Radical Trachelectomy Radical trachelectomy is a procedure that is gaining popularity as a surgical management option for women with stage 1A2 and IB1 disease who desire uterine preservation and fertility. This procedure may be performed vaginally, abdominally, laparoscopically, or robotically (Fig. 36.6), and it usually is accompanied by pelvic lymphadenectomy and cervical cerclage placement. The risk of positive pelvic lymph nodes with stage Ia2 cancer may be as high as 8%, indicating the need for lymphadenectomy. Lymphadenectomy may be performed laparoscopically, robotically, or by the open laparotomy technique. Experience with this therapeutic modality is limited, although early results are promising, and it is uncertain whether the long-term outcome is similar to that of traditional therapy. Patients who are ideal candidates for this procedure have tumors less than 2 cm in diameter and have negative lymph nodes. Lymphadenectomy can be performed at the beginning of the procedure, and depending on those results, the procedure can be continued or abandoned. A retrospective trial comparing patients who had tumors with these attributes and were treated with either laparoscopic radical hysterectomy or laparoscopic radical trachelectomy showed similar outcomes and recurrence (69). There are limited data on subsequent pregnancy outcomes after radical trachelectomy; however, successful outcomes were reported. A study found that for women attempting to conceive after radical trachelectomy, the 5-year cumulative pregnancy rate was 52.8%, with an increased risk of miscarriage (70). Although radical trachelectomy and lymphadenectomy are performed with curative intent, it should be remembered that if a recurrence develops, definitive therapy with surgery or radiation is necessary.
Radical Hysterectomy The radical hysterectomy (Fig. 36.7A, B) performed most often in the United States is that described by Meigs in 1944 (71). The operation includes pelvic lymphadenectomy along with removal of most of the uterosacral and cardinal ligaments and the upper one-third of the vagina. This operation is referred to as the type III radical hysterectomy (72).
The hysterectomy described by Wertheim is less extensive than a radical hysterectomy and removes the medial half of the cardinal and uterosacral ligaments (62). This procedure
Figure 36.7 A: Radical hysterectomy. An intraoperative photograph showing the lateral dissection during a radical hysterectomy. Note the ureter running beneath the uterine artery (tissue in the clamp). B: Radical hysterectomy specimen.
is often referred to as the modified radical or type II hysterectomy. Wertheim’s original operation did not include pelvic lymphadenectomy but instead included selective removal of enlarged lymph nodes. The modified radical hysterectomy (type II) differs from the radical hysterectomy (type III) in the following ways: 1.
The uterine artery is transected at the level of the ureter, thus preserving the ureteral branch to the ureter.
2.
The cardinal ligament is not divided near the sidewall but instead is divided close to its midportion near the ureteral dissection.
3.
The anterior vesicouterine ligament is divided, but the posterior vesicouterine ligament is conserved.
4.
A smaller margin of vagina is removed.
Radical hysterectomies can be further classified as extended radical hysterectomy (type IV and type V). In the type IV operation, the periureteral tissue, superior vesicle artery, and as much as three-fourths of the vagina are removed. In the type V operation, portions of the distal ureter and bladder are resected. This procedure is rarely performed because radiotherapy should be used when such extensive disease is encountered (72).