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 dysfuntion이 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