Introduction
Clark performed the first radical hysterectomy for cervical
cancer at John Hopkins Hospital in 1895. In 1898,
Wertheim, a Viennese physician, developed the radical
total hysterectomy with removal of the parametrium
and pelvic lymph nodes. In 1905, Wertheim reported
the outcomes of his first 270 patients - the operative
mortality rate was 18% and the major morbidity rate was
31%.
In 1901, Schauta described the radical vaginal
hysterectomy and reported a lower operative mortality
rate than the abdominal approach. In the late 20th
century, radiation therapy became the favored approach
because of the high mortality and morbidity of the
surgical approach.
In 1944, the surgical approach was re-popularized by
Meigs. He developed a modified Wertheim operation
with removal of all pelvic nodes (the Wertheim-Clark plus
Taussig operation). Meigs reported a survival rate of 75%
for patients with stage I disease and demonstrated an
operative mortality rate of 1% when these procedures
were performed by a specially trained gynecologist.
This article is an attempt to highlight the new
classification system of radical hysterectomy based on
three dimensional anatomic template of parametrial
resection and the current place of this surgical procedure
in the management of gynecologic malignancies.
The routes or techniques of performing a radical
hysterectomy are beyond the scope of this article.
Conventional Classification of Radical
Hysterectomy
Abdominal radical hysterectomy has been continuously
modified throughout the past century by different
surgical schools in Europe, Asia, and the USA. A
standardized international classification of radical
hysterectomy became an urgent necessity. Various
reasons for adopting an international classification system
include clarification of the details of common surgical
variations, standardization of nomenclature in reports
and publications, clinical protocols and randomized
controlled trials, evaluation of complications and side
effects, education and training. General gynecologists,
fellows and residents in training may not be familiar with anatomy of the retroperitoneal space. A uniform
classification will encourage them to speak the same
language as trained gynecologic oncologists.
Since the 1970s, the operative classification of Piver,
Rutledge, and Smith was widely used to assess radicality
of surgery. The Piver-Rutledge-Smith (RPS) classification
published in 1974 has been the most widely used system.
It describes five classes of radical hysterectomy – type I
to V. The Piver-Rutledge-Smith classification applies only
to open abdominal surgery, not taking into account the
development of endoscopic techniques and the revival of
vaginal surgery.
In 2007, new principles of classification were presented
at the International Symposium on Radical Hysterectomy
dedicated to Hidekazu Okabayashi (Feb 7–10, 2007,
Kyoto, Japan) to accommodate new trends in surgery.
Recommendations for a new classification were published
in 2008 by Querleu and Morrow who described four
types (including subtypes) of radical hysterectomy (A–D),
which considered nerve preservation and paracervical
lymphadenectomy.
Newer Concept in Classification of Radical
Hysterectomy
An updated and a new, simple and anatomy based
classification was published by Querleu and Morrow in
2008 as highlighted in Table 1.
All types of radical hysterectomy are combined with
lymph-node dissection.
Level 1—external and internal iliac level
Level 2—level 1 plus common iliac and presacral
Level 3—level 2 plus aortic infra-mesenteric
Level 4—level 3 plus aortic infrarenal
Current Place of Radical Hysterectomy in
Surgical Management of Gynecologic Cancers
Radical hysterectomy was initially developed as a surgical
treatment for cervical cancer due to the absence of
other modalities for treatment. The first choice is to
preserve the nerves with minimum damage or without
reducing radicality during radical hysterectomy type
C (type III in previous terminology) for invasive cancer
cervix. A second approach to preserving nerves is to
use less radical surgery with less radical resection of the paracervix—radical hysterectomy type B (type II in the
old terminology).
Table 1: Querleu and Morrow Classification of Radical Hysterectomy1
Table 2: Stage Wise Indications of Radical Hysterectomy in the Management of Gynecologic Malignancies
For IB and IIA stage cancer cervix, tumors may be treated
with surgery, radiotherapy or concurrent chemoradiation.
Table 2 highlights stage wise indications of radical
hysterectomy in the management of carcinoma cervix,
endometrium and vagina.
In addition, a young woman desiring ovarian preservation
and retention of a functional, non-irradiated vagina will
be an ideal candidate for a radical hysterectomy. Women
who have relative or absolute contraindications to
radiation therapy, such as a pelvic kidney or a history of
pelvic abscess or pelvic irradiation will also benefit form
surgical management.
Contraindications to Radical Hysterectomy
- Relative contraindication – selected cases of stage IB2/
IIA cervical cancer, intra-operative findings of locally
advanced disease with overt parametrial involvement
or grossly positive pelvic or para-aortic lymph nodes
- Patients whose religious or personal beliefs prohibit
blood product transfusion
Summary
Radical hysterectomy with pelvic lymphadenectomy
remains the cornerstone of treatment for women with
stage IA2-IB1 carcinoma cervix. Apart from carcinoma
cervix, surgical treatment by radical hysterectomy is also
recommended for carcinoma endometrium with cervical
involvement (FIGO Stage II) and stage I-II vaginal cancers.
While reporting intra-operative findings and the
procedure performed, it is recommended to follow the recent internationally accepted classification of radical
hysterectomy for uniformity.
Radical hysterectomy is a relatively safe procedure with
minimal morbidity in the hands of trained gynecologic
oncologists. Surgical training and expertise is required
for radical hysterectomy to be performed abdominally,
laparoscopically or robotically. Proper case selection
is essential. Women properly selected for radical
hysterectomy being operated by trained gynecologic
oncologists have a 5 year survival rate of over 90%
without lymph node metastases. The operative morbidity
with this procedure has been significantly lowered with
improvements in surgical techniques, use of prophylactic
antibiotics, thromboprophylaxis, availability of blood
components and advancement in postoperative and
critical care.
Suggested Reading
- Querleu D, Morrow CP. Classification of radical hysterectomy.
Lancet Oncol 2008; 9: 297–303.
- Rachel A. Ware and John R. van Nagell Jr. Radical
Hysterectomy with Pelvic Lymphadenectomy: Indications,
Techniques and Complications. Obstetrics and Gynecology
International volume 2101, article ID 587610
- NCCN Guidelines Cervical Cancer version 1.2012
|
