Radical hysterectomy

INTRODUCTION

Radical hysterectomy refers to the excision of the uterus en bloc with the parametrium (ie, round, broad, cardinal, and uterosacral ligaments) and the upper one-third to one-half of the vagina, with the ovaries left intact. The surgeon usually also performs a bilateral pelvic lymph node dissection. The procedure requires a thorough knowledge of pelvic anatomy, meticulous attention to sharp dissection, and careful technique to allow dissection of the ureters and mobilization of both bladder and rectum from the vagina. Particular care must be taken with the vasculature of the pelvic side walls and the venous plexuses at the lateral corners of the bladder to avoid excessive blood loss. Removal of the ovaries is not part of a radical hysterectomy; they may be preserved if clinically appropriate. (See "Oophorectomy and ovarian cystectomy", section on 'Elective oophorectomy at hysterectomy'.)

The major issues associated with radical hysterectomy will be reviewed here including indications, patient selection, operative technique, preoperative and postoperative care and complications. The outcomes after surgery and comparisons to other therapeutic modalities for specific tumors are discussed separately.

INDICATIONS

Radical hysterectomy is performed as a primary therapy for:

• Stage IB or IIA cancer of the cervix (table 1)
• Selected patients with stage II adenocarcinoma of the endometrium in whom radical surgery seems feasible
• Upper vaginal carcinoma, uterine or cervical sarcomas, and other rare malignancies confined to the area of the cervix, uterus, and/or upper vagina.

The procedure is also a potential salvage therapy for women with cervical cancer who have been treated with irradiation and subsequently develop a small central pelvic recurrence or have a small central area of persistent disease. In these cases, the procedure may offer curative salvage treatment as an alternative to exenterative surgery.