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Robot-assisted radical hysterectomy for cervical cancer


Medical editor M. Bilal Sert MD
Gynecological Oncologist
Oslo University Hospital

General

Early stage cervical cancer is treated either with surgery or radiation therapy. Surgery is usually the treatment of choice due to the favorable side effect profile. Cervical cancer in stage Ia1 can be treated by local extirpation of the tumor, usually by conization. For stages Ia2 and Ib less than 2 cm fertility-sparing surgery or radical hysterectomy are performed. A radical hysterectomy must be performed for larger tumors in stage Ib. Small tumors in stage IIa are sometimes also treated by radical hysterectomy.

A serious side effect of a radical hysterectomy is bladder denervation which may cause difficult urination or urinary incontinence. Bladder denervation is caused by injury to autonomous nerves to the bladder during surgery. These nerves should therefore be avoided during surgery. During the operation, the sacrouterine and cardinal ligaments are cut at a distance of 2-3 cm from the cervix to remove any micrometastases near the cervix.

A radical hysterectomy is supplemented with pelvic lymph node dissection to examine for possible micrometastases.

The first laparoscopic radical hysterectomy in the Nordic countries was performed at the Norwegian Radium Hospital in April 2004.

The first robot-assisted radical hysterectomy outside the US was performed at the Norwegian Radium Hospital in November 2005.

Indications

  • Cervical cancer stage Ia2
  • Cervical cancer stage Ib
  • Cervical cancer stage IIa

Goal

  • Cure the disease.

Preparation

  • Large bowel emptying
  • Thrombosis prophylaxis
  • Antibiotic prophylaxis

Implementation

  • The patient lies in the lithotomy position during the operation.
  • Tip the patient's cranial end (Trendelenburg position). Special shoulder supports and legs supports are used.
  • A five-trocar technique is used. Open the umbilicus 1 cm and place a Hason trocar (10 or 12 mm).
  • Insufflate intraabdominally with 3 liters of carbon dioxide gas.
  • Insert a camera in the trocar.
  • Inspect the peritoneum and upper abdomen for possible pathological findings.
  • Insert two 8 mm trocars on the arms of the robot around 10 cm from the umbilicus at the umbilical level.
  • Insert one 5 mm trocar at the umbilical level on the right side 4 cm from the umbilicus.
  • Insert one 10 or 12 mm trocar at the umbilical level on the left side 4 cm from the umbilicus.
  • These last two trocar areas are used by the assistant for suction, forceps, and a ligature instrument.
  • Dissect the pararectal and paravesical spaces.
  • Dissect and push the bladder down from the cervix.
  • Ligate the uterine artery bilaterally using a ligature instrument.
  • Dissect the ureters.
  • Autonomous nerve pathways to the bladder follow the ureters. Dissection of the ureters must be close to the peritoneum to spare these nerve pathways.
  • The ureters are released from the parametria by opening the ceiling of the ureter tunnel.
  • Ligate the adnexa using a ligature instrument.
  • Dissect and divide the sacrouterine and cardinal ligaments on both sides at a distance of 2-3 cm from the cervix.
  • Extirpate the uterus with a 2-3 cm vaginal cuff.
  • Remove the surgical specimen vaginally.
  • Suture the top of the vagina.
  • Check hemostasis in the pelvis and continue withpelvic lymph node dissection
  • Deflate the gas.
  • Check the trocar areas.
  • Close the fascia by the 10/12 mm openings. Otherwise, close the skin intracutaneously.

Follow-up

Observations

  • The patient will usually have a urinary catheter for 3 days.
  • After removal of the catheter, residual urine must be checked and an ultrasound of the kidneys is performed.
    • If the amount of residual urine is less than 100 ml, the patient is discharged.
    • If the amount of residual urine is more than 100 ml, the patient is trained for self-catheterization before discharge.
  • The patient is normally discharged after 3 days.

Complications

  • Urinary tract infection due to inadequate bladder emptying.
  • Lymph edema of the lower extremities.

Follow-up

Outpatient follow-up should be after 3 weeks and thereafter every 3 months with a gynecological examination for the first 2 years, 6 month intervals the next 3 years, thereafter annually.


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