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Abdominal Radical Hysterectomy
According to National Comprehensive Cancer Network (NCCN) guidelines, radical hysterectomy is the preferred treatment for patients with histologically confirmed stage IB1 to IIA1 cervical cancer who are not interested in future fertility. Radical hysterectomy requires comprehensive knowledge of pelvic anatomy and the relationship among vital structures such as the rectum, ureters, bladder, and pelvic vasculature and the vast pelvic neural network. The aim of this chapter is to present an overview of various topics of interest on radical hysterectomy, including indications for the procedure, preoperative workup, surgical approaches, a detailed description of surgical technique, and management of complications.
History of Radical Hysterectomy
The first radical hysterectomy was performed by John Clark and Emil Ries at Johns Hopkins Hospital. Subsequently, Ernest Wertheim performed his first radical hysterectomy in 1898, and later, in 1911, he published the largest series at the time, on the abdominal approach, with more than 500 patients included in that report. The reported mortality rate and 5-year cure rate were 18.6% and 42.4%, respectively. In 1908 Schauta published the results of 564 vaginal radical hysterectomies, with a mortality rate of 10.8% and a 5-year cure rate of 39.7%.
In 1921 Hidekazu Okabayashi described a more radical procedure, dissecting the ureters completely from their peritoneal attachment, allowing a broader lateral parametrial resection. Subsequently, in 1944 Alexander Meigs published his experience with radical hysterectomy and proposed that, given the high failure rates associated with radiotherapy at the time, radical hysterectomy should be the primary approach to patients with cervical cancer. In 1961 Kobayashi introduced the concept of nerve-sparing radical hysterectomy with a technique that involved a very detailed dissection of the hypogastric nerve in the medial leaf of the broad ligament, with a focus on sparing this structure and ensuring its bilateral preservation. This procedure had as its primary goal the prevention of postoperative bladder complications. Over the past 20 years, a laparoscopy or robotic approach has become increasingly more popular in the management of early-stage cervical cancer. Descriptions of the first laparoscopic and robotic radical hysterectomy (RRH) procedures were published in 1992 and 2006, by Nezhat and colleagues and Sert and Abeler, respectively. These minimally invasive approaches have shown benefit to the patient in terms of lower postoperative complication rates and faster return to daily activities. To date, there has been no prospective randomized trial that has evaluated whether minimally invasive surgery offers an advantage over laparotomy in the management of cervical cancer. An ongoing prospective randomized trial (LACC [Laparoscopic Approach to Cervical Cancer] trial) will, it is hoped, shed light on this question.
Classification of Radical Hysterectomy
The most recent classification of radical hysterectomy was published by Querleu and Morrow. In applying such a classification, several elements should be noted. These include the extent of parametrial resection and the three parts of the parametria—anterior or ventral, posterior or dorsal, and lateral—with clear limits and landmarks for identification (see the discussion of surgical technique later in this chapter). The radicality may be different on each side of the pelvis, according to tumor growth or clinical presentation. One of the most important features offered by this classification system is that there are anatomic landmarks that must be recognized, in a reproducible way, thus allowing surgeons a uniformity in the approach to the procedure.
Type A Radical Hysterectomy
Type A radical hysterectomy corresponds to the extrafascial hysterectomy, which allows full removal of the pericervical tissue up to the attachment of the vaginal fornices.
The ureter does not need to be unroofed. In this type of radical hysterectomy, the surgeon is not required to resect the ventral or lateral parametria, nor the dorsal parametria. The hypogastric plexus, therefore, remains fully preserved.
Type B Radical Hysterectomy
Type B radical hysterectomy corresponds to the modified radical hysterectomy. Identification of autonomic nerves is not required, and the hypogastric plexus is fully preserved. With regard to the ventral parametria, the ureter is unroofed only in its course through the parametria, allowing for the resection of only a small initial part of the medial leaf of the ventral parametria. In the lateral parametria, as the ureter is unroofed, dissected from the cervix, and displaced laterally (but not dissected from the lateral or ventral parametria), the resection margin is at a medial aspect of the ureteral bed, thus allowing for the horizontal resection of about 1 to 1.5 cm of the lateral parametria. The ureteral artery, branching from the uterine artery at its crossing of the ureter, can serve as a helpful landmark and is usually easily identified and can be spared. The longitudinal (deep parametrial or vertical) resection limit is formed by a tangential plane of the vaginal cuff resection. In the dorsal parametria, the type B radical hysterectomy aims for horizontal resection of 1 to 2 cm dorsally from the cervix. The resection line corresponds to the amount of lateral parametria removed. Longitudinally, the margin of resection is at the level of the vaginal cuff; however, it is important not to dissect below the course of the ureter because this is where one will find the branches of the hypogastric plexus.
Type C Radical Hysterectomy
The Morrow and Querleu classification distinguishes between a type C1 procedure, which corresponds to the nerve-sparing modification, and the type C2 procedure, which aims for a complete parametrial resection. There are significantly distinct resection margins between the two types, particularly in the longitudinal (deep parametrial or vertical) dimension, which are determined by the course of the main branches of the inferior hypogastric plexus in the type C1 procedure.
Type C1 requires separation of two parts of the dorsal parametria: the medial part, which entails rectouterine and rectovaginal ligaments, and the lateral laminar structure, also called mesoureter, which contains the hypogastric plexus. Furthermore, type C1 requires only a partial dissection of the ureter from the ventral parametria, which is usually asymmetric toward more extensive resection of the medial leaf of the cranial (above the ureter) part of the ventral parametria. In the type C2 procedure, the ureter is completely dissected from the ventral parametria up to the urinary bladder wall. Defining the resection limits on the longitudinal (deep parametrial or vertical) plane is crucial for distinguishing between types C1 and C2.
With regard to ureteral dissection, in the type C1 procedure the ureter is unroofed and dissected from the cervix and from the lateral parametria but only partially from the ventral parametria (1–2 cm). The type C2 procedure requires complete dissection of the ureter from the ventral parametria up to the bladder wall.
Lateral Parametria—Transverse (Horizontal) Resection Margins
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C1 and C2: The lateral border is identical for both types, formed by the medial aspect of the internal iliac vein and artery.
Longitudinal (Deep Parametrial or Vertical) Resection Margins
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C1—vaginal vein (deep uterine vein): The deep parametrial resection margin is formed by the vaginal vein; thus the caudal part of the lateral parametria containing the splanchnic nerves is preserved.
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C2—pelvic floor (sacral bone): The resection line continues alongside the medial aspect of the internal iliac vessels and pudendal vessels caudally up to the pelvic floor. The pararectal and paravesical spaces are completely unified; the splanchnic nerves in the caudal part are sacrificed. Such deep resection allows for greater mobility of the lateral parametria, facilitating its complete removal.
Ventral Parametria—Transverse Resection Margins
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C1: Partial dissection of the ureter from the ventral parametria allows for resection of 1 to 2 cm of the ventral parametria.
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C2—urinary bladder wall: Complete dissection of the ureter from the ventral parametria is required, which allows for complete removal of the ventral parametria up to the urinary bladder wall; both medial and lateral leaves of the ventral parametria are resected equally.
Longitudinal Resection Margins
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C1: The resection line is formed by bladder branches of the hypogastric plexus located below the course of the ureter.
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C2: The resection line is formed by the level of the paracolpium and vaginal resection. Both cranial and caudal (below the ureter) parts of the ventral parametria are removed. Bladder branches of the hypogastric plexus are sacrificed; thus their identification is not required.
Dorsal Parametria—Transverse Resection Margins
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C1 and C2: The dorsal border is identical for both types, formed by the rectouterine ligament attachment to the rectum.
Longitudinal Resection Margins
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C1: Sagittal dissection of the hypogastric nerves from the rectouterine and rectovaginal ligaments is performed. The main branches of the hypogastric plexus must be preserved on the lateral part (mesoureter); the caudal limit of the rectouterine and rectovaginal ligaments is formed by the tangential plane of the vaginal cuff resection.
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C2: Complete resection of the dorsal parametria is performed deeply below the rectal attachment; thus branches of the hypogastric plexus are sacrificed.
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