Radical hysterectomy for cervical cancerMedical editor Gunnar B. Kristensen MD
Oslo University Hospital
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 or simple hysterectomy, depending on desires for future fertility. For stages Ia2 and Ib less than 2 cm without lymphatic or vascular tumor invasion, 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 damage of the bladder innervation which may cause difficult urination or urinary incontinence. This damage 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.
- Cervical cancer stage Ia2
- Cervical cancer stage Ib
- Cervical cancer stage IIa
Gynecological surgery tray
- Large bowel emptying
- Thrombosis prophylaxis
- Antibiotic prophylaxis
A midline incision is made in the abdomen.
The pelvis and upper abdomen are inspected for metastatic desease.
The pararectal and paravesical spaces are dissected.
The bladder is dissected and pushed down away from the cervix.
The uterine artery is ligated bilaterally.
The ureters are dissected.
The 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 dissected from the parametria by opening the ceiling of the ureter tunnel.
Avoid dissecting the plexus area.
Cut and ligate the adnexa and attach these to the pelvic or abdominal wall. Mark with metal clips. The ovaries are often fixed to the abdominal walls of the iliac fossa.
Dissect and split the sacrouterine and cardinal ligaments on both sides at a distance of 2-3 cm from the cervix.
Extirpate the uterus using diathermy 2–3 cm distal to the cervix so the specimen will have a 2–3 cm large vaginal cuff.
Suture the vagina ad modum Benedetti Panizi. Start from behind and suture toward the front. This will create a rounded vaginal top without deep hollows in the vaginal corners.
Check hemostasis again and close the abdomen.
When operating for small cell cancer and stage Ib2, the paraaortal area is also opened and visible lymph nodes are removed.
The patient will usually have a urinary catheter for 3-5 days.
After removal of the catheter, residual urine must be checked. The patient may have problems emptying her bladder.
The amount of residual urine should be less than 100 ml before the patient is discharged.
Outpatient follow-up should be every 3 months with a gynecological examination for the first 2 years and followed by 6 month intervals the next 3 years, thereafter annually.