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. 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 and fallopian tubes is not part of a radical hysterectomy; they may be preserved if clinically appropriate. (See "Elective oophorectomy or ovarian conservation at the time of hysterectomy", section on 'Introduction'.)

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 with other therapeutic modalities for specific tumors are discussed separately. (See "Management of early-stage cervical cancer".)

INDICATIONS — Radical hysterectomy is performed as a primary therapy for:

●Stage IA2 through IB2 cervical cancer (table 1 and table 2)

●Selected patients with stage II endometrial carcinoma (cervical involvement (table 3 and table 4))

Treatment decisions regarding these cancers are discussed separately. (See "Invasive cervical cancer: Staging and evaluation of lymph nodes" and "Management of early-stage cervical cancer" and "Management of locally advanced cervical cancer" and "Endometrial carcinoma: Staging and surgical treatment".)

Rare indications for radical hysterectomy include very small vaginal carcinomas arising in the upper vagina; unusual cervical malignancies, such as sarcomas or melanomas; adenocarcinomas in which an endocervical versus endometrial primary site cannot be determined; and low-grade uterine sarcomas that have spread in a worm-like manner into the parametrium (endolymphatic stromal myosis).

The procedure is also a potential salvage therapy for patients 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. Further, indicated hysterectomy in the face of extensive nonmalignant pelvic pathology, such as endometriosis or pelvic tuberculosis, may require the same parametrial resection, and ureteral, bladder, and rectal dissection, as a radical hysterectomy.

PATIENT SELECTION — The ideal candidates for radical hysterectomy are young, thin patients with no intercurrent medical problems and who are highly motivated toward a rapid return to normal activity, as opposed to an extended course of radiation therapy. Properly selected older patients with no significant underlying medical diseases also can do well with radical surgery; postoperative morbidity and mortality (less than 1 percent [1]) are similar to those in the younger patients [2-8]. Thus, chronologic age alone should not preclude a patient from radical hysterectomy.

Obesity is a relative contraindication to radical hysterectomy [9,10], but clinicians differ in their assessment of what constitutes obesity in this setting. Meticulous attention to both preoperative and postoperative preparation and access to long instruments and adequate surgical assistance are mandatory when operating on these patients.

In open cases on patients with class III obesity, the author selectively performs a panniculectomy before opening the abdomen and starting the radical hysterectomy because this often simplifies placement of fixed and movable retractors and enhances visualization of the pelvis [11,12]. In one report, panniculectomy also improved the yield of paraaortic lymph nodes during staging of endometrial cancer [13].

The risks of radiotherapy are increased by certain medical conditions, such as Crohn disease, connective tissue disorders, past history of peritonitis, or extensive pelvic adhesions, thereby favoring a surgical approach to therapy. Prior radiation to the pelvis is an additional contraindication to radiotherapy but may also complicate surgical intervention.

INFORMED CONSENT — The patient should be counseled about the indications for surgery, expected benefits of the procedure, alternatives (usually radiation therapy), and complications. At a minimum, the following points should be raised with each patient:

●Radiotherapy has the advantage of avoiding operative complications, such as hemorrhage, visceral injury, dehiscence, wound infection, postoperative pain, and anesthesia-related problems. Patients with intercurrent medical disease generally tolerate irradiation better than surgery. (See "Complications of gynecologic surgery".)

●Radiotherapy is contraindicated in patients with significant connective tissue disease that has compromised tissue vascularity, active enterocolitis, extensive prior pelvic or abdominal surgery, or prior radiation to the pelvis.

●Radiation damage to tissue never heals and is progressive. In comparison, intraoperative injuries to the bowel, bladder, and ureters are more readily repaired because their blood supply has not been damaged by prior radiation, although further major surgery may be required.

●Radical hysterectomy results in shortening and possibly some denervation of the vagina [14], but sexual function is superior to that of the contracted vagina after radiation therapy. After pelvic radiation, the vagina may shorten and become stenotic with a loss of pliability. Estrogen therapy and lifelong vaginal rehabilitation with dilators can minimize this problem. (See "Overview of sexual dysfunction in female cancer survivors".)

●Ovarian function is lost after irradiation (unless the ovaries are surgically moved out of the radiation field) and retained after radical hysterectomy.

●A radical hysterectomy is a major operative procedure that entails anesthesia, extensive pelvic dissection, and all of the risks associated with any major abdominal operation (eg, dehiscence, infection, hemorrhage, ileus or small bowel obstruction, injury to the bladder, ureters, or rectum, atelectasis, pneumonia, and pulmonary embolus) [10]. Visceral injury presents intraoperatively or within the immediate postoperative period and can usually be managed with preservation of organ function. Return to normal daily activities can be as rapid as a few weeks, although bladder dysfunction may persist longer. Once the patient has recovered from their surgery, delayed complications are exceedingly rare.

●Surgery removes the primary disease and provides maximum tissue for histologic analysis and accurate assessment of the extent of disease, which may aid in planning adjunctive therapy or offering a prognosis.

●Postoperative radiation and/or chemotherapy are sometimes necessary after a radical hysterectomy, although oncologists differ in their opinions. The patient should be informed if another series of treatments is required after surgery.

PREOPERATIVE PATIENT MANAGEMENT — Medical assessment prior to surgery consists of confirming the diagnosis of cancer, determining the extent (stage) of disease, and assessing medical problems (see "Overview of preoperative evaluation and preparation for gynecologic surgery"). Specific issues prior to radical hysterectomy for the treatment of cancer include:

●Ask about symptoms of sciatica (eg, unilateral flank pain radiating to the anterior thigh or lateral thigh), which is very suggestive of common iliac/external iliac metastatic disease, and warrants an abdominal and pelvic computed tomography (CT) scan.

●Order urodynamic testing to help resolve issues of postoperative bladder dysfunction if there is any suggestion of voiding difficulty, such as stress incontinence, urgency, or neurogenic overflow voiding.

●Place special emphasis on the abdominal, pelvic, and lymph node examinations. Disease metastasis to the groin or supraclavicular area is a contraindication to radical surgery.

●Evaluate unilateral ankle edema, which may indicate occult pelvic side wall disease, by pelvic examination and CT scan, as needed. Percutaneous biopsy of possibly metastatic lesions may prove advanced disease and markedly change the treatment plan.

Patient preparation — Prophylactic antibiotics are administered within the 60 minutes prior to surgical incision (table 5). We do not routinely use an osmotic bowel preparation prior to radical surgery. Other aspects of patient preparation are reviewed separately. (See "Overview of preoperative evaluation and preparation for gynecologic surgery" and "Overview of control measures for prevention of surgical site infection in adults" and "Antimicrobial prophylaxis for prevention of surgical site infection in adults".)

TYPES OF RADICAL HYSTERECTOMY — The term "radical hysterectomy" can refer to a wide range of surgical procedures that differ in the extent of the resection. Removal of the tubes and ovaries is not necessarily part of a radical hysterectomy. The Piver-Rutledge-Smith system is the most commonly used classification of hysterectomy and is listed here and shown in the table (table 6) [15]:

●Class I is a nonradical, extrafascial hysterectomy (ie, the pubovesicocervical fascia is removed with the uterus).

●Class II is an extrafascial hysterectomy with removal of the parametrium medial to the ureter.

●Class III is the traditional radical procedure of 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. The lateral attachments of the distal ureter are retained to preserve the blood supply.

●Class IV is a class III procedure but with a complete ureteral dissection, a more extensive resection of iliac vessels, and removal of three-fourths of the vagina.

●Class V involves excision of the uterus en bloc with the parametrium and partial resection of the ureter, portion of the bladder, or both. This procedure is usually done when unexpected direct extension of the cancer requires more extreme surgery to obtain a clear margin.

Bilateral pelvic lymphadenectomy is usually performed with Classes II to V. If the radical hysterectomy is done to resect persistent disease after the patient has received curative pelvic radiation, then the lymph node dissection may not be performed, at the surgeon's discretion. In this circumstance, there is no convincing evidence that the lymph node dissection improves survival, but it does prolong the procedure and add potential morbidity.

Other classification systems (eg, Querleu and Morrow (table 7)) have also been described and may be preferred in some settings [16,17].

As it is impossible to describe all variations of these procedures in any one classification system, a careful description of the operation must be documented by the surgeon.

OPERATIVE TECHNIQUE — The patient is placed in a modified dorsal lithotomy position. This position permits vaginal examination if there is any question of adequacy of margins at the time of specimen removal, and allows placement of a vaginal pack to elevate the pelvic viscera and facilitate parametrial dissection in patients with obesity or an excessively deep pelvis for open procedures, and allows access to the vagina for manipulator placement and movement for laparoscopic surgery. If a vaginal pack is placed, it is removed after completing the ureteral dissection or may be left until the vaginal incision is made.

The right-handed surgeon stands on the patient's left and places two assistants opposite, or one assistant opposite and the other between the patient's legs. The latter position is useful for improving retraction and exposure during dissection of the most inferior parts of the lymphadenectomy and bladder dissection.

The author uses a Foley catheter with a third port that will allow filling of the bladder with sterile fluid if needed intraoperatively.

Open procedures — The procedure can be performed through a transverse or vertical incision; a Pfannenstiel incision may be adequate in very slender patients. The transverse muscle-splitting incision provides superb access to the pelvic nodes and side walls but can present difficulties with exposure to the paraaortic lymph nodes. The author prefers a vertical incision for patients with obesity and those with a narrow pelvis or a previous vertical scar. The vertical incision offers excellent exposure at all sites but is obviously less cosmetically acceptable than a transverse one. Panniculectomy is a consideration in patients with class III obesity, and either a transverse or vertical fascial incision may be used.

Upon opening the abdomen, adhesions are lysed to restore normal anatomy and the undersurfaces of the diaphragm, liver, gallbladder, stomach, omentum, large and small bowel, and kidneys are palpated and visualized, if possible. The procedure should be terminated if metastatic disease is detected and confirmed by frozen section, outside of the pelvis (ie, in the omentum, bladder, liver, or bowel), in the adnexa, or if the tumor has broken through into the peritoneal cavity.

Washings are obtained of the pelvis and then place a self-retaining Balfour retractor with a C-arm upper extension to which one or more malleable blades can be attached to hold back the bowel. The side blades should be at the level of the infundibulopelvic ligaments, and the blades should retract only the abdominal wall without putting direct pressure on the soft tissues of the side wall, and should be of appropriate depth. Wet laparotomy pads are then placed in each paracolic gutter and at the midline beneath the malleable blade at each of these sites before it is tightened. It should not be necessary to adjust this retractor during the rest of the procedure. The head of the table is then lowered approximately 15 degrees.

Examination of lymph nodes — The side wall and paraaortic areas are inspected for obviously enlarged or matted lymph nodes. Determining metastasis intraoperatively must depend upon frozen section analysis; clinical assessment is inaccurate.

There is no consensus regarding the management of patients with positive nodes. Some surgeons will terminate the procedure, while others may proceed as long as the nodes are resectable and a negative node is found higher in the lymph node chain. This diversity of approaches reflects the lack of agreement regarding which patients benefit from postoperative radiotherapy and the effect of prior radical hysterectomy and node dissection on the morbidity of subsequent radiation. In addition, completion of hysterectomy in these patients may not improve survival. In one retrospective study including over 500 patients with cervical cancer in whom lymph node involvement was detected intraoperatively, patients who underwent hysterectomy as planned compared with those in whom hysterectomy was abandoned had similar rates of disease recurrence and death during the 58-month (median) follow-up period; the majority of patients in both groups received chemoradiation after the surgical procedure [18].

Paraaortic node sampling — The area above the bifurcation of the aorta may be approached in one of three ways:

●Transperitoneally by elevating and directly incising the peritoneum.

●Laterally by dividing the peritoneum over the paracolic gutter and mobilizing the colon medially toward and across the midline.

●Inferiorly by dividing the peritoneum lateral to the iliac vessels and dissecting upward toward the duodenum, elevating the bowel with retractors, and retracting the ureters laterally.

The aorta should be visualized at or near its bifurcation, and the overlying peritoneum retracted laterally either by holding it with clamps or placing a Harrington-type retractor. A right angle or tonsil clamp can be used to elevate the soft tissues anterior to the great vessels prior to ligating the afferent and efferent lymphatic trunks. Nodes posterior to the great vessels are not sampled. Dissecting close to the aorta and inferior vena cava improves safety, particularly in patients with extensive retroperitoneal fat, but care must be taken to avoid the ureters and inferior mesenteric vessels.

The finished dissection extends from lateral to the inferior vena cava on the right to lateral to the aorta on the left. It is helpful to place clips at the extremes of the sampling area to allow identification if subsequent irradiation is required. The retroperitoneum over the biopsy site does not have to be closed.

Pelvic lymphadenectomy — The author prefers performing pelvic lymphadenectomy prior to the radical hysterectomy (see 'Radical hysterectomy' below). The pelvic lymph nodes surround the iliac vessels and appear as discrete, easily visualized nodes or as a band of soft tissue running along the vessels. Using ring pickups, the lymphatic tissue is lifted off and sharply dissected free of the external iliac artery, staying as close as possible to the vessel. Metzenbaum scissors can be used for the sharp dissection; sharp-pointed cautery used cautiously is another option that allows minimal use of clips, which speeds up the dissection. The dissection begins above the bifurcation of the iliac vessels (or where the paraaortic dissection has stopped) and extends to where the external iliac vein crosses from medial to lateral (figure 1). The lymphatic bundle is divided inferior to this vessel, and the external chain is then dissected off the psoas muscle, moving superiorly toward the common iliacs. The genitofemoral nerve runs lateral to the external iliac artery on the psoas. It may be sacrificed if it prevents adequate lymph node resection, although numbness over the anterior thigh and upper labia will develop.

The dissection of the iliac lymphatics may then be carried sharply superior to the bifurcation of the aorta. The lymphatics overlying the external iliac vein are dissected from lateral to medial and allowed to descend inferiorly gently by gravity into the pelvis.

The external iliac artery is freed from its lateral attachments by sharp dissection from the bifurcation of the common iliac to the point of crossing of the external circumflex vein. The artery and vein are freed from each other and intervening lymphatic tissue removed. By retracting the vessels medially and then laterally, the obturator fossa becomes accessible, so that lymph tissue can be excised and the obturator nerve identified (figure 2). The obturator nerve must be clearly identified and protected during this dissection to avoid division. The area of the bifurcation of the common iliac should be cleanly dissected to remove the nodes most commonly involved in metastasis.

A common error is failing to cleanly dissect vessels for fear of injuring them, and consequently leaving significant soft tissue behind. This leads to misidentification of planes and vascular injury.

The dissection is subsequently carried 1 to 2 cm down the internal iliac artery, where the obturator nerve is again identified in the obturator fossa by gently spreading the tips of Metzenbaum scissors parallel to the vessels. In dissecting the obturator fossa, medial and inferior tension on the superior vesical artery enhances exposure, as does placing a retractor into the perivesical space. A right-angle clamp can be used to free the lymphatics above the obturator nerve; this lymphatic bundle is traced inferiorly to the pelvic muscles and divided. The vein retractor and sharp dissection can now be used to separate the external iliac artery and vein and remove the lymphatics between them. Nodes adjacent or beneath the obturator nerve may be seen and removed, taking care to avoid injury to the obturator artery or vein, either or both of which may be sacrificed. Injury to the obturator nerve, the motor nerve to the adductors, should be avoided, although intentional resection is sometimes necessary due to tumor involvement of adjacent nodes. Morbidity from unilateral obturator nerve injury is minimal; bilateral injury interferes with ambulation. Despite meticulous attention to sharp dissection, a complete resection of the pelvic lymph nodes is essentially impossible [19].

Closure of the peritoneum is not necessary and is associated with higher rates of febrile morbidity (42 versus 17 percent) and formation of lymphocysts (52 versus 23 percent) than nonclosure [20]. In addition, one randomized study of patients who underwent routine drainage or no drainage of the retroperitoneum after paraaortic lymphadenectomy reported that morbidity was threefold higher and length of hospitalization was two days longer in the former group [21].

Radical hysterectomy — The author begins the procedure by dividing the right round ligament at its point of entry into the pelvis; this opens the peritoneum of the broad ligament. An assistant exerts traction on the round ligament stump laterally and the uterus medially and superiorly, so the surgeon can extend the peritoneal incision superiorly to the beginning of the peritoneum of the right paracolic gutter, while staying lateral to the external iliac artery (figure 3). The peritoneal incision is then extended slightly inferiorly and medially to the anterior midline of the pelvic peritoneum as the assistant elevates the bladder serosa. Using nontraumatic forceps, the surgeon frees the peritoneum laterally from its soft tissue attachments, then sharply develops the right perivesical (Latzko fossa) space, bounded by the iliac vessels laterally, the lateral aspect of the bladder medially, and the bony pelvis inferiorly. The posterior medial broad ligament is opened with the ureter retracted toward the midline and the perirectal space, bounded by the bifurcation of the iliac vessels laterally and the ureter medially (figure 4A-B). This much of the radical hysterectomy is done prior to starting the node dissection to facilitate exposure.

If the ovaries are to be removed, each infundibulopelvic ligament containing the ovarian artery and vein is lifted free of the ureter and the iliac vessels, ligated, and divided 2 centimeters or more above the iliacs, keeping the ureters in view. If the ovaries are to be preserved, the fallopian tube and utero-ovarian ligament may be divided, ligated, and the ovary placed under the laparotomy pad in each paracolic gutter.

After the left side of the bladder peritoneum is incised, upward traction is placed on the bladder and sharp dissection is used to free the bladder from the anterior uterine surface. This anterior margin is where the surgeon is closest to the cervical malignancy. Cancer noted beneath the bladder or in its base would contraindicate radical hysterectomy unless partial cystectomy was considered.

The surgeon can now introduce an index finger or the tip of a suction device into the newly created spaces, gently widening them with circular motion (figure 4A-B). The parametrium should be assessed by placing an index finger into the perivesical space and the middle finger into the perirectal space. The superior vesical artery can be identified and mobilized medially and the ureter can be seen crossing the iliac vessels at or near their bifurcation.

Beginning at the pelvic brim, the ureter is freed from its soft tissue attachments, elevated approximately 2 cm above the vessels with umbilical tape, and retracted medially. There is a relatively constant arterial branch to the ureter, 3 to 5 mm below the common iliac bifurcation, that should be identified and divided. The ureteral dissection is easier if the initial dissection is sufficiently close to allow visualization of the vascular web, which runs along its surface.

As the dissection proceeds into the pelvis, tension can be placed on the previously identified superior vesical artery; this will cause the medial pelvic branches of the internal iliac vessels to become taut, facilitating identification of the uterine artery. The uterine artery is then dissected free, divided, and ligated or clipped at its origin. A tonsil clamp or slightly opened Metzenbaum scissors make excellent dissecting tools; blunt dissection is hazardous. As the artery is skeletonized, the uterine vein(s) will be identified and should be individually divided and ligated. Freeing the ureter medially is more difficult if the artery and vein are resected as a single pedicle. The entire internal iliac artery can be resected, if necessary, to accomplish an en bloc resection of the parametrium due to unexpected tumor infiltration along the uterine artery, endometriosis, or dense adhesions.

Tonsil or right-angle clamps are used to free the ureter down to the uterine artery pedicle, which is gently retracted medially while the ureter is rolled laterally (figure 5). The ureter inferior to the uterine artery can be dissected by applying upward traction to the bladder, using a Penrose drain to place lateral tension on the ureter, and introducing a right-angle clamp along its superior surface (figure 6). When the tip of the clamp is visible through the web of tissue at the corner of the bladder, the clamp may be gently opened and closed to widen the space, and one side of a second right-angle clamp may then be placed into the tunnel, rolled toward the bladder, and closed. Veins at the corner of the bladder can bleed copiously and should be avoided by clamping the pedicle, rather than trying to sharply dissect the last 1 to 2 cm of ureter. The same dissection is then carried out on the opposite side.

The uterus is then reflected over the symphysis, the rectum retracted upward and posteriorly, and the posterior cul-de-sac sharply incised (figure 7). The posterior vagina and anterior rectum are separated with sharp and blunt dissection, taking care to appreciate the curve of the posterior pelvis. Failure to recognize this curve can cause an injury to the anterior rectum. The index finger is then placed into the space posterior to the uterus and the middle finger just lateral to the uterosacral ligament to stroke the soft tissues first toward the cervix, then toward the rectum, thus bringing together the tissues in the pedicle. The posterior peritoneum is incised, and the uterosacral pedicle is clamped as close to the rectum as possible with a Wertheim clamp while the ureters are retracted laterally. The pedicle is then divided and suture ligated bilaterally; more than one bite is usually required on each side, with the second bite adjusting to the curve of the rectum anteriorly.

The surgeon uses one hand to retract the parametrium medially, while an assistant retracts the ureter laterally. The parametrium is then isolated, clamped, divided, and suture ligated (figure 8). The bladder is sharply dissected until half the underlying vagina is free. With the subsequent parametrial bites, the anterior blade of a Wertheim clamp is placed as close as possible to the bladder corner, while the posterior blade approximates the uterosacral pedicle. The ureteral insertion into the bladder and the vertical fibers of the rectal musculature should both be visible. When placing the parametrial clamps, it may be helpful to put a long Kelly clamp on the specimen side and apply traction medially to help define the tissue in the pedicle clamped with the Wertheim clamp.

The vaginal tube is then sharply divided. Clamps may be placed across the vagina, and the excision carried out distal to the clamps to prevent spillage or contamination. As the vagina is transected, long Kocher clamps are placed on the vaginal edge, taking care to exclude the bladder (figure 9). If the clamps block the surgeon's view, the vagina can be divided before clamping the vaginal edges. In a very deep pelvis, finding the vaginal edge can be difficult. An assistant can introduce a gloved hand or lubricated sponge into the vagina and push the vaginal edges towards the surgeon to facilitate identification. The vagina is carefully inspected to ensure an adequate margin. If any question exists, a section of the distal vagina (not the specimen side) can be removed and sent for frozen section to assure a satisfactory margin. The vagina is then closed with interrupted sutures. Copious irrigation of the pelvis is carried out with warm saline, and the ureters and all pedicles are inspected. The pelvic vessels are examined to ensure that the previous lymphadenectomy was complete. To test for integrity of the ureters and bladder, the bladder can be filled through the Foley catheter with methylene blue or sterile milk.

The pelvic peritoneum is left open. Drains are not used. The ureters are not suspended in the pelvis, but left lying on the side walls. If the ovaries are being preserved, it is prudent to suspend them out of the pelvis to avoid adhesion to the vaginal apex, a cause of deep dyspareunia, and to keep them out of the radiation field if postoperative radiation is required. The ovaries can be marked with hemoclips to facilitate identification for radiation field planning. Ovarian preservation is reasonable in patients with squamous cell carcinoma of the cervix, but not in patients with adenocarcinoma of the cervix since squamous lesions seldom metastasize to the ovaries, while adenocarcinomas may metastasize [22]. However, transposed ovaries do not always function normally and may have a shorter life span than expected. Ovarian function may also be impaired in ovaries left in situ after hysterectomy [23]. Therefore, these patients should be followed closely to detect menopausal symptoms when they occur.

Infrequently, parametrial disease that was clinically inapparent preoperatively will be encountered after advancing through much of the procedure. In this circumstance, the operation is usually completed, occasionally requiring partial ureteral resection with reimplantation.

The median duration of surgery was 240 minutes in a multicenter European series including a total of 234 patients [1].

Laparoscopic techniques — Laparoscopic radical hysterectomy may be performed as a laparoscopically assisted radical vaginal hysterectomy (vaginal radical hysterectomy is typically performed using the Schauta technique [24]) or as a total laparoscopic radical hysterectomy [25-27]. In addition, robot-assisted laparoscopic procedures may be performed [28].

Importantly, in radical hysterectomy for cervical cancer, the oncologic outcomes may not be equivalent to open surgery (see "Management of early-stage cervical cancer", section on 'Mode of surgery'). Use of a laparoscopic approach offers benefits of less blood loss and a shorter recovery period compared with laparotomy [29-33] but may have a slight increased risk of urologic injury [34].

Robot-assisted laparoscopy — With the robotic approach, purchase and maintenance of the system are quite expensive. However, use of the robotic procedure would allow a surgeon to work without assistants, which may facilitate radical surgery by clinicians in small practices.

Robot-assisted laparoscopic radical hysterectomy can be performed with similar or shorter duration than laparotomy or conventional laparoscopy, comparable retrieval of lymph nodes, and few complications [35-39]. Small comparative studies have reported decreased blood loss with the robotic versus open approach [36,38-41]. Robot-assisted and total laparoscopic radical hysterectomy were compared in a meta-analysis of 27 observational studies, which reported that the robotic approach was associated with significant decreases in transfusion rates (5.5 versus 9.6 percent) and hospital stay (3.3 versus 6.3 days) [42]. A major advantage of the robotic laparoscopic radical hysterectomy is a shortened length of hospitalization, generally one versus two to four days, and more rapid return to full function.

Video segments of a robot-assisted laparoscopic radical hysterectomy are shown, including dissection of the right uterine artery (movie 1), division of the right uterine artery (movie 2), and closure of the vaginal cuff (movie 3).

Robot-assisted laparoscopy is discussed in detail separately. (See "Robot-assisted laparoscopy".)

PROCEDURES IN PATIENTS WITH PRIOR HYSTERECTOMY — Prior to performing a hysterectomy for benign disease, it is imperative that a negative cervical cytology has been documented and the cervix appears normal. However, despite these precautions, occasionally, a pathology report of the excised uterus will reveal an unanticipated invasive cancer of the cervix. The choice of surgery or medical treatment for these patients is discussed in detail separately. (See "Management of early-stage cervical cancer", section on 'Incidentally diagnosed cancer'.)

Radical parametrectomy is performed in patients with a prior total hysterectomy, and radical trachelectomy with parametrectomy is performed in patients with a history of subtotal (supracervical) hysterectomy. Details of these procedures are discussed below.

Prior to surgery, the operative report from the prior hysterectomy should be reviewed or the procedure discussed with the surgeon who performed the hysterectomy, if possible.

Postoperative care for these procedures is the same as for patients who have undergone a radical hysterectomy.

Radical parametrectomy — The abdomen may be opened through a transverse or vertical incision, depending on which incision gives the best access, and patient and surgeon preference. The abdomen is explored. If occult liver or other intraabdominal metastasis is present, the procedure is aborted, since medical therapy is indicated in patients with advanced disease.

The paraaortic and pelvic lymph nodes are then visualized and palpated through the peritoneum. Matted or enlarged nodes can be sampled and sent for frozen section to confirm cancer spread. As while performing a radical hysterectomy, it is controversial whether the surgical procedure should proceed if positive lymph nodes are present. Some surgeons will proceed, while others will abort the procedure. The technique for lymph node sampling and lymphadenectomy is described above. (See 'Examination of lymph nodes' above.)

The major challenge that a radical parametrectomy presents to the surgeon, as compared with a radical hysterectomy, is that with the uterus surgically absent, there is no structure to use to create medial traction during the ureteral dissection. Also, the bladder flap and posterior space between the rectum and vagina are more difficult to create because of the absent cervix.

The paravesical and pararectal spaces are then developed on both sides. If ovarian conservation is planned, the ovary is dissected from any medial pedicle attachments. An attempt is made to develop a long vascular pedicle for each ovary by incising the peritoneum from the ovarian vessels. At the conclusion of the procedure, the author suspends the ovaries (see "Ovarian transposition before pelvic radiation"). If the ovaries are present, but are to be removed, the infundibulopelvic ligaments are divided as high out of the pelvis as feasible, and this tissue is left in continuity with the parametrial specimen.

Any round ligament pedicle that remains should be divided as laterally as possible and mobilized medially as part of the specimen if soft tissue attachments are present. If no remnants of the medial tissue are present, the lateral remains of each round ligament are removed as separate specimens.

Adnexal and round ligament remnants help create a tissue mass, upon which, with the development of the bladder flap and prerectal space, clamps can be placed to use for traction during lateral dissection.

To develop the bladder flap, the peritoneum can be incised from lateral to medial, beginning in each paravesical space. If the plane between the bladder and vagina is still not easily identified, the bladder can be filled with fluid to locate the bladder edge. In extreme cases, it is feasible to enter and develop the prevesical space of Retzius, and then sharply enter the extraperitoneal bladder with a vertical incision. When the bladder is opened extraperitoneally to facilitate dissection of the bladder flap, at the conclusion of the procedure or whenever convenient the bladder is closed with a running absorbable suture.

The surgeon can then place a finger into the bladder and sharply dissect down onto the vagina and create the plane. The author finds that attaching Allis or Kocher clamps on the vaginal edge as soon as feasible facilitates the procedure.

The space between the rectum and posterior vagina can similarly be developed sharply by beginning in each pararectal space and dissecting toward the posterior midline. The position of the patient in stirrups allows the surgeon to place a hand, sponge, or end to end anastomosis sizer into the vagina, which can facilitate the development of the anterior and posterior planes to the vagina.

The superior vesical arteries can be identified at each paravesical space, and the vessels can be dissected free and a space created beneath them. A narrow Deaver retractor can then be placed into this space, and downward traction placed in a caudal direction. This will place the internal iliac artery branches under tension, allowing identification and division of the uterine arteries at their origin. This largely compensates for the usual medial traction obtained by retracting the uterus to the contralateral side during a radical hysterectomy.

The remainder of the procedure, including ureteral dissection and development and division of the parametrium, is identical to that described above. (See 'Radical hysterectomy' above.)

Radical trachelectomy — Infrequently, patients will present with invasive cancer of the cervix with a prior history of a supracervical hysterectomy. This is sometimes referred to as "cancer of the cervical stump." Either radical surgery or radiation may be offered to the patient. However, if radical surgery is selected, the procedure, a radical trachelectomy, may be somewhat more challenging than a typical radical hysterectomy.

The surgical margins of supracervical hysterectomies vary. It is helpful to review the operative report or to discuss the procedure with the surgeon who performed the hysterectomy, if possible. If a substantial amount of the lower uterine segment has been left behind, then the surgical technique is identical to that of a radical hysterectomy. When all or most of the uterine fundus is absent, there is no central tissue mass to use for providing contralateral medial traction during the ureteral and parametrial dissection. Developing the bladder reflection and creating the space between the rectum and posterior vagina may be difficult. An approach to dealing with these anatomic issues is discussed above. (See 'Radical parametrectomy' above.)

The use of radical trachelectomy for fertility preservation in patients with cervical cancer is discussed separately. (See "Fertility-sparing surgery for cervical cancer".)

POSTOPERATIVE CARE — Patient-controlled epidural or intravenous analgesia is administered for pain relief. Early ambulation is encouraged, and intermittent pneumatic compression devices are used while the patient is in bed. The author does not routinely order heparin or nasogastric tubes but encourages incentive spirometry for the first 72 hours after surgery.

Diet is advanced as the patient requests. Postoperative colonic stasis after major abdominal surgery lasts for approximately three days, but does not typically require nasogastric decompression or preclude early feeding [43]. In fact, early feeding of a regular diet can stimulate the bowel and decrease the length of hospitalization, although emesis is more common.

The author administers prophylactic antibiotics prior to all radical hysterectomies and subsequently administers oral antibiotics while the urinary catheter is left in place, although the latter practice is controversial (see "Catheter-associated urinary tract infection in adults"). Estrogen therapy (with unopposed estrogen) is started at discharge, if indicated, or when the patient notes symptoms of estrogen deficiency. (See "Treatment of menopausal symptoms with hormone therapy".)

A routine intravenous pyelogram in the postoperative period is of no value. If radiotherapy is planned, it is started approximately four weeks postoperatively. Minor wound separation does not delay institution of radiation.

COMPLICATIONS

Overview — Radical hysterectomy with pelvic lymphadenectomy entails meticulous dissection near the bladder, rectum, ureters, and great vessels of the pelvis. Understandably, the more common complications relate to injuries to these viscera (see "Complications of gynecologic surgery" and "Urinary tract injury in gynecologic surgery: Epidemiology and prevention" and "Urinary tract injury in gynecologic surgery: Identification and management"). Other complications, such as pulmonary embolus, myocardial infarction, pneumonia, or fluid or electrolyte imbalance, are common to all major surgeries.

A retrospective study of almost 1900 patients undergoing radical hysterectomy (85.0 percent abdominal, 11.0 percent laparoscopic, 3.5 percent robotic) from 2006 to 2010 reported the following overall frequency of short-term complications: intraoperative complications (6.0 percent), surgical site complications (3.0 percent [including wound infection, abscess, hemorrhage, and bowel obstruction]), and blood transfusion (13.5 percent) [44]. Bladder and ureteral injuries comprised the majority of the intraoperative complications at 43/110 and 32/110, respectively. The issue of bladder dysfunction was not discussed in this study and is described elsewhere. (See 'Bladder dysfunction' below.)

A multicenter European series including 234 patients undergoing radical hysterectomy reported perioperative mortality in less than 1 percent, urinary tract infection in 42 percent, deep vein thrombosis in 3 percent, and fistula in 2 percent [1].

Infection — Febrile morbidity after radical hysterectomy is usually attributable to infection of the urinary tract, wound, or pelvic cellulitis [1,10,45]. Fever within the first 48 hours of surgery is almost always due to atelectasis and is best treated with ambulation, incentive spirometry, and respiratory toilet; blood and urine cultures are not necessary. Superficial wound infection/hematoma, urinary tract infections, and pelvic cellulitis (ie, fever, negative cultures, leukocytosis) each occur in approximately 10 to 20 percent of patients. (See "Posthysterectomy pelvic abscess".)

The author administers metronidazole and gentamicin when beginning empiric therapy of postoperative fever from an undocumented source. It is appropriate to obtain an intravenous pyelogram to look for occult ureteral obstruction in patients febrile after 24 hours of antibiotics. Ureteral obstruction should be treated by percutaneous stent placement.

If a patient remains febrile with no localizing signs of infection after 48 hours of broad-spectrum antibiotics, the author initiates heparin therapy for presumed septic pelvic thrombophlebitis. (See "Septic pelvic thrombophlebitis", section on 'Treatment'.)

If the patient remains febrile despite negative cultures and therapeutic partial thromboplastin time levels, then the author orders a computed tomography scan of the pelvis with contrast to look for occult fluid collections that can be drained percutaneously.

Cellulitis following pelvic lymph node dissection is discussed in detail separately. (See "Cellulitis following pelvic lymph node dissection".)

Bladder dysfunction — Bladder dysfunction is present in 70 to 85 percent of patients for up to 12 months postoperatively, including urinary or anal incontinence or retention [46]. The etiology of these complications is likely injury to the sensory and motor nerve supply to detrusor muscle of the bladder during the resection of anterior, lateral, and posterior parametrium and vaginal cuff [46-48]. Denervation results in detrusor hypertonicity. The type and severity of voiding disorder varies with the extent of radicality of the procedure. Pelvic radiation therapy may exacerbate bladder dysfunction [49].

During the first postoperative year, the typical symptoms are decreased bladder sensation and urinary retention [46,50]. Some patients require self-catheterization or suprapubic pressure (Credé maneuver) to empty the bladder completely.

There are few data regarding long-term effects of radical hysterectomy on bladder function. However, it appears that stress urinary incontinence develops in approximately 30 percent of patients who have undergone radical hysterectomy [46,51]. The largest and only comparative study reported survey results from 66 patients who had undergone radical versus 152 who had an extrafascial abdominal hysterectomy. Urinary incontinence symptoms did not differ significantly between the two groups [51].

Urodynamic studies of patients after radical surgery report varied and inconsistent findings. There is usually a phase during which the bladder has increased resting tone and small volume, with intermittent uncontrolled contractions. This is usually followed by a period of decreased bladder tone, increased residual volume, and absence of bladder wall contractions. Fortunately, constant drainage over several weeks or months often allows the bladder to resume more normal function. However, many patients continue to report decreased sensation and an inability to completely empty the bladder without increased abdominal pressure or suprapubic pressure [52-54].

ABORTED RADICAL HYSTERECTOMY — Less than 10 percent of patients scheduled for radical hysterectomy have the procedure terminated prior to completion. In less than 1 percent of patients, the procedure is abandoned because of intraoperative complications, such as cardiac irregularities, hypertension, unsuspected infection, or hemorrhage. The majority of patients have the procedure abandoned because of extrapelvic extension of cancer, while extensive unsuspected pelvic disease accounts for the remainder.

There are no preoperative characteristics that clearly and distinctly identify patients likely to have their procedure terminated without completion. This group has a poorer prognosis than those in whom radical hysterectomy can be accomplished, and optimal management has not been determined [55,56].

PREGNANT PATIENTS — Pregnancy changes some aspects of the surgical technique. If the fetus is viable, a vertical uterine incision for delivery is wise to avoid extension into the parametrium. If the fetus is nonviable, the intact uterus should be removed to minimize blood loss. The gravid uterus is enlarged, soft, and hard to hold; therefore, radical hysterectomy should precede the pelvic lymph node dissection to improve exposure. The perivesical and perirectal spaces should be well developed so that the hypertrophied blood supply to the pregnant uterus is clearly exposed. Vessels in the broad ligament may require individual ligation since the ovaries are usually preserved in these patients. Finally, when cutting across the vagina, the elasticity of the pregnant vagina must be taken into account to prevent the removal of excessive amounts of vaginal tissue.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Treatment of cervical cancer".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Beyond the Basics topics (see "Patient education: Cervical cancer treatment; early-stage cancer (Beyond the Basics)" and "Patient education: Fertility preservation in early-stage cervical cancer (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●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. (See 'Introduction' above.)

●Radical hysterectomy is performed as a primary therapy for stage IA2 through IB2 cervical cancer and selected patients with stage II endometrial carcinoma. Rare indications for radical hysterectomy include upper vaginal carcinoma, uterine or cervical sarcomas, and other rare malignancies confined to the area of the cervix, uterus, and/or upper vagina. Radical hysterectomy may be used as salvage therapy in patients with recurrent or persistent cervical cancer limited to the cervix. (See 'Indications' above.)

●Properly selected older patients with no significant underlying medical diseases can do well with radical surgery. Obesity is a relative contraindication to radical hysterectomy. (See 'Patient selection' above.)

●In patients in whom unanticipated invasive cancer of the cervix is discovered after hysterectomy, radical surgery may be indicated. Radical parametrectomy is used for patients with a prior total hysterectomy, and radical trachelectomy with parametrectomy for patients with a history of subtotal (supracervical) hysterectomy. (See 'Procedures in patients with prior hysterectomy' above.)

●The most common complications of radical hysterectomy are infection and bladder dysfunction. (See 'Complications' above.)