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Radical hysterectomy with pelvic lymphadenectomy remains the treatment of choice for women with Stages IA2 and IB1 carcinoma of the cervix, and selected patients with Stage II endometrial cancer. Improvement in surgical techniqe, administration of prophylactic antibiotics, thromboemolic prophylaxis, and advances in critical care medicine have resulted in lower operative morbidity associated with this procedure. Major urinary tract complications such as ureteral injury or vesico-vaginal fistula are now extremely rare (<1%). Five-year survival rates following this procedure vary according to a number of clinical and histologic variables, and may be as high as 90% in women without lymph node metastases.
The number of patients with early stage cervical cancer has steadily increased with the widespread use of the Papanicolaou test for screening. In 2009, it is estimated that there will be 11,070 new cases of cervical cancer in the United States and nearly 500,000 new cases worldwide. Approximately 85% of newly diagnosed cervical cancer in industrialized countries are expected to have localized or regional disease [1, 2]. With the trend toward early detection, more patients with invasive cervical cancer are diagnosed with early stage disease and are candidates for primary surgical treatment with radical hysterectomy and pelvic lymphadenectomy.
In 1898, Ernst Wertheim of Vienna described the operation of radical hysterectomy including removal of the parametrium and pelvic lymph nodes. In 1905, Wertheim reported outcomes of the first 270 patients treated by radical hysterectomy, which included an operative mortality rate of 18% and a major morbidity rate of 31%. Since that time, radical hysterectomy with pelvic lymphadenectomy has been performed with modifications in surgical technique as the major surgical treatment for early stage invasive cervical cancer [3, 4]. The use of prophylactic antibiotics, thromboembolic prophylaxis, administration of blood products, and advances in postoperative and critical care medicine all have lowered operative morbidity, and increased the survival rate of cervical cancer patients treated with this operation.
The primary indication for radical hysterectomy with pelvic lymphadenectomy is Stage I invasive cervical cancer. Early invasive cervical cancer is divided by the International Federation of Gynecology and Obstetrics (FIGO) Staging System into Stage IA1, which includes lesions invading the cervical stroma to a depth of 3mm, or less and a maximum horizontal spread of 7mm, and Stage IA2, which includes lesions with stromal invasion of 3–5mm and a maximum horizontal spread of 7mm . These diagnoses can be made only after careful histologic evaluation of a conization specimen using an ocular micrometer to establish the depth of stromal invasion. Patients with Stage IB1 cervical cancer have microscopic evidence of stromal invasion >5mm, horizontal spread >7mm or a clinically visible cervical lesion ≤4.0cm diameter. In patients with FIGO Stage IA1 cervical cancer and no evidence of lymph vascular space invasion (LVSI), conservative therapy with cervical conization or simple hysterectomy is appropriate [6–11]. However, patients with Stage IA2 or Stage IB1 cervical cancer have a significant risk of lymph nodal spread and should be treated by radical hysterectomy and pelvic lymphadenectomy. Patients with Stage IB2 or Stage IIA cervical cancer are treated with chemoradiation or combined therapy in many institutions. However, selected patients with Stage IB2 or IIA cervical cancer may be treated with radical hysterectomy and pelvic lymphadenectomy [12–14].
Radical hysterectomy may also be considered in the treatment recurrent cervical cancer. This procedure is appropriate only in patients with small central recurrences, following primary radiation of early stage disease. Maneo and colleagues, for example reported that radical hysterectomy is a safe alternative to pelvic exenteration in patients with Stage IB/IIA cervical cancer treated by primary radiation therapy, who have a recurrence <4cm in diameter without evidence of ureteral obstruction or parametrial involvement .
Finally, radical hysterectomy with pelvic lymphadenectomy is indicated in patients with endometrial cancer and endocervical involvement (FIGO Stage II disease). Boente reviewed the clinical, surgical, and histopathologic data from 202 patients with endometrial adenocarcinoma and cervical involvement, and reported a survival advantage for patients treated by radical hysterectomy with pelvic lymphadenectomy when compared to total abdominal hysterectomy. This advantage was most notable in patients with multiple high-risk factors . Radical hysterectomy with pelvic lymphadenectomy alone can be therapeutic in selected patients with Stage II endometrial cancer, thereby avoiding the morbidity associated with combination therapy .
Prior to undergoing radical hysterectomy, patients should have a thorough evaluation to insure that there are no major medical contraindications to surgery. The anesthesiologist should be aware of the potential for blood loss in patients undergoing this procedure and should make preparation for central venous access as well as the availability of properly typed and cross-matched blood. A prophylactic antibiotic, usually a first generation cephalosporin, is given within 30 minutes of skin incision . Heparin 5000 units is given subcutaneously prior to surgery and three times daily in the postoperative period for thromboembolic prophylaxis. In addition, sequential compression devices (SCDs) are placed on both lower extremities immediately prior to surgery, and are left in place until the patient is ambulating .
Complications of radical hysterectomy with pelvic lymphadenectomy are summarized in Table 1. Bladder dysfunction and lymphocyst formation are among the most common complications of radical hysterectomy and occur in 5%–15% of cases in recent reports. Bladder dysfunction results from extensive dissection of the ureters at the bladder base and transection of the uterosacral ligaments, which interrupts autonomic nerve supply to the bladder. In general, more radical dissection results in a higher frequency of bladder dysfunction. However, preservation of the superior vesical artery and blood supply to the distal ureter has resulted in a marked decrease in the frequency of vesicovaginal and ureterovaginal fistula following radical hysterectomy.
Lymphocyst formation after radical hysterectomy and lymphadenectomy is due to interruption of efferent pelvic lymphatics and can result in lymphedema, pelvic discomfort, and infection as well as an increase in the frequency of deep venous thrombosis and pulmonary embolism. Variation in the incidence of lymphocyst formation depends on the extent of lymphadenectomy, retroperitoneal drain placement, and differences in the surgical technique used for ligating lymphatic channels. Lymphocysts can be managed with guided-percutaneous drainage or laparoscopic surgical resection [35, 36].
The incidence of thromboembolic disease after radical hysterectomy has decreased over time, as a result of widespread implementation of thromboprophylaxis with preoperative and postoperative Heparin and lower extremity sequential compression devices. Nevertheless, it remains the leading cause of mortality in the immediate postoperative period. Multiple clinical trials have provided irrefutable evidence that thromboprophylaxis decreases the risk of deep venous thrombosis and pulmonary embolus. Pulmonary embolus has been cited as the most common cause of preventable hospital death, therefore making thromboprophylaxis the number one strategy to improve safety for patients undergoing major pelvic surgery .
The 5-year survival in patients with early stage cervical cancer treated with radical hysterectomy and pelvic lymphadenectomy varies between 80% and 95% according to a number of clinical and histologic findings, and is summarized in Table 2. Patients with low-risk early-stage disease, undergoing radical surgical treatment have a survival of nearly 100% . However, patients with more advanced disease have lower reported outcomes. Several risk factors related to poor prognosis include large tumor volume, deep stromal invasion, presence of lymph vascular space invasion, and lymph node metastases [31–33]. A thorough analysis of these factors is helpful in determining which patients may benefit from postoperative therapy following radical hysterectomy.
Radical hysterectomy with pelvic lymphadenectomy is the treatment of choice for healthy women with stage IA2-IB1 cervical carcinoma. Women with nonbulky IB2 and IIA cervical carcinoma, centrally recurrent disease, and endometrial carcinoma with cervical involvement may also be considered for surgical treatment by radical hysterectomy. Improvements in surgical technique, prophylactic antibiotics, thromboembolic prophylaxis, administration of blood products, and advances in postoperative and critical care medicine all have lowered operative morbidity from this procedure. Five-year survival rates in excess of 90% can be achieved when this procedure is performed for the proper indications.