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International Journal of Gynecological... Feb 2023The most common cancer in women worldwide is cervical cancer. For early-stage disease the standard treatment is radical hysterectomy. One of the main issues faced by... (Review)
Review
The most common cancer in women worldwide is cervical cancer. For early-stage disease the standard treatment is radical hysterectomy. One of the main issues faced by surgeons performing a radical hysterectomy is the wide variation in the terminology used to define the procedure and the nomenclature used to describe the anatomical spaces critical to the success of the surgery. The aim of this review was to synthesize currently used anatomical landmarks with relation to surgical avascular spaces for the performance of radical hysterectomy.A computer-based comprehensive review of the MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase, and SciSearch databases, as well as National Comprehensive Cancer Network and European Society of Gynaecological Oncology guidelines, was performed. With all relevant data collected, and previous anatomical studies during surgeries and on cadavers performed by authors, a manuscript of the definition of avascular spaces, methods of dissection, and anatomical limits was prepared.Avascular pelvic spaces developed during radical hysterectomy, such as the paravesical, pararectal, ureter tunnel, and paravaginal, were considered and included in the manuscript. A clear definition of avascular spaces may aid a better understanding of the anatomical aspects of the radical hysterectomy. It could improve surgeon knowledge of the structures that need to be preserved and those that need to be resected during a radical hysterectomy. Additionally, the detailed exposure of anatomical boundaries will facilitate the appropriate tailored radicality depending on the risk factors of the disease. Moreover, knowledge of these spaces could make pelvic surgery safer and easier for other types of gynecological and non-gynecological procedures.
Topics: Female; Humans; Neoplasm Staging; Hysterectomy; Uterine Cervical Neoplasms; Pelvis; Dissection
PubMed: 36581489
DOI: 10.1136/ijgc-2022-004071 -
The Lancet. Oncology Mar 2008Since the first publications about surgery for cervical cancer, many radical procedures that accord with different degrees of radicality have been described and done.... (Review)
Review
Since the first publications about surgery for cervical cancer, many radical procedures that accord with different degrees of radicality have been described and done. Here, we propose a basis for a new and simple classification for cervical-cancer surgery, taking into account the curative effect of surgery and adverse effects, such as bladder dysfunction. The international anatomical nomenclature is used where it applies. For simplification, the classification is based only on lateral extent of resection. We describe four types of radical hysterectomy (A-D), adding when necessary a few subtypes that consider nerve preservation and paracervical lymphadenectomy. Lymph-node dissection is considered separately: four levels (1-4) are defined according to corresponding arterial anatomy and radicality of the procedure. The classification applies to fertility-sparing surgery, and can be adapted to open, vaginal, laparoscopic, or robotic surgery. In the future, internationally standardised description of techniques for communication, comparison, clinical research, and quality control will be a basic part of every surgical procedure.
Topics: Cervix Uteri; Female; Humans; Hysterectomy; Lymph Node Excision; Uterine Cervical Neoplasms
PubMed: 18308255
DOI: 10.1016/S1470-2045(08)70074-3 -
Current Treatment Options in Oncology Jan 2022Radical hysterectomy with pelvic lymph node assessment is the standard initial therapy for early-stage cervical cancer. Radical hysterectomy via laparotomy (an "open"... (Review)
Review
Radical hysterectomy with pelvic lymph node assessment is the standard initial therapy for early-stage cervical cancer. Radical hysterectomy via laparotomy (an "open" approach) was first described more than 100 years ago and has been the standard for decades. Minimally invasive surgery (MIS) has been increasingly adopted by many surgeons due to its reported perioperative benefits. MIS was deemed safe for radical hysterectomy for many years based on multiple retrospective publications. Recently, the Laparoscopic Approach to Cervical Cancer (LACC) trial reported that patients randomized to MIS had inferior oncologic outcomes. The results of the LACC trial and subsequent retrospective studies led multiple professional societies to state that open radical hysterectomy should remain the gold standard surgical approach. We acknowledge that the open approach for radical hysterectomy is an appropriate option for all cervical cancer patients eligible for surgical treatment. However, considering the limitations of the LACC trial and the available data from other retrospective studies, we feel the MIS approach should not be simply abandoned. There may still be a role for MIS in cervical cancer surgery for properly and carefully selected cases and with detailed counseling; surgeons should analyze their own outcomes closely in order to perform such counseling. Modification of surgical technique and maintaining proper oncologic surgical principles are key for MIS to remain a viable option. Tumor manipulation and contamination should be avoided. Transcervical uterine manipulators should not be used. Cervical and tumor containment prior to colpotomy, as is performed during an open approach, is required. This will all require validation in future trials. We await the results of ongoing randomized trials to further inform us. A one-size-fits-all approach may be short-sighted; we may need to decide treatment strategy based on the notion of the right surgical approach for the right patient by the right surgeon.
Topics: Female; Humans; Hysterectomy; Laparoscopy; Minimally Invasive Surgical Procedures; Neoplasm Staging; Randomized Controlled Trials as Topic; Retrospective Studies; Uterine Cervical Neoplasms
PubMed: 35167007
DOI: 10.1007/s11864-021-00919-z -
Best Practice & Research. Clinical... Jun 2005The radical hysterectomy is the standard approach for the treatment of women with early cervical cancer. However, it has increasingly been recognized that a more... (Review)
Review
The radical hysterectomy is the standard approach for the treatment of women with early cervical cancer. However, it has increasingly been recognized that a more individualized approach to treatment should be taken. In particular, careful pretreatment evaluation should reduce the number of women receiving adjuvant radiotherapy. Laparoscopic lymphadenectomy is an attractive technique that seems likely to reduce the use of dual modality therapy. The laparoscopic approach to the evaluation of lymph nodes in cervical cancer has also allowed the development of the fertility-preserving radical trachelectomy. Outcomes for women with early cervical cancer are generally good, and it therefore becomes increasingly relevant to develop methods of reducing long-term morbidity.
Topics: Female; Humans; Hysterectomy; Lymph Node Excision; Neoplasm Staging; Patient Selection; Perioperative Care; Uterine Cervical Neoplasms
PubMed: 15985254
DOI: 10.1016/j.bpobgyn.2004.12.003 -
Current Treatment Options in Oncology Feb 2022Classical radical vaginal hysterectomy first performed by Anton Pawlik in Prague in 1888 and popularized by Frederic Schauta is now a historical technique virtually... (Review)
Review
Classical radical vaginal hysterectomy first performed by Anton Pawlik in Prague in 1888 and popularized by Frederic Schauta is now a historical technique virtually abandoned due to painful perineal incision, a high rate of urinary dysfunction, and the inability to perform lymph node assessment. However, the heritage of this approach has been still used and taught in a few centers outside their Austrian birthplace. A combined vaginal and laparoscopic approach was developed in the 1990s by French and German surgeons who designed diverse surgical techniques for which a novel classification is proposed. All these techniques are different from the so-called laparoscopically assisted radical vaginal hysterectomy (LARVH), a term widely used for laparoscopic radical hysterectomies with vaginal extraction of the specimen. Interestingly, after the publication of the LACC trial (Laparoscopic Approach to Cervical Cancer), the radical vaginal approach has found a very timely application. The creation of a vaginal cuff before performing radical laparoscopic hysterectomy described in 2007 by Leblanc as "Schautheim" operation can be used as a protective maneuver to avoid tumor spillage and potentially overturn the negative outcome of minimally invasive surgery in early-stage cervical cancer. As a result, the combination of radical vaginal and laparoscopic steps of surgery is one possible evolution after the LACC trial that needs further investigation. The forgotten vaginal surgical technique needs a specific learning curve. The creation of a vaginal cuff should be mastered by every gynecological oncologist.
Topics: Clinical Trials as Topic; Female; Humans; Hysterectomy; Hysterectomy, Vaginal; Laparoscopy; Uterine Cervical Neoplasms; Vagina
PubMed: 35195838
DOI: 10.1007/s11864-022-00937-5 -
Annals of Surgical Oncology Oct 2017One of the most important principles in modern cervical cancer surgery is the concept of tailoring surgical radicality. In practice, this means abandoning the...
BACKGROUND
One of the most important principles in modern cervical cancer surgery is the concept of tailoring surgical radicality. In practice, this means abandoning the "one-fits-all" concept in favor of tailored operations. The term "radical hysterectomy" is used to describe many different procedures, each with a different degree of radicality. Anatomic structures are subjected to artificial dissection artifacts, as well as different interpretations and nomenclatures. This study aimed to refine and standardize the principles and descriptions of the different classes of radical hysterectomy as defined in the Querleu-Morrow classification and to propose its universal applicability.
METHODS
All three authors independently examined the current literature and undertook a critical assessment of the original classification. Images and pathologic slides demonstrating different types of radical hysterectomy were examined to document a consensual vision of the anatomy. The Cibula 3-D concept also was included in this update.
RESULTS
The Querleu-Morrow classification is based on the lateral extent of resection. Four types of radical hysterectomy are described, including a limited number of subtypes when necessary. Two major objectives remain constant: excision of central tumor with clear margins and removal of any potential sites of nodal metastasis.
CONCLUSION
Studies evaluating radicality in the surgical management of cervical cancer should be based on precise, universally accepted descriptions. The authors' updated classification presents standardized, universally applicable descriptions of different types of hysterectomies performed worldwide, categorized according to degree of radicality, independently of theoretical considerations.
Topics: Female; Humans; Hysterectomy; Lymph Node Excision; Prognosis; Uterine Cervical Neoplasms
PubMed: 28785898
DOI: 10.1245/s10434-017-6031-z -
Bailliere's Clinical Obstetrics and... Mar 1997Radical hysterectomy for the treatment of cervical cancer was first performed just over 100 years ago. Refinements of surgical technique and improvements in supportive... (Review)
Review
Radical hysterectomy for the treatment of cervical cancer was first performed just over 100 years ago. Refinements of surgical technique and improvements in supportive measures, such as transfusions and antibiotics, have brought about a marked decrease in morbidity and mortality from surgery and improvement in overall survival. The indications for operation, pre-operative investigations and preparation, surgical technique, post-operative complications and their management, and factors influencing prognosis are discussed.
Topics: Female; History, 19th Century; History, 20th Century; Humans; Hysterectomy; Patient Selection; Preoperative Care; Urologic Diseases; Uterine Cervical Neoplasms
PubMed: 9155941
DOI: 10.1016/s0950-3552(97)80055-7 -
Best Practice & Research. Clinical... Apr 2021The incidence of placenta accrete spectrum (PAS) disorders is increasing worldwide. Pregnancies complicated by PAS are at a high risk of intrapartum surgical... (Review)
Review
The incidence of placenta accrete spectrum (PAS) disorders is increasing worldwide. Pregnancies complicated by PAS are at a high risk of intrapartum surgical complications, mainly due to severe maternal hemorrhage, potentially leading to death, thus highlighting the need for a tailored an appropriate surgical management for these women. Despite its clinical relevance, there are still unanswered questions regarding the surgical management of women with PAS. Hysterectomy has been considered as the gold standard for the surgical treatment of these women. However, the surgical approach has not yet been standardized, and several conservative surgical procedures such as the Triple P Procedure are also being performed for PAS. Interventional radiology techniques have been demonstrated to reduce the risk of severe blood loss in women with postpartum hemorrhage, but their role in the management of women with PAS has not yet been fully defined. The aim of this chapter is to provide an up-to-date insight on the radical surgical approach to adopt during cesarean delivery in pregnancies complicated by PAS disorders.
Topics: Cesarean Section; Female; Humans; Hysterectomy; Incidence; Placenta Accreta; Postpartum Hemorrhage; Pregnancy
PubMed: 33824063
DOI: 10.1016/j.bpobgyn.2021.01.008 -
The Cochrane Database of Systematic... Feb 2019Radical hysterectomy is one of the standard treatments for stage Ia2 to IIa cervical cancer. Bladder dysfunction caused by disruption of the pelvic autonomic nerves is a... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Radical hysterectomy is one of the standard treatments for stage Ia2 to IIa cervical cancer. Bladder dysfunction caused by disruption of the pelvic autonomic nerves is a common complication following standard radical hysterectomy and can affect quality of life significantly. Nerve-sparing radical hysterectomy is a modified radical hysterectomy, developed to permit resection of oncologically relevant tissues surrounding the cervical lesion, while preserving the pelvic autonomic nerves.
OBJECTIVES
To evaluate the benefits and harms of nerve-sparing radical hysterectomy in women with stage Ia2 to IIa cervical cancer.
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 4), MEDLINE via Ovid (1946 to May week 2, 2018), and Embase via Ovid (1980 to 2018, week 21). We also checked registers of clinical trials, grey literature, reports of conferences, citation lists of included studies, and key textbooks for potentially relevant studies.
SELECTION CRITERIA
We included randomised controlled trials (RCTs) evaluating the efficacy and safety of nerve-sparing radical hysterectomy compared to standard radical hysterectomy for women with early stage cervical cancer (stage Ia2 to IIa).
DATA COLLECTION AND ANALYSIS
We applied standard Cochrane methodology for data collection and analysis. Two review authors independently selected potentially relevant RCTs, extracted data, evaluated risk of bias of the included studies, compared results and resolved disagreements by discussion or consultation with a third review author, and assessed the certainty of evidence.
MAIN RESULTS
We identified 1332 records as a result of the search (excluding duplicates). Of the 26 studies that potentially met the review criteria, we included four studies involving 205 women; most of the trials had unclear risks of bias. We identified one ongoing trial.The analysis of overall survival was not feasible, as there were no deaths reported among women allocated to standard radical hysterectomy. However, there were two deaths in among women allocated to the nerve-sparing technique. None of the included studies reported rates of intermittent self-catheterisation over one month following surgery. We could not analyse the relative effect of the two surgical techniques on quality of life due to inconsistent data reported. Nerve-sparing radical hysterectomy reduced postoperative bladder dysfunctions in terms of a shorter time to postvoid residual volume of urine ≤ 50 mL (mean difference (MD) -13.21 days; 95% confidence interval (CI) -24.02 to -2.41; 111 women; 2 studies; low-certainty evidence) and lower volume of postvoid residual urine measured one month following operation (MD -9.59 days; 95% CI -16.28 to -2.90; 58 women; 2 study; low-certainty evidence). There were no clear differences in terms of perioperative complications (RR 0.55; 95% CI 0.24 to 1.26; 180 women; 3 studies; low-certainty evidence) and disease-free survival (HR 0.63; 95% CI 0.00 to 106.95; 86 women; one study; very low-certainty evidence) between the comparison groups.
AUTHORS' CONCLUSIONS
Nerve-sparing radical hysterectomy may lessen the risk of postoperative bladder dysfunction compared to the standard technique, but the certainty of this evidence is low. The very low-certainty evidence for disease-free survival and lack of information for overall survival indicate that the oncological safety of nerve-sparing radical hysterectomy for women with early stage cervical cancer remains unclear. Further large, high-quality RCTs are required to determine, if clinically meaningful differences of survival exist between these two surgical treatments.
Topics: Autonomic Nervous System; Disease-Free Survival; Female; Humans; Hysterectomy; Neoplasm Recurrence, Local; Neoplasm Staging; Organ Sparing Treatments; Pelvis; Postoperative Complications; Randomized Controlled Trials as Topic; Urinary Bladder; Urination Disorders; Uterine Cervical Neoplasms
PubMed: 30746689
DOI: 10.1002/14651858.CD012828.pub2 -
Gynecologic Oncology Jul 2022Radical hysterectomy and pelvic lymphadenectomy are considered the standard treatment for early-stage cervical cancer (ECC). Minimal Invasive approach to this surgery... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Radical hysterectomy and pelvic lymphadenectomy are considered the standard treatment for early-stage cervical cancer (ECC). Minimal Invasive approach to this surgery has been debated after the publication of a recent prospective randomized trial (Laparoscopic Approach to Cervical Cancer, LACC trial). It demonstrated poorer oncological outcomes for Minimal Invasive Surgery in ECC. However, the reasons are still an open debate. Laparo-Assisted Vaginal Hysterectomy (LAVRH) seems to be a logical option to Abdominal Radical Hysterectomy (ARH). This meta-analysis has the aim to prove it.
METHODS
Following the recommendations in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, the Pubmed database and Scopus database were systematically searched in January 2022 since early first publications. No limitation of the country was made. Only English article were considered. The studies containing data about Disease-free Survival (DFS) and/or Overall Survival (OS) and/or Recurrence Rate (RcR) were included.
RESULTS
19 studies fulfilled inclusion criteria. 9 comparative studies were enrolled in meta-analysis. Patients were analyzed concerning surgical approach (Laparo-Assisted Vaginal Radical Hysterectomy) and compared with ARH Oncological outcomes such as DFS and OS were considered. 3196 patiets were included for the review. Meta-analysis of 1988 0f them highlighted a non-statistic significant difference between LARVH and ARH (RR 0.8 [95% CI 0.55-1.16] p = 0.24; I = 0%; p = 0.98). OS was feasible only for 4 studies (RR 0.84 [95% CI 0.23-3.02] p = 0.79; I = 0 p = 0.44). Sub-analysis for tumor with a maximum diameter greater than 2 cm was performed. Data about the type of recurrences (loco-regional vs distant) were collected.
CONCLUSION
LARVH does not appear to affect DFS and OS in ECC patients. The proposed results seem to be comparable with the open approach group of the LACC trial, which today represents the reference standard for the treatment of this pathology. More studies will be needed to test the safety and efficacy of LARVH in the ECC.
Topics: Female; Humans; Hysterectomy; Hysterectomy, Vaginal; Laparoscopy; Neoplasm Staging; Retrospective Studies; Uterine Cervical Neoplasms
PubMed: 35513934
DOI: 10.1016/j.ygyno.2022.04.010