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