Treatment

• Both primary lesion and potential sites of spread

should be treated

• Surgery, radiotherapy, chemoradiation

• Radiation therapy can be used in all stage but

surgery alone is limited (stage I or IIa)

• Optimal therapy: radiation + surgery

 Surgery

• Advantage (instead of radiotherapy)

-conservation of the ovary
-bladder and bowel problem: easily repair and
without long-term complication
-sexual dysfuntion 이 덜 함
(radiation: vagina shortening, fibrosis, atrophy)
-the epithelium does not become atrophic
• Genenally, it is prudent not to operate on lesions than 4cm
in diameter because these patients will require
postoperative radiation therapy
 Radical hysterectomy and
Pelvic node dissection
Type II (modified) hysterectomy
-medial half of the cardinal & uterosacral lig.
selective removal of the enlarged LN

Type III hysterectomy

-cardinal & uterosacral lig.
upper 1/3 of the vagina
 Radical hysterectomy and
Pelvic node dissection
Type IV hysterectomy
-the periureteral tissue
superior vesicle artery
¾ of the vagina

Type V hysterectomy
-distal ureter and bladder
rarely performed because radiotherapy
 Radical hysterectomy and
Pelvic node dissection
• The abdomen : midline incision
low transverse incision
-exposure of the lateral pelvis
pelvic LN dissection
wide resection of primary tumor
• Metastatic disease : liver
omentum
both kidney
paraaortic LN
 Radical hysterectomy and
Pelvic node dissection
• Tumor extension, nodularity 확인
-vesicouterine fold
rectouterine fold
cervix
cardinal ligment

• The ovaries are conserved

-younger than 40 yars of age
 Radical hysterectomy and
Pelvic node dissection
• Paraaortic lymph node evaluation
-peritoneum is incised medial to the ureter
and over the right common iliac artery
-expose the aorta and the vena cava
-any enlarged LNs are dissected
-analysis by frozen section
+: discontinue and use radiotherapy
-: left side LN palpable through the IMA
if heaithy, not sumitted for frozen section
 Radical hysterectomy and
Pelvic node dissection
• Development of the pelvic space
-paravesical space
umbilical artery : medial
obturator internus : lateral sidewall
cardinal lig. : posterior
pubic symphysis : anterior

-pararectal space
rectum : lateral
cardinal lig. : anterior
hypogastric artery : lateral
sacrum : posterior
• The coccygeus muscle forms the floor of the
pararectal space
 Radical hysterectomy and
Pelvic node dissection
• Pelvic lymphadenectomy
-begin by opening the round lig.
ureter elevated, expose the common iliac artery
common iliac & ext. iliac node are dissected
(avoid injuring the genitofemoral n.)

-lateral chain of ext. iliac LN->median chain

->obturator LN 순으로 dissection 함
 Radical hysterectomy and
Pelvic node dissection
• Dissection of the bladder

-tumor extension to the base of the bladder

not adequate mobilization

-bladder off : the upper 1/3 of the vagina

remove the tumor safely
adequate margin
 Radical hysterectomy and
Pelvic node dissection
• Dissection of the uterine artery
-usually arised from the sup. vesicle artery , is
isolated and devided. and the vesicle artery are
preserved

• Dissection of the ureter

-the ureter is dissected free from its medial
peritoneal flap of the level of the uterosacral
ligament
 Radical hysterectomy and
Pelvic node dissection
• Posterior dissection
-across the cul-de-sac
expose the uterosacral ligament
the cardinal lig. separate from rectum
 Modified Radical
Hysterectomy
• The uterine artery is tansected at the level of the
ureter, thus preserving the ureteral branch to the
ureter
• The cardinal ligment is not divided near the
sidewall but instead is divided at about its
midportion near the ureteral dissection
• The anterior vesicouterine ligament is divided,
but the posterior vesicouterine ligament is
conserved
 Complications of
Radical Hysterectomy
• Acute complication
-Blood loss
ureterovaginal fistula
vesicovaginal fistila
Pulmonary embolus
small bowel obstruction
Febrile morbidity
 Complications of
Radical Hysterectomy
• Subacute complication
-bladder dysfunction
bladder vol. decreased
filling pr. Increased
the sensitivity to filling is diminished
be unable to intiate voiding
->adequate bladder drainage during this time
to prevent over distension
 Complications of
Radical Hysterectomy
• Subacute complication
-lymphcyst formation (cause is uncertain)
ureteral obstrustion
partial venous obstruction
thrombosis
->adequate drainage of the pelvis

• Chronic complication
-bladder hypotonia or atony
result of bladder denervation