was a significant reduction in recurrence rates and fewer radiotherapy complication rates in the neoadjuvant chemotherapy/radical hysterectomy group.[30]

In a separate retrospective study of 33 Japanese patients with bulky stage IB2-IIB squamous cell carcinoma of the uterine cervix who underwent neoadjuvant chemotherapy followed by radical hysterectomy, investigators identified the presence or absence of lymph node metastasis before administration of neoadjuvant chemotherapy as a significant prognostic factor for overall survival.[31]

Surgical Therapy

Surgical therapy is tailored to the patient and the extent of disease (see Staging). For patients with stage IA1 lesions, an extrafascial hysterectomy or cold-knife cone with adequate negative margins may be performed if future fertility is an issue. In these patients, the risk of having tumor in the pelvic lymph nodes is 0.5-1.5%.

For patients with stage IA2-IIA lesions, a modified radical or Wertheim radical hysterectomy with pelvic lymphadenectomy is usually chosen because of the increased risk of extension beyond the primary lesion, which is approximately 7.3%. The modified radical hysterectomy differs from the classic type III hysterectomy, or Meigs radical hysterectomy, in that the surgeon removes approximately half of the uterosacral ligament, cardinal ligament, and uterine artery at the time of surgical resection. During the type III procedure, the uterosacral ligaments are taken at their attachment to the sacrum; the cardinal ligaments, at the pelvic sidewalls; and the uterine artery, at its origin from the internal iliac artery.

In young patients who wish to retain future fertility are candidates for radical trachelectomy (removal of the cervix and parametrial tissue) if they have stage IA2-IB1 cervical cancer with small tumors that do not extend beyond the internal cervical os.[32, 33] This surgery may be approached vaginally, abdominally, or laparoscopically (either traditional or robotic-assisted).

Preoperative Details

The preoperative workup includes evaluation for underlying pulmonary or cardiac disease that would be a relative contraindication to prolonged surgery. Consider having blood available during the operation in the event of exceptional blood loss, which may occur with radical surgery and pelvic lymphadenectomy. The radical hysterectomy is begun after the surgeon is certain that the patient is appropriately positioned on the operating table and that sequential compression devices are functioning properly. The procedure can take several hours to complete; therefore, these precautions must be taken to avoid injury to the patient.

Intraoperative Details

Strict attention to patient positioning helps decrease nerve injury during any prolonged surgery. At various points during the surgery, the surgeon must determine if the operation should continue.

Radical hysterectomy can be performed through an abdominal, vaginal, or minimally invasive (traditional of robotic-assisted laparoscopy) approach.

For the abdominal approach, several types of incisions have been described. A vertical infraumbilical incision allows adequate exploration of the pelvic area and permits superior extension in the event extensive paraaortic dissection is necessary. In addition, less blood loss occurs through vertical midline incisions, which may be a consideration if the patient has personal or religious objections to transfusion. Most surgeons advocate a low transverse incision (eg, Maylard incision, Cherney incision), which allows adequate exposure, although these methods require separation of the rectus muscles either from the symphysis or by muscle-splitting techniques.

Before opening the peritoneum, some surgeons perform an extraperitoneal approach to the pelvic lymphadenectomy. In the event the hysterectomy is abandoned secondary to positive pelvic and/or paraaortic nodes, the peritoneum is undisturbed, thereby decreasing bowel morbidity during subsequent radiation therapy. After the bilateral pelvic lymphadenectomy is performed and all nodes are deemed negative for malignancy after frozen section analysis, the peritoneal cavity is opened.

The entire abdomen and pelvis are explored in a systematic fashion to evaluate for any palpable evidence of disease spread beyond the cervix. Locally, the peritoneal surfaces anterior and posterior to the cervix are carefully inspected and palpated. The uterus, fallopian tubes, ovaries, and upper abdomen are carefully inspected for evidence of gross disease.

The paravesical and pararectal spaces are opened, which allows better palpation of the parametrium for evidence of disease. Next, the bladder flap is taken down. Take caution in this endeavor because an adherent bladder flap may be an indication of tumor invading through the cervix and into the bladder. If this is discovered, consider termination of the procedure in order to give the patient the best chance at a cure via radiotherapy.

Next, the uterine artery is isolated from its origin at the internal iliac artery. This can be identified by finding the superior vesicle artery and tracing it to the hypogastric artery. The uterine artery is ligated. The uterine vein can also be identified and ligated to avoid bleeding during the remainder of the parametrial dissection. The parametrial margins are illustrated in the image below.

Radical hysterectomy specimen demonstrating the pa Radical hysterectomy specimen demonstrating the parametrial margins.

The ureter is dissected from the parametrium. Begin by dissecting the ureters free from the medial leaf of the broad ligament; use of vessel loops around the ureters may be helpful for continuous identification for the remainder of the procedure. Additionally, this allows tension to be applied during the more difficult unroofing of the parametrial web of the ureter. As the ureter is dissected from the parametrial web, elevation of the uterine artery may be helpful. Also, the use of Clark clamps to clamp tissue superolateral to the ureter may facilitate division and ligation of such tissue. After dissecting the ureters from the tunnel of the cardinal ligament and moving the bladder a couple of centimeters below the cervix, the posterior dissection is performed.

Just inferior to the cervix, the posterior peritoneum is grasped with Allis clamps in order to open the Douglas pouch. The rectovaginal space can usually be dissected with blunt dissection directly in the same plane as the vagina (ie, toward the patient's feet). The peritoneum is freed bilaterally from the uterosacral ligaments. The uterosacral ligaments can then be divided to define the posterior-most boundary of the dissection. The use of Endo-GIA staplers has simplified this step of the procedure and may facilitate decreased blood loss.[34]

The cardinal ligaments are then clamped, divided, and ligated at the pelvic sidewall. This step can also be simplified with the Endo-GIA stapler. If the ovaries are to be removed, the infundibulopelvic ligament is clamped, ligated, and divided. In most premenopausal patients, the ovaries do not need to be removed because the risk of disease metastasis to the ovary with squamous carcinomas and adenocarcinomas is approximately 0.5% and 1.5%, respectively.

The parametria is then taken from its inferior attachments with multiple lateral-to-medial clamps until the vagina is reached. The vagina may be clamped with 90° angulated clamps or divided via sharp dissection after application of the Vicryl TA-55 stapler. These steps avoid a "rabbit ear" configuration of the vagina, which can be difficult to monitor clinically for evidence of recurrence. A 2-cm margin of vaginal cuff around the cervix is recommended, although this tissue retracts somewhat after being transected from its natural attachment to the vagina. The vaginal margins are illustrated in the image below.

Radical hysterectomy specimen demonstrating the va Radical hysterectomy specimen demonstrating the vaginal margin.

Careful attention to hemostasis upon completion of the operation is essential to prevent postoperative hematoma and its associated complications. Most authors no longer close the retroperitoneal spaces, nor do they place drains in the pelvis. A suprapubic catheter or silastic transurethral catheter is placed, usually followed by continuous mass closure.

Postoperative Details

Careful detail to postoperative care is essential in order to decrease postoperative morbidity. Early ambulation, aggressive pulmonary toilet, and deep venous thrombosis prophylaxis are critical postoperative considerations. Depending on the radical nature of the procedure, the patient should retain a Foley or suprapubic catheter for several days or weeks after the procedure. Regardless, voiding trials are performed to ensure that the patient can completely empty her bladder. This helps prevent bladder distension and damage.

Follow-up

After the initial treatment, the patient is closely monitored with a thorough history, physical examinations, pelvic examinations, and Pap smears every 3 months for the first 2 years. The interval between examinations increases to every 6 months for up to 5 years. Approximately 90% of patients who are destined to have recurrences do so within the first 2 years after completion of initial therapy. History and physical examination findings direct the need for further tests. For example, a patient who reports new-onset cough or hemoptysis should have a chest radiograph taken to seek evidence of recurrence in the chest.

For patient education resources, see the Cancer and Tumors Center, as well as Cervical Cancer.

Complications

Intraoperative complications include damage to surrounding structures during the intended procedure. Injury may occur to the bladder, bowel, ureters, pelvic vessels, and nerves. Large-volume blood loss and subsequent need for transfusion may occur. As with any abdominopelvic operation for cancer, these patients are at an extremely high risk for deep venous thrombosis and subsequent embolism. Because the upper 2 cm of the vagina are removed, some patients may note vaginal shortening, particularly if even more of the vagina was removed because of stage IIA disease or in the event that postoperative adjuvant radiation therapy was administered.

Postoperative complications include wound complications such as skin separation, abscess, and dehiscence (eg, seroma, hematoma). Poor healing due to comorbid illnesses, such as obesity, steroid dependence, chronic obstructive pulmonary disease, and poor preoperative nutritional status, can significantly contribute to an increased risk of wound complications.

Postoperative issues involving the ureter, which may be significantly devitalized during the dissection, include ureteral stricture and fistula. Bladder complications, such as overflow incontinence, urinary retention, loss of bladder sensation, and detrusor instability, occur because of bilateral disruption of parasympathetic and sympathetic nerve fibers of the bladder and ureter. By the third postoperative week, most patients can adequately empty the bladder. Surgical technique that spares the pelvic autonomic nerves may significantly reduce bladder function complications, as well as anorectal complications, although the use of this technique prolongs operating times.[35, 36]

Vesicovaginal fistulae may occur in the postoperative period. If radiation therapy is not indicated, repair should be delayed to allow continuous bladder drainage for several weeks, which increases potential healing and decreases inflammation secondary to the initial procedure.

Rectal dysfunction manifested by abnormal internal sphincter relaxation, decreased rectal sensation, and increased abdominal pressure required to produce a bowel movement are rarely reported, although these conditions may be the result of disruption of autonomic sensory nerves as previously described. Small bowel obstruction resulting from postoperative adhesion formation may occur as with any exploratory laparotomy. The risk of bowel complications is markedly increased with the addition of postoperative radiation therapy in addition to radical hysterectomy.

Outcome and Prognosis

Outcomes for patients with cervical cancer are largely dependent on the stage of tumor and several identified risk factors.[37, 38] Patients with bulky tumors (>4 cm) are at a higher risk for both nodal metastasis and pelvic recurrence. Patients with deep stromal invasion, positive vaginal margins, or positive parametrial margins are at increased risk for recurrence. Patients with positive pelvic nodes and one of the previously mentioned risk factors are usually treated with adjuvant radiation therapy to the pelvis.

The 5-year survival rate for patients with surgically treated stage I disease without positive pelvic nodes is approximately 90%; patients with positive pelvic nodes have a 5-year survival rate of 50-60%. Patients with paraaortic nodes that contain tumor have a markedly decreased 5-year survival rate of 20-45%.

Treatment outcomes for early-stage cervical cancer using surgery or radiation therapy as the primary modality are equivalent. Whether outcomes will continue to be equivalent with the addition of chemosensitizing platinum along with radiation is unknown.

Future and Controversies

A growing literature supports the use of robotic-assisted radical hysterectomy in early-stage cervical cancer; one review found that robotic-assisted radical hysterectomy is associated with minimal blood loss, a shortened hospital stay, and few operative complications.[39]

Other treatments for cervical cancer include the use of a laparoscopic and/or vaginal approach to complete all or part of the radical hysterectomy. Published reports include surgical feasibility of the traditional radical vaginal hysterectomy (the Schauta procedure), modified laparoscopically assisted radical vaginal hysterectomy, and complete laparoscopic radical hysterectomy. Some groups in Canada and France have advocated the use of radical trachelectomy with complete laparoscopic pelvic lymphadenectomy for treatment of reproductive-aged women with early invasive lesions.[40] Because these procedures have been performed on very few patients, there is a need for more convincing outcome data regarding the safety and equivalency of these procedures, compared with the more traditional approaches. A study by Cui et al that included 15,150 women with cervical cancer of which 14,714 underwent hysterectomy and 436 underwent trachelectomy reported similar rates of survival for trachelectomy and hysterectomy. The study also reported an increase in trachelectomy rates particularly in women younger than 30 years of age with early-stage cervical cancer.[41]

While the treatment outcomes of radical hysterectomy and radiation therapy have been noted to be equivalent, studies have shown a decrease in the death rate from the addition of chemosensitizing cisplatin to radiation therapy in patients with stage IB2 lesions and greater.[42, 43] No outcome studies have been performed to investigate chemosensitizing radiotherapy versus radical hysterectomy. Radiotherapy may again take the dominant role in the treatment of all cervical cancers if chemosensitizing cisplatin offers a survival advantage.