Infeksi Plasenta (Plasentitis, Korioamnionitis)

Infeksi virus atau bakteri pada plasenta, terutama amnion dan korion dekat insersi tali pusat, sering ditemukan setclah ketuban pecah yang sudah lama berlangsung. Tanda-tanda yang mengisyaratkannya adalah menggigil, demam, nyeri tekan atau hipertonus uterus pada ibu, serta cairan amnion yang berbau busuk.
Leukositosis, dengan hitung jcnis shift to the left, peningkatan laju endap darah, kolonisasi bakteri patogen yang banyak pada kultur serviks dan uterus menunjukkan terjadinya sepsis intrauterin. Gambaran khasnya adalah selaput ketuban yang terlihat seperti susu dan berkabut (akibat adanya lekosit polimorfonuklear dan eksudat) disertai infiltrasi leukosit perivaskular pada tali pusat clan pembuluh darah janin (omfalitis). Peradangan vilus fokal merupakan manifestasi lanjut.

Terapi dengan evakuasi uterus yang cepat, obat-obatan oksitosik, dan terapi antibiotik parenteral masif yang dapat melawan bakteri aerob dan anaerob. Terapi simtomatis mungkin adalah satu-satunya pilihan pada infeksi virus.

Parametritis, salpingitis, peritonitis pelvis, tromboflebitis pelvis, atau kematian ibu dapat terjadi, demikian juga omfalitis, septikemia, pneumonia septik, atau kematian bayi pada masa perinatal.

Referensi
BS Obstetri dan Ginekologi Oleh Ralph C. Benson & Martin L. Pernoll

Burst Abdomen

Definition
- Partial or complete post operative separation of an abdominal wound closure with protrusion or evisceration of the abdominal contents
- Incisional hernia, partial wound dehiscence while the skin was well healed

Incidence
- Incidence varies 0,2 % - 6%
- Mortality rate 10% - 30%
- Does not demonstrate a downward trend compare with earlier reviews

Clinical manifestation
- Occur 7-14 days post-op, without warning
- 85% salmon pink discharge
- Ripping sensation
Predisposing factors
Pre-operative factors
- Malnutrition/hypo-albumin
- Chonic disease.
- Diabetes
- Anemia

Predisposing factors
(intra operative)

- Type of incision
Midline higher than transverse incision

- Closure
Mass clossure equivalent/better than layered
Mass closure is safety, efficacy and speed

Predisposing factors
(intra operative)
Interrupted versus Continues Sutures

- Dehiscence rate 1.6% in the continues and 2% in the interrupted group
- Figure of eight, far-and-near/”Smead Jones” technique does not improve outcomes
- Continues suture is reasonable because of its safety, efficacy and speed
Predisposing factors
(intra operative)
- 15 RCT, 6566 patients

- No difference in wound dehiscence between slowly absorbing(polydiaxanone/PDS) and non absorbing (polypropelene/Prolene)
- Prolonged wound pain (p<0.005) in non absorbable group
Suturing technique
- Suture Length (SL) : Wound Length(WL) = 4 : 1, if less than 4 : 1 risk of wound dehiscence
Predisposing factors
(post operative)
- Elevation of Intra-Abdominal Pressure (coughing, vomiting, ileus
- Wound Infection
- Radiotherapy (past and perioperatively)
- Antineoplastic Agents
Management depends on the patient’s condition
- Unstable, no eviceration conservative
- Covering with a sterile occlusive dressing
- Delayed operative closure may be performed
Management
- Most patients immediate re-operation
- Broad spectrum antibiotics
- Non-absorbable mono filament (Nylon)
- Mass closure technique
- Do not tight too tightly
Retention suture
- Nylon No 1
- Wide interrupted bites at least 3 cm from the wound edge
- A buttress device is use to prevent suture erosion into the skin (plastic/rubber 5-6 cm)
- Do not tight too tightly
- External retention suture usually left for at least 3 weeks
The Unclose able Abdomen
The unclose able Abdomen

Incisional hernia
Mesh Placement Techniques
- Onlay-Technique
- Inlay-Technique
- Sublay-Technique
- Intraperitoneal (IPOM)
Lichtenstein "Tension-Free” Repair With Mesh

Glomerulonefritis Akut

Glomerulonefritis Akut adalah kelainan ginjal berupa proliferasi & inflamasi glomeruliok sekunder mekanisme imunologis thd antigen tertentu seperti bakteri , virus, parasit tertentu dan zat lain.

Tersering disebabkan oleh infeksi streptokokus B hemolitikus grup A GNAPS.

Bbrp bukti GNAPS penyakit imunologis:
- periode laten antara infeksi streptokokus dan gejala klinik
- Kadar Ig G menurun dlm drh
- Komplemen C3 menurun dlm drh
- Endapan Ig G dan C3 di glomerulus
- Titer Anti Streptolysin O (ASTO)
meninggi dlm drh

Gejala klinik
1. Edema
- Gjl yg paling sering: palpebra & tungkai
2. Hematuria
baik makroskopis & mikroskopis.
urin spt air cucian daging / coca cola
3. Hipertensi.
Hipertensi berat: muntah2, skt kepala,
kejang & kesadaran menurun
hipertensi enselofati


4. Oligouria
timbul bila fx ginjal menurun.
5. gejala sistem kardiovaskuler
kongesti sirkulasi: udem pulmonum
6. gejala lain: pucat, malaise, anoreksia
Kelainan laboratorium
Urin: - proteinuria, torak eritrosit
Darah : ASTO↑, komplemen C3 ↓
Radiologis : udem paru & gambaran kardiomegali →nefritik lung
Pengobatan
1. Istirahat
2. diet : rendah garam, jika edema beratdanhipertensi : bebas garam
3. antibiotika
4. simtomatis:
- bendungan sirkulasi : batasi cairan
- Hipertensi : obat hipertensi
SINDROM NEFROTIK
Kumpulan gejala berupa:
1. Edema masif
2. Proteinuria > 50 mg/kgbb/ 24 jam
3. Hipoalbuminemia < 2,5 gm/dl
4. Hiperkolesterolemia

pada anak SN tidak jelas penyebabnya →
sindrom nefrotik idiopatik (SNI)
Insidens: laki : perempuan = 2 : 1

Komplikasi:
- infeksi sekunder
- Syok: hipoalbuminemia berat < 1 gm/dl
- Gagal ginjal
- malnutrisi
Pengobatan
Pengobatan umum
- diet : tinggi protein 3-5 gr/kgbb/ hr
gagal ginjal : protein 1-gr/kgbb/hr
cairan dibatasi
edema berat : garam dibatasi
- istirahat : bila edema berat
- Antibiotika bila ada infeksi sekunder

2. Pengobatan dgn kortikosteroid.
diberikan pd SN ygf sensitif thdpkortikosteroid yaitu SN dgn kelainan minimal.

Penting : SN sering relaps → edukasi ortu
ISK
Banyak pd bayi & anak, sering tanpa gejala (asimtomatik)

Berdasar anatomi :
- ISK atas : ginjal – ureter
- ISK bawah : VU - OUE

Insidens
Bayi : laki > perempuan
Anak besar : perempuan > laki

Etiologi
- infeksi bakteri .
- predisposisi: - Obstruksi sal kemih : batu
- Vesikoureteral refluks
- Defisiensi imunoglobulin
- Kateterisasi



Kuman masuk ke sal. Kemih :
1. pembuluh darah (hematogen)
2. perkontinuitatum ( dr jaringan daerah genitalia
eksterna & perineum → ascederen)
3. Limfogen : aliran limfa

Gejala klinis
1. asimtomatis : Anoreksia, brt bdn kurang
2. Simtomatis : demam, sering kencing, skt
kencing, nyeri suprapubis,skt pinggang, muntah , diare

Laboratorium:
pemeriksaan urine rutin & biakan urine
Pengobatan:
-Pengobatan umum : panas, muntah, diare
-Pengobatan spesifik: antibakteri. Sebaiknya sesuai hsl kulture urine
Pencegahan :
- Kebersihan
- kebiasaan tahan kencing

Penting : ISK sering relaps
Hematuria

Terdapatnya eritrosit dalam urin baik secara makrospik maupun mikrospik
Hematuria hanya merupakan suatu gejaladan bukan penyakit yang dapat disertai gejala gejala lain atau yang disertai rasa sakit (disuria) disebut hematuria simtomik, dan yang tidak disertai gejala lain atau terjadi tanpa rasa sakit disebut hematuria asimtomatik


Etiologi
A. Sistem Saluran Kemih.
1. Ginjal
a. Perdarahan glomerulus :
- Glomerulonefritis akut
- Glomerulonefritis membranoproliferatif
- Nefritis herediter (Sindrom Alport)
- Nefropati IgA (Maladie Berger)
- Hematuria familial
- Hematuria benigna rekuren atau persisten

b. Perdarahan ekstra glomerulus :
- Pielonefritis akut atau kronik
- TBC Ginjal
- Tumor Ginjal
- Hemangioma ginjal
- Ginjal polikistik
- Hidronefrosis
- Nekrosis Papil Ginjal
- Kelainan vaskuler (trombosis vena renalis
- Trauma Ginjal
- Hiperkalsiuri idopatik

2. Luar Ginjal :
- sistitis, ureteritis, uretritis
- batu saluran kemih
- trauma saluran kemih
- kelainan kongenital saluran kemih
- fimosis
- stenosis meatus
- intoksikasi jengkol

B. Penyakit Sistemik
- Sindrom Schonlein Henoch
- Lupus eritematosus sistemik
- Poliarteritis nodosa
- Endokarditis bakterial subakut
C. Penyakit Darah
- Leukemia
- Sindrom hemolitik uremik
- Trombositopenia purpura idiopatik
- Hemofilia
- Penyakit sel sabit

D. Olahraga
Penatalaksanaan : Sesuai etiologi

Perdarahan post partum

Perdarahan post partum adalah perdarahan lebih 500-600 ml selama 24 jam setelah anak lahir. Termasuk perdarahan karena retensio plasenta. Perdarahan post partum adalah perdarahan dalam kala IV lebih 500-600 cc dalam 24 jam setelah anak dan plasenta lahir.

Pembagian perdarahan post partum :
1. Perdarahan post partum primer (early postpartum hemorrhage) yang terjadi
selama 24 jam setelah anak lahir.
2. Perdarahan post partum sekunder (late postpartum hemorrhage) yang terjadi
setelah 24 jam anak lahir. Biasanya hari ke 5-15 post partum.

Tiga hal yang harus diperhatikan dalam menolong persalinan dengan komplikasi perdarahan post partum :
1. Menghentikan perdarahan.
2. Mencegah timbulnya syok.
3. Mengganti darah yang hilang.

Frekuensi perdarahan post partum 4/5-15 % dari seluruh persalinan. Berdasarkan penyebabnya :
1. Atoni uteri (50-60%).
2. Retensio plasenta (16-17%).
3. Sisa plasenta (23-24%).
4. Laserasi jalan lahir (4-5%).
5. Kelainan darah (0,5-0,8%).

Etiologi perdarahan post partum :
1. Atoni uteri.
2. Sisa plasenta dan selaput ketuban.
3. Jalan lahir : robekan perineum, vagina, serviks, forniks dan rahim.
4. Penyakit darah
Kelainan pembekuan darah misalnya afibrinogenemia atau hipofibrinogenemia
yang sering dijumpai :
- Perdarahan yang banyak.
- Solusio plasenta.
- Kematian janin yang lama dalam kandungan.
- Pre eklampsia dan eklampsia.
- Infeksi, hepatitis dan syok septik.

Faktor predisposisi terjadinya atonia uteri :
- Umur
- Paritas
- Partus lama dan partus terlantar.
- Obstetri operatif dan narkosa.
- Uterus terlalu regang dan besar misalnyaa pada gemelli, hidramnion atau janin
besar.
- Kelainan pada uterus seperti mioma uterii, uterus couvelair pada solusio plasenta.
- Faktor sosio ekonomi yaitu malnutrisi.

Cara membuat diagnosis perdarahan post partum :
1. Palpasi uterus : bagaimana kontraksi uterus dan tinggi fundus uterus.
2. Memeriksa plasenta dan ketuban : apakah lengkap atau tidak.
3. Melakukan eksplorasi kavum uteri untuk mencari :
- Sisa plasenta dan ketuban.
- Robekan rahim.
- Plasenta suksenturiata.
4. Inspekulo : untuk melihat robekan pada serviks, vagina dan varises yang pecah.
5. Pemeriksaan laboratorium : periksa darah, hemoglobin, clot observation test
(COT), dan lain-lain.

Perdarahan post partum adakalanya merupakan perdarahan yang hebat maupun perdarahan perlahan-lahan tetapi terus-menerus. Keduanya dapat menyebabkan perdarahan yang banyak dan dapat menjadi syok. Oleh karena itu penting sekali pada setiap ibu bersalin dilakukan pengukuran kadar darah secara rutin; serta pengawasan tekanan darah, nadi dan pernapasan ibu, kontraksi uterus dan perdarahan selama 1 jam.

Beberapa menit setelah janin lahir, biasanya mulai terjadi proses pelepasan plasenta disertai sedikit perdarahan. Bila plasenta sudah lepas dan turun ke bagian bawah rahim maka uterus akan berkontraksi untuk mengeluarkan plasenta (his pengeluaran plasenta).

Penanganan Perdarahan Post Partum

Penanganan perdarahan post partum berupa mencegah perdarahan post partum, mengobati perdarahan kala uri dan mengobati perdarahan post partum pada atoni uteri.

Cara mencegah perdarahan post partum yaitu memeriksa keadaan fisik, keadaan umum, kadar hemoglobin, golongan darah dan bila mungkin tersedia donor darah. Sambil mengawasi persalinan, dipersiapkan keperluan untuk infus dan obat-obatan penguat rahim (uterotonika). Setelah ketuban pecah, kepala janin mulai membuka vulva, infus dipasang dan sewaktu bayi lahir diberikan 1 ampul methergin atau kombinasi dengan 5 satuan sintosinon (sintometrin intravena). Hasilnya biasanya memuaskan.

Cara mengobati perdarahan kala uri :
- Memberikan oksitosin.
- Mengeluarkan plasenta menurut cara Credee (1-2 kali).
- Mengeluarkan plasenta dengan tangan.

Pengeluaran plasenta dengan tangan segera sesudah janin lahir dilakukan bila :
- Menyangka akan terjadi perdarahan post ppartum.
- Perdarahan banyak (lebih 500 cc).
- Retensio plasenta.
- Melakukan tindakan obstetri dalam narkossa.
- Riwayat perdarahan post partum pada perssalinan yang lalu.

Jika masih ada sisa-sisa plasenta yang agak melekat dan masih terdapat perdarahan segera lakukan utero-vaginal tamponade selama 24 jam, diikuti pemberian uterotonika dan antibiotika selama 3 hari berturut-turut dan pada hari ke-4 baru dilakukan kuretase untuk membersihkannya.

Jika disebabkan oleh luka-luka jalan lahir, luka segera dijahit dan perdarahan akan berhenti.

Pengobatan perdarahan post partum pada atoni uteri tergantung banyaknya perdarahan dan derajat atoni uteri yang dibagi dalam 3 tahap :
1. Tahap I : perdarahan yang tidak banyak dapat diatasi dengan memberikan
uterotonika, mengurut rahim (massage) dan memasang gurita.
2. Tahap II : bila perdarahan belum berhenti dan bertambah banyak, selanjutnya
berikan infus dan transfusi darah lalu dapat lakukan :
- Perasat (manuver) Zangemeister.
- Perasat (manuver) Fritch.
- Kompresi bimanual.
- Kompresi aorta.
- Tamponade utero-vaginal.
- Jepit arteri uterina dengan cara Henkel.
3. Tahap III : bila belum tertolong maka usaha terakhir adalah menghilangkan
sumber perdarahan dengan 2 cara yaitu meligasi arteri hipogastrika atau
histerektomi.

Retensio Plasenta

Retensio plasenta adalah keadaan dimana plasenta belum lahir selama 1 jam setelah bayi lahir.

Penyebab retensio plasenta :
1. Plasenta belum terlepas dari dinding rahim karena melekat dan tumbuh lebih
dalam. Menurut tingkat perlekatannya :
a. Plasenta adhesiva : plasenta yang melekat pada desidua endometrium lebih
dalam.
b. Plasenta inkreta : vili khorialis tumbuh lebih dalam dan menembus desidua
endometrium sampai ke miometrium.
c. Plasenta akreta : vili khorialis tumbuh menembus miometrium sampai ke
serosa.
d. Plasenta perkreta : vili khorialis tumbuh menembus serosa atau peritoneum
dinding rahim.
2. Plasenta sudah terlepas dari dinding rahim namun belum keluar karena atoni
uteri atau adanya lingkaran konstriksi pada bagian bawah rahim (akibat
kesalahan penanganan kala III) yang akan menghalangi plasenta keluar
(plasenta inkarserata).

Bila plasenta belum lepas sama sekali tidak akan terjadi perdarahan tetapi bila sebagian plasenta sudah lepas maka akan terjadi perdarahan. Ini merupakan indikasi untuk segera mengeluarkannya.

Plasenta mungkin pula tidak keluar karena kandung kemih atau rektum penuh. Oleh karena itu keduanya harus dikosongkan.

Penanganan retensio plasenta berupa pengeluaran plasenta dilakukan apabila plasenta belum lahir dalam 1/2-1 jam setelah bayi lahir terlebih lagi apabila disertai perdarahan.

Tindakan penanganan retensio plasenta :
1. Coba 1-2 kali dengan perasat Crede.
2. Mengeluarkan plasenta dengan tangan (manual plasenta).
3. Memberikan transfusi darah bila perdarahan banyak.
4. Memberikan obat-obatan misalnya uterotonika dan antibiotik.

Manual plasenta :
1. Memasang infus cairan dekstrose 5%.
2. Ibu posisi litotomi dengan narkosa dengan segala sesuatunya dalam keadaan
suci hama.
3. Teknik : tangan kiri diletakkan di fundus uteri, tangan kanan dimasukkan dalam
rongga rahim dengan menyusuri tali pusat sebagai penuntun. Tepi plasenta
dilepas - disisihkan dengan tepi jari-jari tangan - bila sudah lepas ditarik keluar.
Lakukan eksplorasi apakah ada luka-luka atau sisa-sisa plasenta dan
bersihkanlah. Manual plasenta berbahaya karena dapat terjadi robekan jalan
lahir (uterus) dan membawa infeksi.

Inversio Uteri

Inversio uteri adalah keadaan dimana fundus uteri terbalik sebagian atau seluruhnya masuk ke dalam kavum uteri.

Pembagian inversio uteri :
1. Inversio uteri ringan : fundus uteri terbalik menonjol ke dalam kavum uteri
namun belum keluar dari ruang rongga rahim.
2. Inversio uteri sedang : terbalik dan sudah masuk ke dalam vagina.
3. Inversio uteri berat : uterus dan vagina semuanya terbalik dan sebagian sudah
keluar vagina.

Penyebab inversio uteri :
1. Spontan : grande multipara, atoni uteri, kelemahan alat kandungan, tekanan
intra abdominal yang tinggi (mengejan dan batuk).
2. Tindakan : cara Crade yang berlebihan, tarikan tali pusat, manual plasenta yang
dipaksakan, perlekatan plasenta pada dinding rahim.

Faktor-faktor yang memudahkan terjadinya inversio uteri :
1. Uterus yang lembek, lemah, tipis dindingnya.
2. Tarikan tali pusat yang berlebihan.
3. Patulous kanalis servikalis.

Frekuensi inversio uteri : angka kejadian 1 : 20.000 persalinan.

Diagnosis dan gejala klinis inversio uteri :
1. Dijumpai pada kala III atau post partum dengan gejala nyeri yang hebat,
perdarahan yang banyak sampai syok. Apalagi bila plasenta masih melekat dan
sebagian sudah ada yang terlepas dan dapat terjadi strangulasi dan nekrosis.
2. Pemeriksaan dalam :
- Bila masih inkomplit maka pada daerah simfisis uterus teraba fundus uteri
cekung ke dalam.
- Bila komplit, di atas simfisis uterus teraba kosong dan dalam vagina teraba
tumor lunak.
- Kavum uteri sudah tidak ada (terbalik).

Penanganan inversio uteri :
1. Pencegahan : hati-hati dalam memimpin persalinan, jangan terlalu mendorong
rahim atau melakukan perasat Crede berulang-ulang dan hati-hatilah dalam
menarik tali pusat serta melakukan pengeluaran plasenta dengan tajam.
2. Bila telah terjadi maka terapinya :
- Bila ada perdarahan atau syok, berikan infus dan transfusi darah serta perbaiki
keadaan umum.
- Segera itu segera lakukan reposisi kalau perlu dalam narkosa.
- Bila tidak berhasil maka lakukan tindakan operatif secara per abdominal
(operasi Haultein) atau per vaginam (operasi menurut Spinelli).
- Di luar rumah sakit dapat dibantu dengan melakukan reposisi ringan yaitu
dengan tamponade vaginal lalu berikan antibiotik untuk mencegah infeksi.

Sumber
Sinopsis Obstetri : Obstetri Fisiologi & Obstetri Patologi. Jilid I ed. ke-2. dr. Delfi Lutan Sp.OG (editor). Jakarta : EGC. 1998. 298-306.

Aborsi Terapeutik

Aborsi terapeutik ialah aborsi yang diinduksi untuk menyelamatkan hidup atau kesehatan (fisik dan mental) seorang wanita hamil: kadang-kadang dilakukan sesudah pemerkosaan atau inses. Kalau kita berbicara secara lebih sempit, sebenarnya jenis aborsi ini tidak selalu tepat kalau dikatakan terapeutik. Terapi adalah pengobatan penyakit. Misalnya wanita yang mengandung dan punya penyakit jantung; kalau kehamilannya diteruskan sampai dengan kelahirannya akan sangat berbahaya baginya, maka kandungan itu harus dihentikan dengan melakukan aborsi. Tindakan aborsi ini sebenarnya tidak bisa disebut terapeutik sebab tindakan aborsi itu tidak dibuat dalam kerangka menyembuhkan penyakit. Dengan kata lain: dengan di lakukannya aborsi, penyakit jantungnya tidak tersembuhkan. Oleh karena itu dalam arti sempit, aborsi macam itu tidak bisa diartikan sebagai suatu terapi.

Jadi, tindakan itu bukanlah suatu intervensi medis terapeutis untuk menghilangkan suatu penyakit agar menjadi sehat tetapi suatu intervensi atas sesuatu yang sehat (janinnya) untuk menghindarkan ibunya dari suatu penyakit atau risiko kematian sedangkan penyakit si ibu sendiri justru tidak tersentuh. Dalam beberapa hal, lebih tepat dipakai istilah aborsi oleh karena adanya indikasi medis.

Toksoplasma

Bila seorang ibu hamil terinfeksi toksoplasma dampaknya akan sangat serius karma bisa mengakibatkan kematian janin, cacat bawaan pada janin, cacat pada otak, infeksi pada mata dan pertumbuhan janin terhambat. Di kemudian hark anak itu mudah menderita serangan kejang-kejang dan hambatan dalam perkembangan mental. Infeksi toksoplasma terjadi akibat masuknya kista parasit Toxoplasma gondii melalui saluran pencernaan. Infeksinya tidak tampak secara nyata kecuali dengan pemeriksaan darah karena gejalanya demam panas dan dingin sehingga hampir

Ketuban Pecah Dini

Ketuban pecah dini adalah penyebab terbesar terjadinya kelahiran prematur. Yalcni keluarnya cairan berwarna putih keruh kehijau-hijauan seperti air kelapa dari kemaluan tapi bukan air seni, sebelum mulas-mulas, sebagai tanda permulaan kelahiran. Hal tersebut disebabkan sobeknya selaput kantung ketuban. Kejadian ini biasanya karena jatuh, terbentur sesuatu di bagian perut, kelainan letak janin atau kehamilan kembar. Bila air ketuban yang keluar berwarna hijau, maka bayi akan dikeluarkan segera dari rahim, karma hal itu bisa berbahaya bagi janin. Sedang bila hasil pemeriksaan menunjukan cairan ketuban dalam tubuh masih banyak dan berwarna jernih, berartibayi masih cukup aman untuk tinggal dalam rahim dan tinggal menunggu waktu yang tepat untuk dilahirkan.

Hamil Anggur

Seorang ibu yang mengalami hamil anggur akan merasa dirinya hamil, karma tanda dan perubahan yang terjadi pada wanita hamil seperti terhentinya haid, mual-mualjuga dialaminya. Namun dalam perkembangan kehamilannya tidak ditemukan adanyajanin kecuali kelompok sel yang membentuk gelembung-gelembung berisi cairan yang bentuknya seperti buah anggur. Kehamilan seperti ini sangat berbahaya karena dapat terjadi pendarahan yang banyak dan ibu dapat meninggal karena pendarahan tersebut. Oleh karma itu pemeriksaan rutin selama kehamilan penting dilakukan untuk menghindari hal-hal yang tidak diinginkan seperti hal tersebut di alas.

How to approach the pelvic mass in a low resouce setting?

Tumor in the pelvis
3 ways to approach:
- Depending on age: childhood,adolescence, fertile period, postmenopause
- Depending on organ:can origin from every organ in the abdomen: gastro-intestinal, urological, gynecological
- Benign or malignant; primary or metastasis
Age: Childhood
- Pelvic tumors are rare in children
- 10% malignant
- Girls< 10 years: 40% of pelvic tumors is neoplastic of which 2/3 benign
- 80% of ovarian tumors in girls < 10 years is malignant and 60% are germ cell tumors, in adults this is only 20%
After menarche and during adolescence
- Functional cysts can happen at all ages
- Chances on malignancy after menarche decline
- Incidence of epithelial tumors increases with age
- Mature cystic teratoma is most frequent tumor in this age group
- Uterine tumors very rare
- Congenital malformations/hematometra/hematocolpos
- Endometriosis very rare
- PID

Fertile period
- Most frequent: mature teratoma
- Between 30-50 years:25% endometrioma
- Chances on malignancy of ovarium tumors: 20 years: <2%
30 years: 10%
postmenopause: 50%
- Fibroids:20% of women > 40 years have fibroids. Chances on malignanc change: 1:1000
Fertile period DD
- PID: digestive tract, genitals
- Uterus: pregnancy, benign tumors, malignancy
- Ovarium: functional cyst, neoplasma benign or malignant, metastases
- Fallopian tube: ectopic pregnancy, carcinoma
- Bladder: retention, neoplasma
- Congenital abnormality: pelvic kidney, vaginal atresia, imperforated hymen

Post menopause
- 50% malignant
- Majority ovary
- DD: PID, gastro-intestinal tumors, bladder tumors

Diagnosis in low resorce setting
- History
- Physical examination
- Lab tests
- Imaging

Childhood
- History: abdominal pain and swelling are dominant
- Physical examination: abdominal swelling
- Vaginal examination not possible
- Rectal examination not necessary
- Ultrasound if available
- Tumor markers if possible
- Diagnostic laparoscopy

After menarche, adolescence
- History, including questions on sexual behaviour.Well being? Fever?
- Physical exam: virgin? Vaginal and rectal examination
- Lab: pregnancy test, tumor markers
- Transvaginal ultrasound
- Diagnostic laparoscopy
- Laparotomy

Fertile age
- History: Inflamation? Appendicitis, diverticulitis? Pain?
- Menstrual cycle? Amenorrhoea?
- Physical exam: Inspection, percussion, auscultation and palpation of the abdomen. Acute abdomen? peritonitis? Ileus, sub-ileus? Size and consistency of the tumor?
- Pelvic examination: empty bladder!!
- Vaginal ultrasound
- Lab: pregnancy test, tumor markers

Post menopause
- History: many pelvic tumors do not cause specific complaints. Vague gastro-intestinal complaints are always an indication for pelvic examination!!!
- Physical examination, including vaginal and rectal examination
- Ultrasound
- Tumor marker
Imaging Techniques
Cross-sectional imaging modalities have largely replaced conventional radiographic techniques
- CT
- MRI
- US
- PET

Ultrasound:
Initial imaging modality of choice

Advantages
- Ability to scan rapidly in multiple planes
- Low costs
- Wide availability
- Lack of ionidizing radiation

Ultrasound:
Initial imaging modality of choice

Disadvantages
- Full urinary bladder in abdominal us
- Less quality in obese patients
- Difficult to reproduce the images

Ultrasound
- Transabdominal: Larger field of view, higher spatial resolution, urinary bladder used as an acoustic window
- Transvaginal: Smaller field of view, lower spatial resolution, empty bladder
- Sonohysterography:sterile saline infused into the uterine cavity under continuous TVS control
Ultrasound: indications
- Adnexal mass
- Intermenstrual bleeding
- Postmenopausal bleeding
- Punction of tumor or lymph node
Sonohysterography
- 10-50 ml sterile saline slowly infused into the uterine cavity while the probe provides continuous ultrasound guidance
- The saline expands the uterine cavity and separates the endometrial layers
- Endometrial surface visualized
- Images in transverse and sagittal planes

The low resource setting
- No imaging, no laboratory facilities
- Knowledge
- History, physical examination
- Referral
by Prof. A. Peter M. Heintz MD, PhD

Masalah prolaps organ pelvik dan inkontinensia di indonesia

Prolaps organ pelvik adalah turunya atau keluarnya dinding vagina disertai organ pelvik lain kedalam atau keluar liang vagina. Inkontinensia urin adalah keluarnya urin yang tidak dapat dikontrol secara obyektif dapat dilihatkan, suatu masalah sosial dan higene.

Masalah

1. Kunjungan pasien mencari pelayanan kesehatan sangat kecil.



2. Klasifikasi derajat diagnostik pop belum menurut standarisasi.



3. Terapi inkontinensia dan pop masih secara konvensional.

SEBAB KUNJANGAN SEDIKIT
1. Penderita dan masyarakat menganggap kelainan POP dan UI merupakan suatu hal yang biasa terjadi pada orang yang telah melahirkan atau usia lanjut dan tidak mengancam jiwa penderita
2. Merasa malu menceritakan pada famili ataupun pada orang lain termasuk pada tenaga kesehatan
3. Tidak tahu kemana harus berobat
4. Tenaga kesehatan kurang perhatian terhadap kedua kelainan tersebut diatas sehingga kelainan yang diderita penderita diabaikan. Hampir semua penderita telah lama mengalami kelainan diatas, serta ditemukan banyak kasus seperti infeksi saluran kemih, iritasi daerah genitalia, prolaps, sudah terinfeksi dan sulit direposisi kedalam vagina.

Klasifikasi pop menurut Baden walker
Stadium i bila bagian prolapsus masih diatas introitus vagina
Stadium ii bila bagian prolapsus sudah mencapai introitus vagina
Stadium iii bila bagian prolapsus sudah keluar dari introitus vagina
KLASIFIKASI
- Yang dianjurkan dipakai ICS sejak 1996
- Agar komunikasi ≠ sulit -> 1 kata
- Adaptasi sistem Baden & Walker
- Kunci -> Titik tertentu dengan patokan anatomi yang jelas
- Patokan : Himen
- Diukur 6 titik , 2 ukuran eksterna & panjang total vagina
- Struktur diatas himen : - cm
- Struktur dibawah himen : + cm

- Cara Mudah :
Patokan Himen
-Di atas - 1cm Grade I
-1 cm sp + 1cm Grade II
-Di bawah + 1cm Grade III
-Eversi komplit Grade IV

ANJURAN
Dipergunakan klasifikasi secara ICS untuk mendapat kesamaan penentuan derajat prolaps organ pelviks

TINDAKAN OPERASI KONVENSIONAL
- Kolporafi anterior
- Kolporafi posterior
- Kolpoperineografi
- Histerektomi
- Kolpoklisis
- Sakro kolpopeksi
- Sakro spinopeksi

Tindakan operasi untuk kasus POP secara konvensional sudah berlangsung hampir 100 th dan rekurensi cukup tinggi 30%:
- Kolporafi anterior 30%
- Kolporafi posterior 20%
- Histerektomi vaginal 0,1-18,2%

PENGGUNAAN MESH PADA JENIS TINDAKAN OPERASI UNTUK KASUS POP
- Kolporafi anterior untuk sentral sistokel dengan bantuan mesh/graft
- Kolporafi anterior diperluas ke lateral kanan dan kiri dengan jahitan puboservikalis pada ATFP dengan bantuan mesh/graft
- Sakro spinosus ligamen suspensi dengan bantuan mesh/graft
- Sakrokolpopeksi - dengan mesh/graft
- Sakrospinopeksi - dengan mesh
- Iliokoksigius suspensi- dengan mesh

OPERASI UNTUK INKONTINENSIA URIN(konvensional)
1. Kelly Plication (kolporafi anterior)
2. MMK dan Burchs kolposuspensi
3. Sling autograft

Operasi Terbaru Untuk Stres Inkontinensia TVT dan TVTO dengan menggunakan Mesh

SARAN
- Perlu dilakukan sosialisasi dan informasi tentang kasus POP dan UI pada masyarakat dan tenaga kesehatan
- Para dokter terutama ahli Obsgin perlu meningkatkan ilmu pengetahuan dan pemahaman penanganan kasus-kasus POP dan UI

Artikel Masalah prolaps organ pelvik dan inkontinensia di indonesia oleh:
Prof. Junizaf, SpOG(K)
Divisi Uroginekologi Rekonstruksi
Departemen Obstetri dan Ginekologi
Fakultas Kedokteran Universitas Indonesia
Rs. Dr. Cipto Mangunkusumo

Penatalaksanaan Dan Perawatan Robekan Perineum

PERSALINAN PERVAGINAM
Lebih 85 % terdapat robekan perineum
+ 70-80% membutuhkan penjahitan
Dapat terjadi secara spontan atau episiotomi


FUNGSI SFINGTER ANI DAN OTOT PUBOREKTALIS
Puborectalis: mengonterol continence yang kerasi
Sfingter ani Interna : mengonterol fises yang cair
Sfingter ani eksterna membantu sfingter ani interna pada keadaan mendadak kalau dibutuhkan seperti meningkatnya tekanan intera abdomen
Anal cushion -> jumlah yang mengalir melalui fenus aterusus dan mengonterol flatus
Klasifikasi robekan perineum (SULTAN 1999-RCOG-WHO)
Robekan mengenai epitel vagina dan kulit
Derajat II Robekan mengenai otot perineum tapi tidak sampai ke otot sfingter ani
Derajat tiga robek mencapai sfingter ani
3a = robekan kurang dari 50% dari sfingter ani eksterna
3b = robekan mencapai lebih dari 50% dari sfingter ani eksterna
3c = robekan mencapai ke sfingter ani interna

Derajat IV robekan mengenai, perineum, sfingter ani termasuk mukosa sfingter ani dan rektum

FAKTOR RISIKO ROBEKAN PERINEUM DERAJAT III DAN IV
Tindakan dengan forsep > 7%
Partus lama kala dua > 4%
Anak terlampau besar > 2%
Posisi kepala oksiput posterior > 3%
Episiotomi > 3%

KOMPLIKSI ROBEKAN TINGKAT III DAN IV
Inkontinensia fekal
Kerusakan sfingter ani tersembunyi (Occult damage)

PREVALENSI
Robekan perineal derajat III dan IV 0.6-9%
Kerusakan sfingter ani tersembunyi (Occult damage) 36%

DEFINITION
Fecal incontinence is the inability to control the passage of gas, liquid or solid through the anus.

PREVALENSI GEJALA INKONTINENSIA PASCA REPARASI RUPTUR PERINEUM DERAJAT III DAN IV
Gejala inkontinensia 25 - 75%
Flatus 30%
Liquid stool 8%
Solid stool 4%
Fecal urgency 26%

ETIOLOGI KERUSAKAN TERSEMBUNYI ATAU KERUSAKAN SFINGTER ANI
Pengetahuan anatomi dari perineum dan anal yang sangat sedikit
Tidak cukunya latihan dalam Memperbaiki reparasi robekan perineum III dan IV
Klasifikasi berbeda dari RCOG-WHO
Metoda reparasi (end to end or overlap)
Materi benang jahitan : cat gut or poliglactin (vicryl) or monofilaments (Polydioxanone)
Perawatan postoperasi yang tidak adekuat

TIPE REPARASI
END TO END (OBSTETRIC)
OVERLAP (COLORECTAL SURGEON)

Metoda reparasi
Overlap – end to end teknik
Materi Sutur monofilamen
Memisahkan reparasi sfingter ani interna dan eksterna dalam reparasi
Inkontinen anal berkurang dari 41 ke 8% dan sfingter ani eksterna Persisten berkurang dari 85% ke 15%
Teknik reparasi overlap lebih bagus dari End to End

PENILAIAN
Anal manometry
EMG
Anal Endo sonography
MRI

Perawatan Preoperatif
Akut
Tidak ada persiapan yang khusus

Kronik
Kebersihan daerah genitalia eksterna dan sekitarnya
Mencegah atau mengobati bila ada tanda-tanda infeksi
Memperbaiki keadaan penderita
Konseling tentang tindakan yang akan dilakukan
Klisma sebelum tindakan operasi dikerjakan
Pemberian antibiotika sebelum operasi dimulai

Perawatan pasca operasi
Perawatan pasca operasi sangat penting, baik pada yang akut maupun pada kronik, dan perawatan pasca operasi tidak berbeda, antara yang akut dan kronik:
Kateter trans uretra nomor 12 dipasang selama 24 jam, sesudah itu dapat dilepas.

Rawat kebersihan alat genital dengan baik, apalagi kalau masih dalam keadaan akut karena lokhia yang merupakan media untuk kuman berbiak dapat menjadikan sumber infeksi pada luka pasca reparasi.

Diberikan antibiotika, terutama untuk E. Coli diberikan per oral 3 x I hari, dan penderita diberi makanan lunak serta berserat, agar feses menjadi lunak.

Kalau diperlukan diberikan laksan agar penderita mudah defikasi.

Bila penderita sudah buang air besar dan tidak ada keluhan maka pasien telah bisa dipulangkan dan diminta untuk kembali lagi I minggu kemudian untuk dilihat dan dinilai tentang keadaan luka sekaligus keluhan penderita.

Selama di rumah penderita diminta untuk tetap merawat daerah genitalianya, obat antibiotika diteruskan selama 1 minggu dan diet seperti yang diberikan di rumah sakit.

Dua minggu pasca reparasi penderita diminta untuk kembali lagi untuk dinilai keluhan dan keadaan luka pasca reparasi, bila semuanya baik maka penderita sudah diperbolehkan untuk makan yang agak keras.

Penderita sesudah 40 hari pasca reparasi, diminta untuk kembali lagi untuk dinilai keadaan alat genitalianya pasca nifas, serta luka operasi, pasca reparasi termasuk keluhan dari penderita.

Penderita dianjurkan untuk mengikuti program keluarga berencana dan selanjutnya perencanaan tentang persalinan yang akan datang.

Bila ditemukan keluhan inkontinensia alvi yang ringan maka penderita dianjurkan/diajarkan melatih otot-otot dasar panggul dan sfingter ani eksterna dan makan tetap dalam keadaan lunak sampai 3 bulan pasca reparasi.
Pada keadaan dimana keluhan lebih berat, walaupun kelihatannya luka pasca reparasi baik maka reparasi sfingter ani eksterna kembali dilakukan sesudah 3 bulan.

Bila memungkinkan perlu dilakukan pemeriksaan anal ultra sonograf atau endo anal untuk menilai keadaan hasil reparasi yang dilakukan pada otot sfingter ani, sehingga rencana apakah perlu dilakukan reparasi lagi atau cukup dengan latihan otot-otot dasar panggul, atau dianggap hasil reparasi cukup memuaskan.

KESIMPULAN
Persalinan pervaginam dapat menyebabkan robekan perineum dari derajat I sampai derajat IV. Faktor risiko robekan perineum: penggunaan forsep, partus kala dua lama, anak terlampau besar, posisi osiput posterior, episiotomi. Robekan sfingter ani dapat menyebabkan inkontinensia fekal. Defek sfingter ani atau kerusakan tersembunyi prevalensinya tinggi sesudah reparasi konvensional yang dinilai dengan endoanal ultrasonography.

Untuk mengurangi defek sfingter ani dan inkontinensia fekal ahli bedah harus memahami anatomi perineum dan anorektal dan klasifikasi ruptur perineum.
Teknik overlap lebih baik dari pada End to End dan menggunakan material benang monofilamen
Perlu diperhatikan perawatan pre dan post operatif agar reparasi yang telah dikerjakan berhasil dengan baik.

Protocol Endometrial Cancer

Protocol Endometrial Cancer
1. General
2. Screening
3. Diagnosis
4. Surgical treatment
5. Adjuvant treatment
6. Follow up
7. Recurrences
8. Metastases

1. General
Endometrial cancer is the most common gynecologic malignancy in the Western world. In the USA there were in 2003 40 100 new cases. Factors influencing its prominence are the declining incidence of cervical cancer, prolonged life expectancy, earlier diagnosis and the increasing incidence of obesity. Currently endometrial cancer is the fourth most common tumor in women, ranking behind breast, bowel and lung cancers, and the seventh cause of death from malignancy in women. Endometrial cancer is a tumor of women in the postmenopause, although still 4% of the patients are younger than 40 years of age.

In 75% of all cases, the tumor is confined to the uterine corpus at the time of diagnosis.
Uncorrected 5-years survival rates of 75% can be expected.

Most cases of endometrial carcinoma are sporadic. Some cases have a hereditary basis: HNPCC families.

Environmental factors seem to be important. The increasing incidence of endometrial cancer has been attributed to an aging population and to dietary and hormonal factors. Obesity, unopposed estrogen and Tamoxifen for more than one year have been identified as risk factors. This is also the case for hormonal disturbances associated with diabetes mellitus, polycystic ovarian syndrome, and estrogen producing tumors.

Parity and oral contraceptives protect against endometrial cancer.
2. Screening:
There is no effective screening strategy.

3. Diagnosis
Anamnesis:
- Abnormal vaginal blood loss
- Fluor
- Micturation/defaecation
- Pain, weight loss, general health

Family:
Ask for colon, rectal, endometrial carcinoma’s and the age of onset. Also ask for other malignancies.
Physical examination:
- Weight, length, general condition
- Heart, lungs, abdomen
- Pelvic examination
- Lymph nodes inguinal, supraclavicular

Laboratory:
- Pap smear
- Routine preoperative blood chemistry and morphology

Immaging:
- X-thorax
- Transvaginal ultrasound
- CT scan/MRI: only on indication (suspicious for extrauterine disease)
- Cystoscopy and rectoscopy: in cases with voiding and/or defaecation problems.

Pathology:

Histology is needed for the diagnosis endometrial cancer. A tissue sample from the uterine cavity for diagnosis can be obtained in the outpatient office with an endometrium sample system (Pipelle, Vabra, Probette, Milex). This sampling can be done without anaesthesia after the vaginal ultrasound and/or the saline infusion ultrasound. An alternative approach is a hysteroscopy with biopsies of the endometrium under direct vision. In both instances sampling od tissue from the endocervical canal must be performed to rule out macroscopic endocervical involvement. However, the sensitivity of this procedure is low.

If these techniques are not available, a fractionated curettage can be performed.
The report of the pathologist has to include:

- Histologic cell type
- Grade

Advise: Every patient with unfavourable prognostic factors (high risk) or stage II or more needs to be discussed with a gynecologic oncologist and preferrsbly refered to a gynecologic oncology center hospital.

4. Surgical treatment
Clinical stage I:

Total abdominal hysterectomy with bilateral salpingo-oophorectomy.
- Median laparotomy
- Peritoneal washing: aspirate fluid or wash with 20-50 cc saline, aspirate and add 2 drips of heparine to the fluid to prevent clotting.
- Clamps on the tubal corners to prevent tumor spill during uterine manipulation.
- Inspection and palpation of uterus, adnexa, all serosal surfaces, lymph nodes in pelvis and para-aortic.
- Biopsie all suspected areas.
- TAH – BSO.
- Pelvic and lower periaortic lymphadenectomy in high risk patients: lymph nodes have to be removed from the external iliac and lower common iliac area, the obturator fossa, the para-aortic area and pre-caval area between bifurcation and inferior mesenteric artery.

Clinical stage IIa: macroscopic involvement of the cervical canal.
- Radical hysterectomy with bilateral salpingo-oophorectomy and bilateral pelvic lymphadenectomy.
- Lower periaortic lymphadenectomy in case of suspicious nodes.

Clinical stage III:
- Laparotomy and resection of tumor if possible.
- If not: radiotherapy and resection in case the tumor becomes respectable.

Clinical stage IV:
Individualization of treatment based on extension of disease.
After primary treatment and the result of pathological examination, the surgical stage can be determined.

5. Adjuvant treatment
Adjuvant treatment in surgical stage I:
External radiation is directed towards the operation field, parametria, top of vagina, regional lymph nodes.
Based on the PORTEC I study there are 3 risk factors in stage I disease:

- Age =>60 years
- Grade III
- Myometrium invasion > ½ of the myometrium

When 2 of these 3 factors are positive adjuvant radiotherapy is indicated.

Based on the PORTEC-2 study radiotherapy in stage 1-2a will be vaginal brachytherapy. External beam radiation will be given to the high risk group.

In cases where a lymphadenectomy has been performed and where the pathology of the nodes is negative for tumor, adjuvant brachytherapy on the top of the vagina has to be given.

Surgical stage II:
Stage IIA after TAH-BSO with occult tumor growth into the cervix: idem stage 1.
Stage IIA after radical hysterectomy and BSO: only radiotherapy if tumor growth into parametrium, tumor in cutting margins, tumor positive lymph nodes. If the vaginal margin is not free of tumor or tumor free margin < 5 mm: vaginal brachytherapy.

Surgical stage III and IV:
External radiotherapy and vaginal brachytherapy. Extended field irradiation in cases of para-aortic lymph node metastases.

Chemotherapy:
Still experimental. Cisplatin, Paclitaxel with or without Doxyrubicin are frequently tested and seem to be promising.

6. Follow-up:

First year: every 3 months
Second year: every 4 months
Third-fifth year: every 6 months
After 5 years: every year up to 10 years.

Most recurrences occur within 3 years.

Follow-up includes:
- Carefull medical history
- Pelvic examination: visual inspection of the top of the vagina and pelvic palpation.

Routine cytology of the top of the vagina is not necessary and does not contribute to the diagnosis of a recurrence.

7. Recurrences
Recurrences can be local: in the top of the vagina, or regional in the pelvis, or combined.
Vaginal discharge or blood loss after intercourse is often the first symptom of a vaginal recurrence.

In case of a recurrence the following protocol is indicated:

- General examination
- Pelvic examination
- CT scan thorax and abdomen
- Haematology, blood chemistry, CA 125
- Cystoscopy, rectoscopy, bone scan on indication

Treatment local recurrence:
Non radiated area:

Local radiotherapy. 80% complete remission.

Local recurrence > 2 cm: surgical excision before radiotherapy
Radiated area: exenteration in oncology clinic by gynecologic oncologist. Only indicated if distant metastases are ruled out.

Treatment regional recurrence: radiotherapy, eventually combined with surgery, individualization of treatment.
In patients with well differentiated tumors hormonal therapy with high dose progesterone can be indicated, especially if surgery and radiotherapy are not possible.

Distant metastases:
Mostly located in:
- Supraclavicular lymph nodes
- Lung
- Abdomen
- Liver
- Bone

Always try to get cytological (FNA) or histological confirmation.
Treatment: first choice is radiotherapy. If this is no option: individualize.

Referensi
Dutch School - Gynaecologic Oncology & Pelvic Surgery

The radical vaginal trachelectomie: do we need it?

Conventional radical surgical treatment of carcinoma of the cervix uteri is standard treatment in women with stage 1b-2a disease. The survival rates are 90% and more if there are no metastases to the lymph nodes, and drop to 60% in those patients who have node metastases. For young women the consequence is loss of fertility.

Early stage carcinoma of the cervix (< 1b) has a very good prognosis with only hysterectomy or a conisation of the cervix. Survival rates are 98-100% (1).
The radical trachelectomie was introduced in 1987 by the French gynaecologist Daniel Dargent as an alternative for young patients with stage 1a1-2a carcinoma of the cervix, with the desire to preserve fertility (2).

Stage 1a
Patients with stage 1a1 are already for a long time treated with a conization if they want to keep their fertility. The result of this simple operation is 100% cure. Until now there has been no good argument to treat young women with stage 1a disease more radical than with a conization. So, a radical trachelectomie is not necessary in this particular group of women .

Stage 1a2-2a
From a number of studies it became evident that clear margins of amputation of the cervix, tumor size, depth of invasion, lymphatic vascular space invasion, and parametrial invasion are the most important issues in determining which therapy to start(3-5).

Clear margins
The status of the margins of the amputated cervix are a significant predictor of residual invasion (6). The distance between the edge of the tumor and the internal cervical os must be at least 15 mm. Furthermore, if the distance between the edge of the tumor and the superior margin of the removed specimen is less than 10 mm, radical trachelectomie can not be considered as a safe alternative of radical treatment because of the high chance of local recurrence. On the other hand, if the length of the remaining cervix is less than 5 mm wide, childbearing potential is dramatically reduced (7). Preoperative assessment consists of the use of colposcopy and MRI (3,7). Re-conization of another 3-5 mm should be performed if the margins are less than 5 mm, on the condition that sufficient cervix, 1 cm, remains in situ for fertility. If the margins cut through the tumor, a radical hysterectomy is recommended(8). A number of studies conclude that if negative margins are present on the amputated cervix specimen, the likelihood of finding invasive carcinoma in a subsequent hysterectomy specimen is low (9).

Tumor size
With the increase of tumor size, the risk of lymph node involvement and parametrial invasion increases. Stage 1 tumors with a diameter < 2 cm have been considered as a low risk group tumors(10).

Lymph vascular space invasion (LVSI) and lymph node metastases
The rate of positive pelvic lymph nodes varies from 12-30% in large series of patients with stage 1b (11).
The risk of recurrence and lymph node metastases increases, if the LVSI is positive and so there is automatically a correlation between the risk of recurrence and lymph node matastases and depth of stromal invasion (9,12-14). Even though the risk is very low, it should be emphasised that even in the patients with a depth less than 3 mm and with a negative LVSI, recurrences have been reported.

Parametrium invasion
Pathologic parametrial involvement in stage 1a and 1b1 cervical cancer is uncommon. A subgroup of patients can be identified as low risk based upon the absence of specific tumor factors. These include patients with tumor size 2 cm or less, negative pelvic lymph nodes and depth of tumor invasion of 10 mm or less (15). The rate of parametrial involvement in lymph node negative patients with tumors < 5ml, which corresponds with a spherical tumor of 2,1 cm) is 6,6%. Of them 1,7% had tumor deposit only in the lateral parametrium (11).

Histology
Special consideration has to be given to adenocarcinoma of the cervix. The multifocality of this disease and the presence of residual disease in hysterectomy specimen in patients who had free margins in their conization specimen makes them less suitable for a fertility saving procedure. If this procedure is chosen than a carefull examination of the remaining cervical canal during the operation, including an endocervical curettage, and repeated normal endocervical smears during follow up of at least one year, are needed.

Sequellae of the radical vaginal trachelectomie
As RVT is a modification of the Schauta procedure, the late sequellae of the procedure are comparable to the sequellae of the Schauta operation. The close anatomic relation between the inferior hypogastric plexus and the direct surrounding of the uterine cervix and the proximal vagina results in damage of the plexus when the medial part of the parametrium and the proximal part of the vagina are removed. This will lead to disturbed sexual function, voiding and defecation(16). These sequellae are only acceptable if the extent of the resection is indicated.

Since the incidence of parametrium invasion in a stage 1a and 1b1 patient is uncommon and the incidence of parametrial lymph node metastasis is very rare if the pelvic side wall nodes are negative, a parametrectomy in low risk patients leads to overtreatment, with a significant amount of late morbidity (16). Based on the presented data we advise only a conization in these low risk patients. In summary these are: young women who want to preserve their fertility, who have a squamous cell carcinoma with a tumor size less than 2 cm diameter, a depth of tumor invasion of less than 10 mm, safe clear margins, a negative LSVI status and negative pelvic lymph nodes.

Conclusion and protocol
Radical trachelectomy is a safe operation in young women with a cervix cancer =< stage 1b1.
However in the small group of patients in whom the procedure is indicated the parametrectomy and lymphadenectomy do not contribute to the cure rate but do contribute to the sequellae of the operation. In the other patients the risk of recurrence is to high to perform a RVT. For this reason we conclude that the RVT is no longer needed to preserve fertility in low risk early stage cervix cancer.
In summery we advise the following treatment protocol:
Stage 1a1: conization
Stage 1a2-1b1, < 2cm diameter: a pelvic lymphadenectomy. The nodes are carefully examined by the pathologist and if negative a large conization is performed.
The cone is checked on the margins, depth of invasion and LVSI. If the margins are free, the depth of invasion is less than 10 mm, and the LVSI is negative than the operation will suffice.
If the nodes are positive, we advise chemoradiation.
If the margins are not free a re-conization can be performed.
If the tumor invades > 10 mm, and or if the margins are still not free after re-conization a radical hysterectomy has to be performed because of the high risk of local recurrence.

References
1. De Vita VT, Hellman S, Rosenberg SA. Cancer, Principles & Practice of Oncology, 4th edition.
2. Dargent D, Brun JL, Roy M, Mathevet P, Remy I. Trachelectomie elargie ine alternative a l’hysterectomie radicale dans le traitement des cancers infiltrants developpes sur la face externe du col uterin. J Obstet Gynecol 1994 ;2 :285-92.
3. Peppercorn PD, Jeyarajah AR, Woolas R, Shepherd JH, Oram DH, Jacobs IJ, Armstrong P, Lowe D, Reznek RH. Role of MR imaging in the selection of patients with early cervical carcinoma for fertility preserving surgery : initial experience. Radiology 1999;212:395-399.
4. Siller BS, Alvarez RD, Conner WD, McCullough CH, Kilgore LC, Patridge EE, et al. T 2/3 vulvar cancer: a case control study of triple incision versus en bloc radical vulvectomy and inguinal lymphadenectomy. Gynecol Oncol 1995;57:335-339.
5. Thomas GM, Dembo AJ. Is there a role for adjuvant pelvic radiotherapy after radical hysterectomy in early stage cervical cancer? Int J Gynecol Cancer 1991;1:1-8.
6. BenedetJL, Anderson GH. Stage 1A carcinoma of the cervix revisited. Obstet Gynecol 1996;87:1052-9.
7. Dargent D. Using radical trachelectomie to preserve fertility in early invasive cervical cancer. Contemp Obstet Gynecol Arch: May 2000.
8. Martin XJB, Golfier F, Romestaing P, Raudrant D. First case of pregnancy after radical trachelectomie and pelvic radiation. Gynecol Oncol 1999;74:286-287.
9. Jones WB, Mercer GO, Lewis JL, Rubin SC, Hoskins WJ. Early invasive carcinoma of the cervix. Gynecol Oncol 1993;51:26-32.
10. Sevin BU, Nadji M, Averette HE, Hilsenbeck S, Smith D, Lampe B. Microinvasive carcinoma of the cervix. Cancer 1992;70:2121-8.
11. Winter R, Haas J, Reich O, Koemetter R. Tamussino K, Lahousen M, petru E, Pickel H. Parametrial spread in cervical cancer in patients with negative pelvic lymph nodes. Gynecol Oncol 2002;84:252-257.
12. Creasman WT, Kohler MF. Is lymph vascular space involvement an independent prognostic factor in early cervical cancer? Gynecol Oncol 2004;92:525-529.
13. Mota F. Microinvasive squamous carcinoma of the cervix: treatment modalities. Acta Obstet Gynecol Scand 2003;82:505-9.
14. Ostor AG, Rome RM. Microinvasive squamous cell carcinoma of the cervix. A clinico-pathologic study of 200 cases with long-term follow-up. Int J Gynecol Cancer 1994;4:2564.
15. Covens A, Rosen B, Murphy J, LaFramboise F, DePetrillo AD, Lickrish G, Colgan T, Chapman W, Shaw P. How important is removal of the parametrium at surgery for carcinoma of the cervix? Gynecol Oncol 2002;84:145-9.
16. Kenter GG, Heintz APM. Surgical treatment of low stage cervical carcinoma: Back to the old days? Int J Gynecol Cancer 2002;12:429-34.

Artikel The radical vaginal trachelectomie: do we need it? oleh:

Prof. A. Peter M. Heintz, MD, PhD.
The Dutch School of Gynecologic Oncology and Pelvic Surgery
And the University of Utrecht
Utrecht
The Netherlands

Radical Hysterectomy with Pelvic Lymphadenectomy

Introduction
Radical Hysterectomy with pelvic lymphadenectomy is the major treatment modality for women with cervical cancer stage 1b-2a.

The procedure was first performed at the end of the 19th century by Wertheim in Vienna and Clark in Baltimore. The operation is based on the principles of radicality as developed by Halsted to treat breast cancer.

Wertheim reported in his first series of 100 patients an operation mortality of 30%. Because of this the successful introduction of Radium by Marie Curie in 1903, radiotherapy replaced radical surgery largely as the primary treatment modality for cervical cancer. A revival of the radical hysterectomy took place when Jo Meigs in Boston published his first 65 consecutive operations without a postoperative death. In fact Meigs was more radical than Wertheim was. Wertheim’s original procedure was similar to what we refer to these days as a modified radical or type 2 hysterectomy. Besides, Wertheim did not always perform a total pelvic lymphadenectomy. Meig’s operation involved extensive dissection of the pelvic nodes, the ureters and the cardinal- and uterosacral ligaments. Contrary to Wertheim Meigs considered parametrial involvement as a contraindication for the operation.

Patient Selection
Patients with cervical cancer stage 1b-2a can be treated with radical surgery or radiotherapy. Both treatments have equal results in terms of survival. The crux of the matter in these loco-regional treatments is the chance on metastases. If these are present the 5-year survival rate will be much poorer and drop from more than 90% in node-negative patients to less than 80% in node positive patients. Patients at high risk for the presence of Metastatic disease are the ones with a tumor diameter of more than 4 cm. For this reason these patients are these days treated with neoadjuvant chemotherapy, followed by a radical hysterectomy or with chemo-radiation. Large randomized trials are going on to find out which treatment is the best.
The major advantage of surgery as primary treatment is that in case of a loco-regional recurrence radiotherapy is still available to treat the recurrent cancer. Another important advantage is that the ovaries can be preserved in pre-menopausal women.

The disadvantages of surgery are mainly the postoperative chance on thromboembolic disease, urinary tract injuries and recto-vaginal fistula. Since damage of the parasympatic hypogastric nerve system always occurs during the operation, many patients will have disturbed bladder and rectal function after the operation. If to much of the upper vagina is removed, sexual function can be disturbed.

Radiation therapy has the disadvantage of causing serious bladder and/or bowel damage in 2-6% of the patients and vaginal stenosis and dysfunction in almost half of the patients. Fibrosis of the vagina and perivaginal tissue may be delayed and are very difficult to treat. The major complications of surgery appear early and are more easily correctable. Recently a surgical technique has been developed to preserve the hypogastric nerve and plexus which contributes considerably to the prevention of bladder-, bowel-, and sexual sequellae of the operation.

Radical hysterectomy is safe in older patients as long as their medical condition permits a laparotomy.

Radical hysterectomy and Pelvic Lymphadenectomy
During radical hysterectomy the uterus is resected en-bloc with the paracervical lymphatic tissue, the parametria, vessels and pelvic lymph nodes.

Points of controversy are the completeness of the lymphadenectomy and if the radical hysterectomy should be abandoned if the patient has lymph node metastases.

If all pelvic lymph nodes are removed than all patients will suffer from severe lymph edema of the genital area and the legs. Fortunately this does not happen with the present surgical technique. Lymph edema is reported in 15-23% of the patients after the operation. The most important goal of lymphadenectomy is to select patients with metastases to the regional lymph nodes from those who have true local disease. So, this is a diagnostic approach.

If only one lymph node is involved we know that survival is not harmed. Removal of this metastatic node is a therapeutic side effect of the operation. Patients with more positive nodes need further treatment.
However, others consider the lymphadenectomy a therapeutic procedure with diagnostic consequences.
This discussion also relates to the debate on whether the radical hysterectomy should be abandoned if the patient has lymph node metastases. If a patient has metastasized disease than we know for sure that the operation is not curative. We also know for sure that radiotherapy will be necessary and that radiotherapy after radical surgery will increase the side effects of radiation compared to radiation alone without improved survival. These days there is even growing evidence that chemo-radiation in patients with metastasized disease has at least a 10% better 5-year survival than the combination radical surgery-radiotherapy or radiotherapy alone. The only benefit a patient can have from continuation of the lymphadenectomy is the resection of bulky metastases because of the difficulty to sterilize these nodes with radiotherapy. For these reasons it is the opinion of the author that in cases with node metastases the operation should be abandoned after removal of all bulky nodes.

Pre-operative assessment
Preoperative evaluation of every patient should include a complete medical history and physical examination to exclude contraindications for the surgical procedure.
A chest X-ray is needed to exclude pulmonary disease. According to the FIGO staging rules an intravenous pyelogram must be made to rule out urinary tract abnormalities. However these days many gynecologic oncologists prefer a CT scan or MRI to visualize the pelvic and upper abdominal anatomy to rule out metastatic disease.

Cystoscopy and proctoscopy are not indicated in early cervical cancer. Cystoscopy should be performed in patients with extensive involvement of the anterior cervix to rule out bladder involvement and in patients in whom symptoms or physical findings suggest bladder involvement.
Prophylactic antibiotics and prophylactic heparin is strongly recommended to prevent pelvic sepsis, deep venous thrombosis and pulmonary embolism.

Surgical anatomy
A basic requirement for the surgical treatment of cervical cancer is an adequate knowledge of the retroperitoneal anatomy, especially the pelvic ligaments and spaces. The pelvic spaces are filled with connective tissue and are avascular. They can be opened by sharp and/or blunt dissection.
The following avascular spaces can be identified (fig. ):
1. the paravesical space
2. the pararectal space
3. the presacral space
4. the space of Retzius

The paravesical space
The paravesical spaces are located on each side of the bladder between the vesico-uterine ligament and the cardinal ligament. Its borders are:
• anterior: the pubic symphysis
• posterior: the cardinal ligament
• lateral: the obturator internus muscle
• medial: the umbilical artery (obliterated)
• caudal: vaginal attachments to the arcus tendineous

The paravesical space can be opened by opening the pelvic peritoneum just anterior to the round ligament and lateral to the bladder. During a radical hysterectomy the paravesical space can easily be opened by blunt dissection after transaction of the round ligament.

The pararectal space
The pararectal space is located between the hypogastric artery and the uterosacral ligament. Its borders are:
• anterior: the cardinal ligament
• posterior: the sacrum
• lateral: the hypogastric artery (a. iliaca interna)
• medial: the uterosacral ligament and the rectum
• caudal: m. levator ani
The pararectal space can be opened by opening the pelvic peritoneum over the external iliac artery just below the bifurcation. The space can be opened by blunt dissection just medial from the internal iliac artery following the curve of the sacrum. Before doing so the ureter has to be identified and retracted medially. If a salpingo-oophorectomy has to be performed, the procedure is easy after transection of the infundibulopelvic ligament.

If the ovary has to be preserved, the ovary and its vascular pedicle can be mobilized up to the pelvic rim (linea innominata) by cutting the pelvic peritoneum just below the vascular pedicle. After this the retroperitoneum is opened, the ureter and hypogastric artery can easily be identified and the pararectal space opened.

The presacral space
The presacral space is located between rectum and sacrum. Its borders are:
• anterior: the rectum
• posterior: the sacrum
• lateral: the left and right uterosacral ligaments
The presacral space can be opened by mobilizing the rectum by blunt and sharp dissection starting from the right pararectal space. Special attention must be paid to the presacral veins. They can cause serious hemorrhage if damaged.

Space of Retzius
The space of Retzius is located between the symphysis pubis and the bladder. Its borders are:
• anterior: the symphysis pubis
• posterior: the bladder
• lateral (left and right): bladder attachments to the pelvic sidewall
• caudal: bladder neck, urethra, vagina
The space of Retzius can be opened by blunt dissection of the bladder peritoneum from the symphysis pubis.

The pelvic autonomic nerves
Autonomic nerve damage during radical pelvic surgery is responsible for bladder dysfunction, rectal motility disorders and sexual dysfunction. Because of the close relation between the autonomic nerves and the tissue that has to be removed damage of these nerves is thought to be an inevitable part of the radical hysterectomy. However more insight in the biology of cervix cancer has created room for a more individualized approach, especially in women with small tumors. In these patients the autonomic nerves can be saved without compromising survival.

The part of the autonomic nerve system that is important in radical pelvic surgery is the superior hypogastric plexus, the hypogastric nerve, the inferior hypogastric plexus and the splanchnic nerves.
The superior hypogastric plexus is a fenestrated network of fibers located anterior to the lower abdominal aorta. The plexus gets its afferent fibers from the spinal chord between the levels th 10 and L2. From this plexus the hypogastric nerves originate bilaterally just below the level of the promontory. The hypogastric nerves run parallel to the ureter, 2 cm medio-dorsal of them, to the left and right inferior hypogastric plexus. The inferior hypogastric plexus has connections with the sacral roots from S2-S4 via the splanchnic nerves and has relations with the sacral sympathetic chain. Together these nerves form the inferior hypogastric plexus. This plexus is placed in a sagittal plane and measures about 3x4x0.5 cm. The plexus stretches from antero-lateral of the rectum to lateral of the cervix and vaginal fornix to the lateral vaginal wall and the base of the bladder. So, the inferior hypogastric plexus is closely related to the pelvic connective tissue planes: the sacrouterine ligaments, the cardinal ligaments and the vesicouterine ligaments (Maas et al). According to Maas et al wide and deep resection of these structures will result in disruption of the inferior hypogastric plexus.

Voiding, defecation and sexual function can all be severely disrupted when the pelvic autonomic nerves are damaged during surgery. The concept of preservation of the pelvic autonomic nerves was already developed in the sixties by Japanese gynecologists. However, it took until recently before the technique got broad attention in gynecologic oncology.

The pelvic vessels
Vascular anatomy
The vascular supply of the pelvis is characterized by a very rich collateral circulation. The consequence is that, if necessary, most vessels can be interrupted without consequence. However, the better the blood supply, the better the healing and the effect of chemotherapy and radiotherapy. So, whenever possible the vessels should be spared.

The anatomical position of the vessels is largely consistent, but individual variation exists.
The most important anatomical landmarks are the following:
• The aortic bifurcation occurs over the fourth lumbar vertebra, which is at the level of the umbilicus. The aorta divides into the left and right common iliac artery.
• The common iliac artery divides into the external and internal (hypogastric) iliac artery. This bifurcation is located at the right side 1.5 cm, and at the left side 2 cm below an imaginary line drawn across the centre of the sacral promontory.
• The ureter crosses the bifurcation between 2 cm above and one cm below.
• After the bifurcation the internal iliac artery continues unbranched for 2-3 cm. Than the lateral sacral and superior gluteal arteries arise.
• The internal iliac artery divides into an anterior visceral and a posterior parietal branch. This division can vary considerably and the parietal branches of the inferial gluteal and internal pudendal arteries may also arise from the main trunk. The main vessels of the anterior division are: the obliterated lateral umbilical artery (obliterated hypogastric artery) which give rise to the superior vesical artery. After this point the artery is mostly obliterated, the obturator artery which can originate at the same level as the superior vesical artery or at the level of the division in the anterior and posterior trunks, the uterine artery, which originates mostly from the lateral umbilical artery shortly after its origin from the internal iliac artery.
• The renal vessels originate at the level of the second lumbar vertebra
• The gonadal arteries originate one vertebra lower at the level of the third lumbar vertebra
• The inferior mesenteric artery originates from the aorta just caudal from the third part of the duodenum.
• The superior mesenteric artery leaves the aorta just cranial of the duodenum.
• The left gonadal vein has its drainage into the left renal vein and the right gonadal vein empties in the cavil vein.
• The lymphatic drainage parallels the course of the veins.
The venous drainage of the pelvis is far more complex and inconstant than the arterial pattern.
All small veins that drain to the internal iliac vein are thin walled, easily torn and relatively fixed. It is difficult to mobilize them without damage and bleeding. Particularly the superior and inferior gluteal veins can be damaged during lymphadenectomy and cause severe bleeding. If torn completely across they retract in the lumbosacral plexus. Attempts to ligate or coagulate them may result in permanent neurological damage such as foot drop.

The venous system that accompanies the uterine artery mostly consists of at least two veins, one above and one below the ureter. These veins can be duplicated which results in a venous system comparable to the pampiniform plexus of the ovary.

All venous plexuses are closely interconnected and intercommunicate in the cardinal ligament. This explains why it is sometimes so difficult to stop venous bleeding from this area.
A golden rule for surgery in this area is that the oncologist only cuts what he/she has identified and first clamped. The use of hemoclips can be very helpful in this area. The gynecologic oncologist should be extra careful in the region of the superior and inferior gluteal veins.
Lymphatic drainage of the cervix
Lymphatic drainage parallels mainly the venous blood vessels. However, changes in the lymphatic vessels like obstruction by metastases can lead to retrograde flow of the lymphatic fluid and retrograde metastases. The main drainage of the cervix is via the cardinal ligament to the interiliac nodes in the region of the obturator artery on the lateral pelvic wall. Additional channels drain to the superior and inferior gluteal nodes in this area. A few channels in the upper part of the cervix can drain to the upper part of the interiliac nodes, the common iliac nodes and the upper external iliac nodes. A few channels may by-pass these routes and drain to the lateral sacral glands, the promontorial glands, or occasionally to the lowest aortic glands. Drainage via the uterosacral ligament to the rectal glands has been described.
The pelvic lymphadenectomy for cervical cancer is mostly restricted to the lymphatic tissue around the large vessels and the obturator fossa.

The operation
1. The patient is placed in the dorsal lithotomy position and is prepped for surgery. We prefer to use Iodine for the abdominal wall and Betadine for the vagina. A #16 Foley catheter is placed in the bladder and connected to drainage back with urine volume monitor. A rectum canula is placed in the rectum and connected to drainage back. The meaning of this catheter is to prevent the accumulation of gas in the rectum during the operation. A rectum filled with gas obstructs the vision in the operation field during the second part of the operation.
2. The abdominal incision is made. A midline incision that is extended to just above the umbilicus gives the possibility to enter the upper abdomen if necessary. An other possibility is a May lard incision. This incision gives easier access to the pelvis in patients who are strongly overweight.
3. The abdomen and pelvis are now carefully inspected. The liver, gallbladder, stomach, spleen and kidneys are palpated for metastatic disease. The bowel is inspected and palpated and the small bowel is run from the ileo-cecal junction to the ligament of Treitz. A nasogastric tube is placed and palpated in the stomach.
4. The pelvic and peri-aortic lymph nodes are palpated and suspicious nodes are excised and sent for frozen section evaluation. If metastases are found the procedure is restricted to debulking of the nodes and the radical hysterectomy is abandoned and replaced by chemo radiation.
5. The uterus, bladder and parametria are palpated. The procedure is stopped when there are signs of tumor growth outside the cervix.
6. A self-retaining retractor is placed in the incision. The coecum and sigmoid are mobilized via an incision of the lateral peritoneum. This facilitates the packing of the bowel in the upper abdomen with moist sponges.
7. The right round ligament is clamped, cut and ligated at the right lateral pelvic wall. The anterior leave of the right broad ligament is incised superiorly along the right lateral pelvic wall to the level of the infundibulopelvic ligament. The retro peritoneum is opened by blunt dissection and the right ureter is visualized.
8. Now the right infundibulopelvic ligament can safely be clamped, cut and ligated at the lateral pelvic wall. The posterior leave of the broad ligament is now incised parallel to the vessels of the infundibulopelvic ligament in the direction of the sacro-uterine ligament.
9. If the ovary has to be preserved than the right utero-ovarian ligament and Fallopian tube is clamped, cut and ligated. The ovary is lifted and the peritoneum of the broad ligament is cut parallel to the vessels of the infundibulopelvic ligament up to the pelvic brim. The right ovary is packed in the right paracolic gutter.
10. The above steps are repeated on the left side.

At this point there are two ways to proceed:
• To perform the lymphadenectomy first.
• To perform the hysterectomy first.

It is the preference of the authors to perform the lymphadenectomy at this point.

Pelvic Lymphadenectomy
1. The lymph node dissection is begun by opening the pelvic spaces by blunt dissection. First the paravesical space is opened, next the pararectal space is opened following the dorsal side of the internal iliac artery.
2. Sharp dissection of all lymph nodes bearing connective tissue over the distal 4 cm of the right common iliac artery and the external iliac artery is performed. It is the authors preference to use a preparer schaar and to cut the connective tissue over the dorsal side of the artery up to the crossing vein, which is the distal border of the dissection. The lateral border is the right genito-femoral nerve.
3. The obturator fossa is now opened with the scissors medial from the genito-femoral nerve following the medial border of the psoas muscle. As soon as there is an opening it can be made wider with the index finger. The external iliac artery is retracted medially with two fingers of the left hand while the obturator nerve is visualized using the closed tip of the scissors. The connective tissue is pushed from the nerve by moving the closed tip of the scissors over the nerve from proximal to distal to the obturator foramen . This is even done more easily by pushing the tip of the digit finger of the right hand over the nerve to the obturator foramen.
4. Now the connective tissue is dissected from the lateral sides of the external iliac artery and between artery and vein. This can be done easy by using a ureter hook to lift up the artery.
5. Next the dissection of the connective tissue is continued over the median side of the external iliac vein and under the vein. Connection is made with the obturator fossa and the vein can now be retracted with the ureter hook. This facilitates further dissection of the connective tissue from the obturator fossa. With the digit finger of the right hand the fatty pedicle can be mobilized up to the obturator foramen. On the dorsal side the obturator vessels can be seen. The author prefers to clip and cut these vessels with hemoclips. The distal part of the fatty pedicle can be clipped as well and the obturator fossa can now easily be cleaned from its lymph nodes bearing connective tissue. Most of this tissue is now only attached to the retroperitoneum and can be removed with a forceps. The fatty tissue from each of the major anatomic sites can be placed in separate containers in formalin and submitted for histological examination. The author separates three portions: common iliac, external iliac and obturator fossa. At the end of the dissecting a hemoclip is placed at the top of the dissection level 5cm above the bifurcation of the external and internal iliac artery. The meaning of this clip is that the radiotherapist can easily find the upper border of the treated area.
6. The same procedure is performed at the left side. The author prefers to perform the left lymphadenectomy from the right side of the patient.

The radical hysterectomy
1. The surgeon goes back to his original position at the left side of the patient. The situation is now that the lymphadenectomy has been performed on both sides, the para-vesical and para-rectal spaces are opened, and the web is exposed on both sides.
2. The next step is the division of the uterine artery and vein on both sides. We start on the right side. One finger of the left hand is placed in the para-rectal space and one finger in the para-vesical space. With the left hand the uterus is pushed medially. The lateral umbilical artery is visualized. Surrounding connective tissue is pushed medially with the tip of the scissors. The uterine artery mostly originates from the lateral umbilical artery, a few millimeters from its origin at the internal iliac artery. The uterine artery is clamped, cut and ligated. With the scissors the accompanying veins are dissected, clamped and cut, pushing the connective tissue medially. By doing this the division between the paravesical- and para-rectal space disappears, making it one space. The same procedure is repeated on the left side. Some surgeons like to perform this part of the procedure immediately following the lymphadenectomy on that side because of their position at the operation table (left or right side of the patient). The author likes to use hemoclips in this part of the operation to selectively clamp and cut the vessels. The advantage is that the surgeon only needs one hand to do the clamping and cutting while his other hand is pushing the uterus medially to give him the right exposure. This is a very elegant technique. However, others prefer to clamp and cut the web with one clamp as close as possible to the pelvic wall which is a possibility as well.
3. Now the uterus is pulled cranially by the first assistant and the bladder peritoneum is cut from the right to the left side. The bladder is separated from the cervix by sharp dissection with the scissors.
4. On the right side the ureter is located and mobilized from the peritoneum with a Kelly forceps about 5 cm from the ureteric canal. The author prefers to put a vessel loop around the ureter which makes a-traumatic manipulation with the ureter feasible. If a vessel loop is not available any other silastic or soft material loop, like a neonatal feeding tube, can be used. The ureter is separated from the medial leaf of the broad ligament just above the level of the utero-sacral ligament. The ureter is placed on tension with the vessel loop or by using a Babcock clamp. The ureter is dissected laterally from the parametrial tunnel. This can be done by opening the roof of the tunnel with a Kelly clamp and clamping, cutting and ligating the tissue of the roof of the canal. The ureter is rolled laterally out of the tunnel and freed from the surrounding tissue until its entrance into the bladder.
5. The left ureter is dissected in the same manner.
6. The bladder is dissected further from the anterior cervix and upper vagina.
7. Now the peritoneum between uterus and rectum is incised. The anterior rectal wall is reflected away from the posterior vagina and the utero-sacral ligaments.
8. The uterus is elevated by the first assistant and the utero-sacral ligaments are clamped, cut and ligated. The paravaginal tissue at the level of the vaginal fornices is clamped, cut and ligated from lateral to the vaginal wall. At this stage of the operation the anterior, posterior and lateral attachments of the uterus and parametria have been ligated.
9. The vagina is transected approximately 3 cm below the inferior margin of the tumor. In patients with a small cervical tumor it makes no sense to remove much of the vagina.
10. After hemostasis the vagina is closed with continuous or interrupted sutures.
11. After removal of the specimen the bladder is filled with 300 cc of sterile saline and inspected for lacerations. A suprapubic catheter is inserted through the abdominal wall in the bladder. The retroperitoneal spaces are left open so drainage of lymph fluid to the abdominal cavity is assured.
12. The authors prefer mass closure of the abdominal wall with a continuous monofil suture no 1 (PDS).
The nerve saving modification of the radical hysterectomy (from: Nerve sparring radical pelvic surgery by C.P. Maas, Academic Thesis, LeidenUniversity, 2003. with permission)
As can be concluded from the anatomy of the inferior hypogastric plexus the plexus can easily be damaged during radical pelvic surgery. Because of the long term sequellae of this damage a technique was developed to save the hypogastric nerve system. This means undoubtedly a less radical approach. For this reason nerve saving can only be done in women with tumors smaller than 4 cm in diameter.
The following steps will facilitate the prevention of surgical damage to the pelvic autonomic nerves during radical hysterectomy: (from Maas et al, with permission)

1. Preserving the hypogastric nerve and the proximal part of the inferior hypogastric plexus. The hypogastric nerve and the proximal part of the inferior hypogastric plexus are identified and lateralized. This is performed during the dissection of the sacrouterine ligaments and the rectal pillars. The peritoneum of the pouch of Douglas is incised between the sacrouterine ligaments and the prerectal space is opened by blunt dissection. We can now identify the tissue between the prerectal space and the pararectal space, better known as the sacrouterine ligament. This bundle of tissue consists of a firm medial part and a much softer, looser lateral part. This lateral part lies directly underneath the ureter and forms the medial border of the pararectal space. The firm medial part is in fact the sacrouterine ligament and the looser lateral part consists of the hypogastric nerve and the proximal part of the inferior hypogastric plexus. This ligament can be separated from the nerve tissue by blunt dissection with a sponge stick while pulling the uterus in a ventral direction, the rectum in a medial direction and the ureter in a cranio-lateral direction. This maneuver will cause the formation of a shallow dimple, which can be developed bluntly. This sacrouterine dissection plane separates the medial ligamentous tissue from the lateral nervous tissue. A soft elastic band (vessel loop) can be placed around the nerve tissue and by careful dissection this can be lateralized. Now the sacrouterine ligament can be safely clamped, cut, and ligated without damaging the hypogastric nerve and the proximal part of the inferior hypogastric plexus.

2. Preserving the middle part of the inferior hypogastric nerves and the pelvic splanchnic nerves. This step is taken during the dissection of the parametrium. By dividing the parametrium the paravesical and pararectal spaces are united. In a frontal section through the parametrium two separate parts can be distinguished: an upper part containing vascular structures, fat and loose connective tissue, and a lower part that feels tight on palpation and contains denser connective tissue and the nerve fibers of the inferior hypogastric plexus. The division of the parametrium follows the shape of the bow of a ship from a lateroventral to a mediodorsal position. Through step 1 the plexus was already partly lateralized. Together with step 2 the inferior hypogastric plexus is saved during this stage of the operation.

3. Preservation of the distal part of the inferior hypogastric plexus. The distal part of the inferior hypogastric plexus is situated in the posterior part of the vesicouterine ligament, lateral and caudal of the lower ureter. The anterior segment of the vesicouterine ligament is cut in the usual fashion, ensuring that the ureteral tunnel is developed medially and ventrally to the ureter. Upon further dissection of the ureter, there is a point that the ureter, the bladder and the vagina meet, allowing access to an avascular triangle. Through this area a pointed and curved clamp can be introduced into the direction of the paravesical space, running underneath the posterior part of the vesicouterine ligament. This tissue segment can be caught in an elastic band and pulled laterally. By finger palpation, the lateral nerve part and the medial vascular part of the posterior sheath of the vesicouterine ligament can be distinguished. Then the vascular part can be clamped and cut. By pulling the band in a lateral and caudal direction and by careful blunt dissection, the paravaginal tissue becomes separate from the nerve plexus and can be clamped and cut.

Postoperative care
Following the operation the patient needs close monitoring for protein, electrolyte and fluid losses. The nasogastric tube can be removed immediately after the operation. The suprapubic catheter should be clamped starting on the fifth postoperative day. If the post void residual volume is < 100cc the suprapubic catheter can be removed. If the patient is unable to void, she is discharged with the suprapubic catheter in place and post void residuals are checked on an outpatient basis.

Complications
The most common complications of a classical radical hysterectomy appear to be bladder atony, thrombophlebitis, vesicovaginal and ureterovaginal fistulas, intestinal obstruction, pulmonary embolism and pelvic lymphocysts. The complications related to damage of the hypogastric nerve and the inferior hypogastric plexus can be avoided by using the nerve sparing technique in tumors smaller than 4 cm diameter.
The frequency of urinary tract fistulas has progressively decreased during the last 30 years and is < 3% in the most recent series.
In case of an ureterovaginal fistula ureteral stents should be placed immediately. Spontaneous repair is possible, surgical repair can take place in a later phase when the surgical trauma is healed.
Patients with a vesicovaginal fistula need antibiotics and bladder drainage for at least 6 weeks, prior to surgical repair. The repair can take place as soon as the signs of inflammation and postoperative swelling are disappeared. A too early repair has a very high chance to fail.
The most serious life threatening complication is pulmonary embolism. The incidence of this complication is 1 %. The incidence can be reduced by the use of heparin and external calf compression devices.

Conclusion
Radical hysterectomy and bilateral pelvic lymphadenectomy is a safe and effective surgical procedure to treat women with cervical cancer stages 1b-2a. With adequate patient selection five- year survival rates of 85-95% can be achieved. More insight in the surgical anatomy of the pelvis and in prognostic factors has created the possibility to modify and individualize the procedure based on the needs of the individual patient. This approach has reduced the long term bladder and bowel sequellae and has even created the possibility of saving the fertility in a small group of women with this disease. Development of new endoscopic techniques will result in a further decline of the surgical sequellae of the radical hysterectomy. Improvement of nonsurgical treatments with chemotherapy and radiotherapy will further change the indications of the operation. But irrespective of these developments the radical hysterectomy will be the only chance on cure for many women with cervical cancer in the world.

It is very clear these days that the operation has the best results in the hands of gynecologists with a special training in gynecologic oncology.


Artikel Radical Hysterectomy with Pelvic Lymphadenectomy oleh:
Prof. A. Peter M. Heintz, MD., PhD.
The Dutch School of Gynecologic Oncology and Pelvic Surgery and
The University of Utrecht
The Netherlands

Female Pelvic Anatomy in Gynecological Cancer Surgery

Surgical anatomy
A basic requirement for the surgical treatment of cervical cancer is an adequate knowledge of the retroperitoneal anatomy, especially the pelvic ligaments and spaces. The pelvic spaces are filled with connective tissue and are avascular. They can be opened by sharp and/or blunt dissection.
The following avascular spaces can be identified (fig. ):
1. the paravesical space
2. the pararectal space
3. the presacral space
4. the space of Retzius

The paravesical space
The paravesical spaces are located on each side of the bladder between the vesico-uterine ligament and the cardinal ligament. Its borders are:
• anterior: the pubic symphysis
• posterior: the cardinal ligament
• lateral: the obturator internus muscle
• medial: the umbilical artery (obliterated)
• caudal: vaginal attachments to the arcus tendineous

The paravesical space can be opened by opening the pelvic peritoneum just anterior to the round ligament and lateral to the bladder. During a radical hysterectomy the paravesical space can easily be opened by blunt dissection after transaction of the round ligament.

The pararectal space
The pararectal space is located between the hypogastric artery and the uterosacral ligament. Its borders are:
• anterior: the cardinal ligament
• posterior: the sacrum
• lateral: the hypogastric artery (a. iliaca interna)
• medial: the uterosacral ligament and the rectum
• caudal: m. levator ani
The pararectal space can be opened by opening the pelvic peritoneum over the external iliac artery just below the bifurcation. The space can be opened by blunt dissection just medial from the internal iliac artery following the curve of the sacrum. Before doing so the ureter has to be identified and retracted medially. If a salpingo-oophorectomy has to be performed, the procedure is easy after transection of the infundibulopelvic ligament.
If the ovary has to be preserved, the ovary and its vascular pedicle can be mobilized up to the pelvic rim (linea innominata) by cutting the pelvic peritoneum just below the vascular pedicle. After this the retroperitoneum is opened, the ureter and hypogastric artery can easily be identified and the pararectal space opened.

The presacral space
The presacral space is located between rectum and sacrum. Its borders are:
• anterior: the rectum
• posterior: the sacrum
• lateral: the left and right uterosacral ligaments
The presacral space can be opened by mobilizing the rectum by blunt and sharp dissection starting from the right pararectal space. Special attention must be paid to the presacral veins. They can cause serious hemorrhage if damaged.

Space of Retzius
The space of Retzius is located between the symphysis pubis and the bladder. Its borders are:
• anterior: the symphysis pubis
• posterior: the bladder
• lateral (left and right): bladder attachments to the pelvic sidewall
• caudal: bladder neck, urethra, vagina
The space of Retzius can be opened by blunt dissection of the bladder peritoneum from the symphysis pubis.

The pelvic autonomic nerves
Autonomic nerve damage during radical pelvic surgery is responsible for bladder dysfunction, rectal motility disorders and sexual dysfunction. Because of the close relation between the autonomic nerves and the tissue that has to be removed damage of these nerves is thought to be an inevitable part of the radical hysterectomy. However more insight in the biology of cervix cancer has created room for a more individualized approach, especially in women with small tumors. In these patients the autonomic nerves can be saved without compromising survival.

The part of the autonomic nerve system that is important in radical pelvic surgery is the superior hypogastric plexus, the hypogastric nerve, the inferior hypogastric plexus and the splanchnic nerves.
The superior hypogastric plexus is a fenestrated network of fibers located anterior to the lower abdominal aorta. The plexus gets its afferent fibers from the spinal chord between the levels th 10 and L2. From this plexus the hypogastric nerves originate bilaterally just below the level of the promontory. The hypogastric nerves run parallel to the ureter, 2 cm medio-dorsal of them, to the left and right inferior hypogastric plexus. The inferior hypogastric plexus has connections with the sacral roots from S2-S4 via the splanchnic nerves and has relations with the sacral sympathetic chain. Together these nerves form the inferior hypogastric plexus. This plexus is placed in a sagittal plane and measures about 3x4x0.5 cm. The plexus stretches from antero-lateral of the rectum to lateral of the cervix and vaginal fornix to the lateral vaginal wall and the base of the bladder. So, the inferior hypogastric plexus is closely related to the pelvic connective tissue planes: the sacrouterine ligaments, the cardinal ligaments and the vesicouterine ligaments (Maas et al). According to Maas et al wide and deep resection of these structures will result in disruption of the inferior hypogastric plexus.

Voiding, defecation and sexual function can all be severely disrupted when the pelvic autonomic nerves are damaged during surgery. The concept of preservation of the pelvic autonomic nerves was already developed in the sixties by Japanese gynecologists. However, it took until recently before the technique got broad attention in gynecologic oncology.

The pelvic vessels
Vascular anatomy
The vascular supply of the pelvis is characterized by a very rich collateral circulation. The consequence is that, if necessary, most vessels can be interrupted without consequence. However, the better the blood supply, the better the healing and the effect of chemotherapy and radiotherapy. So, whenever possible the vessels should be spared.

The anatomical position of the vessels is largely consistent, but individual variation exists.
The most important anatomical landmarks are the following:
• The aortic bifurcation occurs over the fourth lumbar vertebra, which is at the level of the umbilicus. The aorta divides into the left and right common iliac artery.
• The common iliac artery divides into the external and internal (hypogastric) iliac artery. This bifurcation is located at the right side 1.5 cm, and at the left side 2 cm below an imaginary line drawn across the centre of the sacral promontory.
• The ureter crosses the bifurcation between 2 cm above and one cm below.
• After the bifurcation the internal iliac artery continues unbranched for 2-3 cm. Than the lateral sacral and superior gluteal arteries arise.
• The internal iliac artery divides into an anterior visceral and a posterior parietal branch. This division can vary considerably and the parietal branches of the inferial gluteal and internal pudendal arteries may also arise from the main trunk. The main vessels of the anterior division are: the obliterated lateral umbilical artery (obliterated hypogastric artery) which give rise to the superior vesical artery. After this point the artery is mostly obliterated, the obturator artery which can originate at the same level as the superior vesical artery or at the level of the division in the anterior and posterior trunks, the uterine artery, which originates mostly from the lateral umbilical artery shortly after its origin from the internal iliac artery.
• The renal vessels originate at the level of the second lumbar vertebra
• The gonadal arteries originate one vertebra lower at the level of the third lumbar vertebra
• The inferior mesenteric artery originates from the aorta just caudal from the third part of the duodenum.
• The superior mesenteric artery leaves the aorta just cranial of the duodenum.
• The left gonadal vein has its drainage into the left renal vein and the right gonadal vein empties in the cavil vein.
• The lymphatic drainage parallels the course of the veins.
The venous drainage of the pelvis is far more complex and inconstant than the arterial pattern.
All small veins that drain to the internal iliac vein are thin walled, easily torn and relatively fixed. It is difficult to mobilize them without damage and bleeding. Particularly the superior and inferior gluteal veins can be damaged during lymphadenectomy and cause severe bleeding. If torn completely across they retract in the lumbosacral plexus. Attempts to ligate or coagulate them may result in permanent neurological damage such as foot drop.

The venous system that accompanies the uterine artery mostly consists of at least two veins, one above and one below the ureter. These veins can be duplicated which results in a venous system comparable to the pampiniform plexus of the ovary.

All venous plexuses are closely interconnected and intercommunicate in the cardinal ligament. This explains why it is sometimes so difficult to stop venous bleeding from this area.
A golden rule for surgery in this area is that the oncologist only cuts what he/she has identified and first clamped. The use of hemoclips can be very helpful in this area. The gynecologic oncologist should be extra careful in the region of the superior and inferior gluteal veins.

Lymphatic drainage of the cervix
Lymphatic drainage parallels mainly the venous blood vessels. However, changes in the lymphatic vessels like obstruction by metastases can lead to retrograde flow of the lymphatic fluid and retrograde metastases. The main drainage of the cervix is via the cardinal ligament to the interiliac nodes in the region of the obturator artery on the lateral pelvic wall. Additional channels drain to the superior and inferior gluteal nodes in this area. A few channels in the upper part of the cervix can drain to the upper part of the interiliac nodes, the common iliac nodes and the upper external iliac nodes. A few channels may by-pass these routes and drain to the lateral sacral glands, the promontorial glands, or occasionally to the lowest aortic glands. Drainage via the uterosacral ligament to the rectal glands has been described.
The pelvic lymphadenectomy for cervical cancer is mostly restricted to the lymphatic tissue around the large vessels and the obturator fossa.

Artikel Female Pelvic Anatomy in Gynecological Cancer Surgery oleh:
Prof. A.Peter M. Heintz
Gynecologic Oncologist
The Dutch School of Gynecologic Oncology and Pelvic Surgery and Utrecht University
The Netherlands