Women affected by early stage invasive cancer of the cervix are usually treated by surgery. Radical abdominal hysterectomy with pelvic lymphadenectomy is the most widely used technique. Because the morbidity of the abdominal approach can be important, the radical vaginal hysterectomy has gained acceptance in gynaecologic oncology. New instrumentation in laparoscopy also opens the possibility of treating cervical cancer by laparoscopically assisted vaginal radical hysterectomy and also total laparoscopic radical hysterectomy. Before these techniques become widely accepted, it has to be shown that safety and efficacy are comparable with the ‘standard’ abdominal approach. In this chapter, we review the technique of radical vaginal hysterectomy with pelvic lymphadenectomy and evaluate results of published studies, comparing the abdominal, vaginal and laparoscopic approaches.
Introduction
Vaginal radical hysterectomy for the surgical treatment of cervical cancer was first described by Schauta at the turn of the 20th century. At that time, abdominal radical hysterectomy (ARH), pioneered by Wertheim, was the standard, but had high operative mortality rates. Later, Wertheim showed that his technique had better oncologic results, probably because he was also removing metastatic pelvic lymph nodes. Hence, the standard of care in the surgical treatment of cervical cancer became the ‘Wertheim operation’, which included a complete pelvic lymphadenectomy with ARH. As a consequence, because the pelvic lymphadenectomy could not be carried out vaginally, the Schauta procedure was almost forgotten. In the 1950s, because of the high complication rate of ARH, Mitra described a combined extra-peritoneal pelvic lymph-node dissection and a vaginal radical hysterectomy. Savino et al. reported the Italian experience of Mitra’s operation. This technique did not gain wide acceptance, mostly because of the necessity of two groin incisions to complete the pelvic lymphadenectomy. Developments in surgical techniques allowing pelvic lymphadenectomy to be carried out by laparoscopy in the 1980s offered other options for treatment. After their publications showing the feasibility of laparoscopic lymphadenectomy, Dargent and Mathevet and Querleu, following Canis et al., described the laparoscopically assisted vaginal radical hysterectomy (LAVRH), giving a second life to the Schauta procedure. At the same time, Nezhat et al. pushed laparoscopy one step further in reporting total laparoscopic radical hysterectomy (TLRH).
Technique
In the past 20 years, the concept of ‘ARH’ has evolved. Until the beginning of the 1990s, the standard surgical approach for all cervical cancers was a type III radical hysterectomy. Then, a more conservative type II radical hysterectomy was proposed for lesions measuring 2 cm or less, consequently lowering the rate of major complications. The same changes occurred long before with vaginal radical hysterectomy when Stockel modified the original Schauta operation for smaller lesions. The so-called ‘Schauta–Stockel’ is the equivalent of a Piver type II radical hysterectomy. In this chapter, we will mostly discuss radical vaginal hysterectomy and we will compare the results of abdominal, vaginal and laparoscopic approaches. A detailed description of the technique of the Schauta operation has recently been published.
The ‘classical’ Schauta operation starts with a Schuchardt incision to widen the operative space and help open the para-rectal spaces. Its use is controversial. In our centre, contrary to Sonoda and Abu-Rustrum, we avoid using it because the complication rate is higher. In fact, the Schuchardt incision is a frequent site of bleeding, haematoma, infection, pain, and long-term dyspareunia. Furthermore, metastases in a Schuchardt incision have been reported by Barranger et al. and Bader et al.
Development of the vaginal cuff
After the woman is been placed in lithotomy position, with hyperextension of the legs, the vaginal mucosa is grasped with six to eight straight Kocker clamps at 1 or 2 cm from the ectocervix, depending on the size and location of the cancer. A diluted solution of epinephrine is injected under the mucosa, between the clamps to divide the two folds of the mucosa and to create vasoconstriction. The vaginal mucosa is cut with a scalpel outside the clamps, thereby creating the vaginal cuff, which is grasped with Chroback clamps ( Fig. 1 ). The cervix is therefore covered by the vaginal cuff. This helps prevent spillage of cancer cells and gives the surgeon strong tissue for pulling down the uterus without crushing the cervix.
Opening of the spaces
The connective tissue attaching the bladder to the cervix is sectioned and the bladder is pushed up until the anterior peritoneum is visualised. This opens the vesico-uterine space. Then, with a clamp at 11 o’clock and another one at 9 o’clock on the right side, pulling the vaginal mucosa, a triangle is formed in the centre of which the right para-vesical space is opened, joining the space already prepared at the end of the extra- or trans-peritoneal pelvic lymphadenectomy. The septum between both spaces, the bladder pillars, is important as it harbours the uterine artery and the ureter, which can be palpated between two fingers ( Fig. 2 ).
Identification and dissection of the ureter
With retractors placed in the spaces already dissected, the septum is stretched, facilitating the section of the bladder pillars ( Fig. 3 ). The ureter is visualized, pulled using a Babcock clamp and dissected upwards with the bladder base. This helps the visualization of the uterine artery which is located under the ureter ( Fig. 4 ). One can pull down the uterine artery in order to help sectioning the last fibres between the ureter and the parametrium. The same procedure is then carried out on the other side.
The parametrium
After opening the posterior cul-de-sac, the para-colpos and the utero-sacral ligaments are sectioned and ligated. The parametrium is sectioned 2–3 cm distal to the cervix ( Fig. 5 ), in order to remove tissue that can be involved with cancer in about 5–8% of cases.
Hysterectomy
The uterine fundus is pulled downward, and utero-ovarian ligaments are sectioned and ligated, if adnexae are to be left in place. If not, salpingo-ovariectomy can be carried out by ligating and sectioning the infundibulo-pelvic ligaments. The specimen, cervix, uterus, parametrium and vaginal cuff ( Fig. 6 ), is extracted with or without tubes and ovaries. The vaginal mucosa is then closed with interrupted sutures. A Foley catheter is left in the bladder.
Technique
In the past 20 years, the concept of ‘ARH’ has evolved. Until the beginning of the 1990s, the standard surgical approach for all cervical cancers was a type III radical hysterectomy. Then, a more conservative type II radical hysterectomy was proposed for lesions measuring 2 cm or less, consequently lowering the rate of major complications. The same changes occurred long before with vaginal radical hysterectomy when Stockel modified the original Schauta operation for smaller lesions. The so-called ‘Schauta–Stockel’ is the equivalent of a Piver type II radical hysterectomy. In this chapter, we will mostly discuss radical vaginal hysterectomy and we will compare the results of abdominal, vaginal and laparoscopic approaches. A detailed description of the technique of the Schauta operation has recently been published.
The ‘classical’ Schauta operation starts with a Schuchardt incision to widen the operative space and help open the para-rectal spaces. Its use is controversial. In our centre, contrary to Sonoda and Abu-Rustrum, we avoid using it because the complication rate is higher. In fact, the Schuchardt incision is a frequent site of bleeding, haematoma, infection, pain, and long-term dyspareunia. Furthermore, metastases in a Schuchardt incision have been reported by Barranger et al. and Bader et al.
Development of the vaginal cuff
After the woman is been placed in lithotomy position, with hyperextension of the legs, the vaginal mucosa is grasped with six to eight straight Kocker clamps at 1 or 2 cm from the ectocervix, depending on the size and location of the cancer. A diluted solution of epinephrine is injected under the mucosa, between the clamps to divide the two folds of the mucosa and to create vasoconstriction. The vaginal mucosa is cut with a scalpel outside the clamps, thereby creating the vaginal cuff, which is grasped with Chroback clamps ( Fig. 1 ). The cervix is therefore covered by the vaginal cuff. This helps prevent spillage of cancer cells and gives the surgeon strong tissue for pulling down the uterus without crushing the cervix.
Opening of the spaces
The connective tissue attaching the bladder to the cervix is sectioned and the bladder is pushed up until the anterior peritoneum is visualised. This opens the vesico-uterine space. Then, with a clamp at 11 o’clock and another one at 9 o’clock on the right side, pulling the vaginal mucosa, a triangle is formed in the centre of which the right para-vesical space is opened, joining the space already prepared at the end of the extra- or trans-peritoneal pelvic lymphadenectomy. The septum between both spaces, the bladder pillars, is important as it harbours the uterine artery and the ureter, which can be palpated between two fingers ( Fig. 2 ).
Identification and dissection of the ureter
With retractors placed in the spaces already dissected, the septum is stretched, facilitating the section of the bladder pillars ( Fig. 3 ). The ureter is visualized, pulled using a Babcock clamp and dissected upwards with the bladder base. This helps the visualization of the uterine artery which is located under the ureter ( Fig. 4 ). One can pull down the uterine artery in order to help sectioning the last fibres between the ureter and the parametrium. The same procedure is then carried out on the other side.
The parametrium
After opening the posterior cul-de-sac, the para-colpos and the utero-sacral ligaments are sectioned and ligated. The parametrium is sectioned 2–3 cm distal to the cervix ( Fig. 5 ), in order to remove tissue that can be involved with cancer in about 5–8% of cases.
Hysterectomy
The uterine fundus is pulled downward, and utero-ovarian ligaments are sectioned and ligated, if adnexae are to be left in place. If not, salpingo-ovariectomy can be carried out by ligating and sectioning the infundibulo-pelvic ligaments. The specimen, cervix, uterus, parametrium and vaginal cuff ( Fig. 6 ), is extracted with or without tubes and ovaries. The vaginal mucosa is then closed with interrupted sutures. A Foley catheter is left in the bladder.
Postoperative course
The postoperative period is usually uneventful. In our institution, the Foley catheter is left in place until day 3 after surgery. Then it is removed and, if the woman cannot void spontaneously or empty her bladder with residuals less than 100 cc, self-catheterisation is taught and the woman leaves the hospital the same day if she manages the technique well.
Evolution towards laparoscopy
The technique of radical vaginal surgery for cervical cancer has evolved in the past 15 years. The laparoscopic approach was first used only for pelvic lymphadenectomy to replace Mitra’s technique of lower abdominal incisions and retroperitoneal lymph-node dissection. As more experience was gained with laparoscopy, the dissection and the section of the uterine vessels close to the internal iliac artery, the unroofing of the ureter, the opening of the spaces and the proximal and distal parametrial resection are now carried out laparoscopically. By doing so, one can be more conservative and remove less parametrium vaginally. Today, numerous studies have shown TLRH can also be completed safely with or without a robot.
Laparoscopic procedure
In our institution, we start LAVRH by searching, identifying and retrieving the sentinel lymph node (SLN), followed by a complete pelvic lymphadenectomy. If the SLN is positive on frozen section, the operation is stopped after completing a bilateral laparoscopic para-aortic lymphadenectomy, and the woman is referred for chemo-radiation. When the sentinel nodes are negative, the surgery is completed as planned. The advantages of using SLN mapping are twofold. First, when a SLN is positive on frozen section, we avoid two treatment modalities: radical surgery and chemo-radiation, often linked with higher morbidity. Second, on final pathology, all the SLNs are ultra-staged, and micro-metastasis are found in up to 30% of negative SLNs on frozen section (Roy M, in preparation).
In addition to complete laparoscopic pelvic lymphadenectomy, the vaginal radical hysterectomy is prepared laparoscopically. We first carry out a distal parametrectomy by removing all the fatty tissue covering the vessels and nerves between the internal iliac artery and the side wall, under the obturator nerve and between the bifurcation of the iliac veins and the side wall. Then we remove the tissue along and under the uterine vessels and the fatty tissue of the peri-vesical space. Moving downwards, we open the para-rectal space separating the ureter from the internal iliac artery, freeing the uterine vessels, which are then clipped or cauterised and sectioned ( Fig. 7 ). At the end of this preparation, there should only be vessels, connective tissue and nerves from the side wall to the crossing of the uterine artery and the ureter ( Fig. 8 ). This laparoscopic parametrectomy allows us to be more conservative vaginally in removing less parametrial tissue. As for the ureter, it will be dissected from the vagina and the remaining proximal parametrium and uterus will be removed vaginally. If the ovaries are to be removed, it can be done laparoscopically or vaginally. At the end of the vaginal procedure, the pneumoperitoneum is recreated to verify laparoscopically the integrity of the bladder and the ureters, and to verify haemostasis. The technique of LAVRH is presented in Table 1 .
