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Radical hysterectomy for endometrial cancer


Medical editor Gunnar B. Kristensen MD
Gynecological Oncologist
Oslo University Hospital

General

Endometrial cancer in stage II can either be treated with a radical hysterectomy or a hysterectomy followed by radiation therapy. As per January 2006, there are no studies comparing the effect and morbidity of the two treatment alternatives. At Oslo University Hospital, a radical hysterectomy is performed when MRI shows involvement of cervical stroma. 

Difficulty emptying the bladder is a serious side effect after a radical hysterectomy due to damage to the autonomous nerves of the bladder during the operation. It is therefore very important to avoid these nerves during the operation.

During the operation, the sacrouterine and cardinal ligaments are divided 2-3 cm from the cervix. This is to remove possible micrometastases near the cervix.  

Pelvic and paraaortal lymph node staging is always performed for these patients. 

 

Indication

  • MRI indicates cervical involvement

Goal

  • Cure the disease


Equipment

Gynecological surgery tray


Preparation

  • Enema
  • Thrombosis prophylaxis
  • Antibiotic prophylaxis

Implementation

  • Make a midline incision in the abdomen.
  • Inspect the pelvis and upper abdomen for possible pathological findings.
  • Dissect the pararectal and paravesical spaces. 
  • Dissect and push the bladder away from the cervix.
  • Ligate the uterine artery bilaterally.
  • Dissect the ureter.
  • Autonomous nerve pathways to the bladder follow the ureter. The dissection of the ureters must be close to the peritoneum to preserve these nerve pathways. 
  • The ureters are dissected from the parametria by opening the roof of the ureteral tunnel.
  • Avoid dissecting the plexus area.
  • Cut and ligate the adnexae and attach them to the pelvic or abdominal wall. Mark with metal clips. Usually, the ovaries are attached to the abdominal walls in the iliac fossa.
  • Dissect and divide the cardinal and sacrouterine 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 that the specimen has a 2-3 cm vaginal cuff.
  • Suture the vagina using the Benedetti Panizi method. Start from behind and suture towards the front. This will create a rounded vaginal top without deep hollows in the vaginal corners. 
  • Perform hemostasis in the pelvis and continue with the para-aortic and pelvic lymph node dissection.
  • Perform hemostasis again and close the abdomen.

Follow-up

Observations

  • The patient normally has a bladder catheter for 3 to 5 days after the operation. 
  • After removal of the catheter, residual urine must be checked. The patient may have problems emptying her bladder.
  • The volume of residual urine should be less than 100 ml before the patient is discharged.

Complications

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

Follow-up

The patient should have an outpatient follow-up visit every 3 months with a gynecological examination in the first 2 years, 6 month intervals the next 5 years, and then annually.


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