RADICAL ABDOMINAL HYSTERECTOMY (TYPE III)
The five “types” of hysterectomy are defined in Chapter 30 (p. 666). Of these, radical hysterectomy differs from simple hysterectomy in that the parametrial, paracervical, and paravaginal tissues and their lymphatics are widely resected to achieve negative tumor margins. Described in this section, type III (radical) hysterectomy is chiefly indicated for stage IB1 to IIA1 cervical cancer or small central recurrences following radiation therapy. It may be suitable for clinical stage II endometrial cancer when tumor has extended to the cervical stroma (Koh, 2018a, 2019).
Most women with cervical cancer are treated with laparotomy and radical hysterectomy. Although type III radical hysterectomy may be performed with minimally invasive surgery (MIS), recent prospective and epidemiologic studies suggest lower disease-free and overall-survival rates in those treated for cervical cancer with an MIS approach compared with an open abdominal radical hysterectomy (Melamed, 2018; Ramirez, 2018). Speculations for these survival differences include insertion of a uterine manipulator, tumor handling during paracervical resection, and pneumoperitoneum during colpotomy. Until further work is completed to identify the true cause for this inferior survival rate, we offer open radical hysterectomy as the preferred modality for surgical management of cervical cancer. Some physicians continue to offer type III radical hysterectomy performed by MIS approaches in select cases and after careful discussion and shared decision-making with the patient.
Radical hysterectomy is discouraged for women with higher-stage cancers (stage IIB through IV). Thus, accurate clinical staging is critical prior to selection of this surgery. Pelvic examination under anesthesia with cystoscopy and proctoscopy is not mandatory for smaller cervical cancer lesions, but the clinical staging described in Chapter 30 (p. 660) should be completed before proceeding surgically. To refine patient selection, for most patients with grossly visible cervical tumors, abdominopelvic computed tomography (CT) or magnetic resonance (MR) imaging is also performed to identify nodal metastases or undetected local tumor extension. The soft-tissue resolution offered by MR imaging may be especially helpful to exclude parametrial invasion, which would instead benefit from primary radiotherapy (Kong, 2016). That said, there are limitations on what can be reliably detected preoperatively (Chou, 2006).
Women undergoing hysterectomy are specifically counseled regarding the loss of fertility. In those considering bilateral salpingo-oophorectomy (BSO), a discussion of menopause and hormone replacement is included and detailed in Chapter 43 (p. 957). The tone of the consenting process should reflect the extent of the operation required to hopefully cure or at least begin treatment of the malignancy. Moreover, a patient must be advised that the procedure may be aborted if metastatic disease or pelvic tumor extension is found (Leath, 2004).
Radical abdominal hysterectomy can result in significant morbidity from short- and long-term complications. Surgery may be more difficult and complication rates ...