Box 26-1 Master Surgeon’s Corner
The size and histologic cell type of the lesion, together with the desire for future fertility, help guide the technique and extent of the procedure.
A cervical conization refers to the surgical excision of the squamous-columnar junction. The indications are both therapeutic and diagnostic. It is a therapeutic procedure in cases of cervical intraepithelial neoplasia grade 2 or 3 and microinvasive carcinoma of the cervix (negative margins). Diagnostic indications include unsatisfactory colposcopy, positive endocervical curettage, persistent positive cytology for dysplasia in the presence of a normal colposcopy, and a cervical biopsy positive for microinvasion. The full management paradigm has been discussed in previous chapters and will not be reviewed here (see Chapters 4 and 5). A knife cone biopsy is the gold standard and has the advantage of proper evaluation of the margins because no thermal energy is used; however, for the most part, a loop electrosurgical excision procedure (LEEP) is sufficient. The exception is in cases in which a precise margin is essential. LEEP is usually performed as an outpatient procedure under local anesthesia, whereas in cases of knife cone biopsy, general or regional anesthesia is used.
Knife Cone Biopsy
Preoperatively a colposcopic evaluation of the cervix is performed to evaluate the extent of disease. Biopsies from appropriate areas are sent, and if a conization is indicated, formal informed consent is obtained with emphasis on possible complications including cervical incompetence, bleeding, and infection. The patient is admitted to the hospital on the day of surgery.
Box 26-2 Caution Points
Optimal visualization is important in order to properly evaluate the extent of the lesion and thus minimize the need for repeat procedures.
The size of the excision should be sufficient to remove the entire lesion; however, it should be kept in mind that the deeper the conization, the greater is the likelihood of future cervical incompetence.
The use of relatively large loop electrodes can lead inadvertently to removal of large amounts of the cervix.
The procedure is performed under general or regional anesthesia. The patient is put in the semilithotomy position, and a bimanual examination is performed. The patient is then prepped and draped and the bladder emptied via a catheter. A speculum is inserted into the vagina for maximum visualization. Lugol’s stain may be used to help delineate the dysplasia. A single-tooth tenaculum is used to grasp the anterior aspect of the cervix. Bleeding from the cervix can be minimized by injecting a dilute solution of vasopressin in lidocaine into the 4 quadrants of the cervical stroma. Figure-of-eight “stay” stitches of 1-0 delayed-absorbable suture can be placed at the 3 o’clock and 9 o’clock positions on the cervix just below the cervicovaginal junction. These stitches will aid in hemostasis and can be used to manipulate the cervix during conization. A #11 or a #15 blade is used to make a circumferential incision incorporating the demarcated area and the entire transformation zone. A cone-shaped incision should be made to the depth of approximately 2 to 2.5 cm, depending on the depth of the cervix (Figure 26-1). The cone should preferably be excised in a single piece and a suture placed at 12 o’clock to facilitate orientation of the specimen by the pathologist. Once the cone has been removed, an endocervical curettage is performed.
FIGURE 26-1. Knife cone biopsy.
Hemostasis of the cone bed can be obtained using one of many techniques. Electrocautery, either with a ball electrode or a regular cautery tip, is commonly used. Monsel’s solution applied generously to the cone bed can also control the bleeding. An additional option is suturing the bed of the cone with either a running lock absorbable suture or interrupted figure-of-eights that also approximate the proximal and distal edges. A combination of techniques, together with direct pressure or hemostatic agents (eg, Surgicel), may be used in case of heavy bleeding.
Loop Electrosurgical Excision Procedure
Loop diathermy has been shown to be an effective and reliable alternative to cold knife conization with the advantages of it being performed in an outpatient setting without the need for general anesthesia. It has been found to be technically easier and less time consuming than cold knife conization.1,2
The LEEP probe consists of a wire loop (stainless steel or tungsten), which comes in multiple sizes, attached to an insulated T-bar. It is performed with a blend of coagulation and cutting. The size of the loop is chosen with respect to the volume of the lesion. Most commonly, loop sizes of 10 to 20 mm are used. Although there is an advantage in obtaining the entire specimen in 1 pass because it helps the pathologist identify the surgical margins, the depth required usually entails a minimum of 2 passes of the loop (Figure 26-2). The procedure is performed under colposcopic guidance, and therefore, the margins can be re-examined before completion of the procedure. Bleeding from the cone bed can be controlled with the same techniques mentioned earlier for knife cone biopsy.
FIGURE 26-2. Loop electrosurgical excision procedure (LEEP).
Box 26-3 Complications and Morbidity
Significant bleeding may occur 10 to 21 days after the procedure (5%-10% of cases) and is more common when using a larger loop and when a vasoconstrictive agent is not injected prior to the procedure.
Cervicitis and ascending endometritis are rare but can occur.
Cervical incompetence and, as a result, premature delivery have been reported to be doubled (approximately 6%) after a cervical excisional procedure.3 However, no increase in neonatal morbidity or mortality has been shown.
Cervical stenosis is an uncommon result (3%) of a cervical excisional procedure.
Patients usually tolerate cervical excisional procedures well and are discharged home on a regular diet the same day.
Box 26-4 Master Surgeon’s Corner
The oncologic outcomes of the radical trachelectomy are comparable to those of radical hysterectomy; therefore, patients wishing to preserve fertility who meet the eligibility criteria should be offered this procedure.
The radical trachelectomy is a fertility-sparing procedure that consists of removing the majority, if not all, of the cervix jointly with the parametrium and the upper portion of the vagina. It can be performed by an abdominal or vaginal approach. The latter was initially described by Dargent and, when performed together with a laparoscopic pelvic lymph node dissection, has been shown to have low morbidity, comparable onco-logic outcomes to the radical hysterectomy, and good obstetric outcomes.3–5 The indications are desire to preserve fertility, tumor size less than 2 cm, International Federation of Gynecology and Obstetrics (FIGO) stage IA1 disease with lymph vascular space involvement, stage IA2 or IB1 tumors, squamous cell or adenocarcinoma, no involvement of the upper endocervical canal, and no metastasis to regional lymph nodes on computed tomography or magnetic resonance imaging.6
Radical Abdominal Trachelectomy
Once a patient is diagnosed with cervical cancer and expresses a desire to retain fertility, thorough evaluation is warranted to help decide whether a radical trachelectomy is appropriate. Because the FIGO staging of cervical cancer is clinical (as previously discussed in Chapter 5), the first step is a complete history, physical, and pelvic examination. When the pelvic examination is challenging, an examination under anesthesia should be performed. In patients with early-stage disease, a chest x-ray, complete blood count (CBC), and kidney function (creatinine) are frequently performed preoperatively. Additional imaging and blood work are left to the discretion of the treating oncologist while taking into consideration the patient’s symptoms, comorbidi-ties, and results of the clinical examination.
Once a decision is made to proceed with a radical trachelectomy and pelvic lymph node evaluation, informed consent is obtained. It is important to discuss the possibility of bladder dysfunction, urinary tract injury, and lymphedema and the option of a radical hysterectomy, in addition to bleeding, infection, and injury to other adjacent organs.
The patient is admitted to the hospital on the morning of the operation. Prophylactic antibiotic is administered prior to surgery.
Box 26-5 Caution Points
The height of the cervical amputation should be as far away from the internal os as possible, as long as a surgical margin of 5 mm is obtained.
In a radical abdominal trachelectomy, the uterine artery is identified; however, attempts to preserve it should be made, and only the descending branches of the uterine artery should be ligated.
The patient is put in semilithotomy position, and general anesthesia is induced. Care is taken to place the legs appropriately to avoid pressure on the peroneal nerves. A bimanual examination is performed to assess the extent of disease to further guide the procedure. The abdomen and perineum are prepped and draped, and an indwelling Foley catheter is inserted into the bladder.
The incision can be either transverse (Pfannenstiel, Maylard, or Cherney) or a low midline incision from the umbilicus to the pubic bone. This is decided both by the extent of disease and the patient’s habitus.
Once the peritoneal cavity is entered, a full abdominal and pelvic exploration is performed to look for metastatic disease. Special attention to the retroperitoneal nodes and to penetration of the tumor through the cervix toward the parametrium and pelvic side-walls is noted. The patient is then put in Trendelenburg position, a self-retaining retractor is inserted, and the bowel is packed off to facilitate maximum exposure of the pelvis. Care must be taken to avoid undue pressure on the psoas muscles by the blades of the retractor to avert a femoral nerve injury secondary to compression. Thin patients are particularly vulnerable.
A bilateral pelvic lymph node dissection is usually performed prior to the trachelectomy. The retroperitoneum is entered either by dividing the round ligament or by opening up the peritoneum overlying the psoas muscle. Clamps may be placed on the round ligament stumps to facilitate uterine manipulation; however, clamps should not be placed across the fallopian tube/utero-ovarian ligament complex. This window to the retroperitoneum is then extended caudally toward the bladder reflection and cephalic toward the infundibulopelvic ligament. The retroperitoneal structures, including the psoas muscle and the external iliac vessels, are exposed while the uterus is retracted to the opposite side. The ureter is then identified as it crosses over the iliac bifurcation. The anterior peritoneum overlying the bladder is then dissected off the anterior wall of the vagina.
The paravesical and pararectal spaces are then developed (Figure 26-3). Care must be taken not to damage the adnexa, the uterus, or the ovarian vessels when manipulating the uterus. The pararectal space is found by carefully developing the space between the ureter and the internal iliac artery posterior to the cardinal ligament (ie, the uterine artery). The dissection is parallel to the sacrum and slants medial. The borders of the pararectal space are composed of the rectum medially, the internal iliac artery laterally, the cardinal ligament anteriorly, and the sacrum posteriorly. Care must be taken when developing the space in order to avoid bleeding from the lateral sacral or hemorrhoidal vessels and internal iliac vein. The paravesical space is then developed by gently dissecting between the obliterated hypogastric artery medially and the external iliac vein laterally. The dissection is carried to the level of the pelvic floor. Although this is potentially an avascular space, an aberrant obturator vein (24% of patients) may occupy this space and cause bleeding; therefore, care must be taken. The paravesical space is bordered by the obliterated umbilical artery medially, the obturator internus muscle laterally, the cardinal ligament posteriorly, and the pubic symphysis anteriorly.