Removal of uterine sarcomaMedical editor Gunnar B. Kristensen MD
Oslo University Hospital
Raphael Pollock, MD, PhD
MD Anderson Cancer Center
Patients suspect of harbouring a soft tissue sarcoma of the uterus or other internal gynecological organs by clinical examination and/or radiological studies should promptly be referred to a specialized sarcoma center. This should be done without previous biopsy.
Prognosis of patients with localized gynecological sarcomas is as with other abdominal sarcomas greatly dependent on the correct initial treatment.
At the specialized sarcoma center, the patient will be evaluated by a multidisciplinary team which will determine the need for biopsi and the treatment plan.
Total hysterectomy and bilateral salpingo-oophorectomi is the standard treatment for localized sarcomas of the uterus not infiltrating through the serosal surfaces.
An extended resection is indicated for all tumors extending beyond the uterus serosa and multiorgan resection must be carried out for tumors densely adhered to or infiltrating neighbouring organs. Since especially endometrial stromal sarcomas, but also other gynecological sarcomas are hormone sensitive, bilateral ooporectomy is always indicated.
Utmost care must be taken to achieve negative tumor margins over all surfaces and including in the vagina. The limited pelvic space renders resection of large gynecological sarcomas especially challenging. Laparoscopic resections for uterine sarcomas should not be attempted.
- Curative treatment where the avoidance of spreading of tumor cells is considered.
- Gynecological laparotomy tray
- Bookwalters retractor
- Surgical stapler (f.ex. TA®)
- Bowel emptying
- Thrombosis prophylaxis
- Antibiotic prophylaxis
For the operative treatment of gynecological sarcomas, the same oncological principles described in the resection of retroperitoneal sarcomas are applied.
- Make a mid-line incision.
- Use a Bookwalters retractor.
- Check the entire abdomen for possible spreading:
- Liver, spleen, lymph nodes, diaphragm, stomach, bowels, pelvis, top of uterus.
- Palpate the ovaries and fallopian tubes for adherances or infiltration into uterus (from either the disease, previous endometriosis, or previous infection)
- Lower the patient's head to to remove the bowels away from the operation field (Trendelenburg).
- Pack away the bowels in a compress soaked with NaCl 9 mg/ml. Hold in place with decharp og spekler.
- Stitch the peritoneum to the symphysus to remove the bladder from the operation field.
- Hold the uterus by salpinger with two Kocher forcepses.
- Open to the retroperitoneum on the pelvic side-wall.
- Incise the bladder peritoneum to separate the bladder from the anterior uterus.
- Separate the bladder from the anterior uterus and cervix.
- Identify the superior vesical artery and follow it to the origin from the internal iliacal artery.
- The uterine artery is ligated close to the vesical artery.
- Identify both ureters and follow them to the confluence with the bladder.
- Remove the supportive tissue on the ureter (go through ”roof of the tunnel") and release ureter.
- Retract the ureter to include resection of the parametria which lies adjacent to the uterus as well as to achieve space for instruments for removal of uterus.
- Make sure the ureter is not separated from the pelvic wall to maintain the blood supply to the ureter.
- Avoid damage of nerves.
- Check that the ureter is retracted from the area to be resected.
- Remove the uterine adjacent part of the parametrium (approx. 2 cm) as there may be cancer there. This is not done for a routine hysterectomy.
- Conserve the parametrium as much as possible in order to avoid nerve damage causing for urinating.
- Do not remove lymph nodes for sarcoma operations since there is very little chance of metastases in them.
- Repeat the procedure on the other side of the uterus.
- Open the peritoneum from behind to retract the colon (the rectum is attached to the posterior vaginal wall)
- Divide the sacral-uterine ligament and make a suture ligate. Go gradually forward.
- Push the rectum down to create more room to separate the top of the vagina.
- Divide the cardinal ligament down along the vaginal wall and cut with the tip of the scissors all the way down to the wall.
- Use a surgical stapling instrument (for example TA®) to close the top of the vagina (due to sarcoma)
- Rinse the remainder of the vagina with sterile water (hypotonic solution to destroy possible tumor cells)
- Put a new row of staples below the previous row with a surgical stapler. Make sure the ureter is not clamped in the instrument.
- Divide between the two rows of staples. Be certain of cutting below the first row (to avoid contamination of tumor cells in the abdomen - spill of tumor cells is crucial for the patient's prognosis)
- The unfixed specimen should be delivered dry and immediately to the laboratory.
- Secure hemostasis.
- Count gauze pads and instruments.
- Rinse the abdomen with 2 L sterile water to remove possible tumor cells.
- Suture the fascia.
- The skin may be closed with a skin stapler.
A detailed operative description, including status of peritoneal surfaces, inadvertent intralesional dissection and tumor rupture must be reported in order to aid in risk-classification and prognosis.
Complications that can occur:
- Urination problems: the patient should have a catheter for 3-5 days. Monitor bladder emptying after removal of Foley catheter.