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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_759_Библиотеки_им_академика_М_И_Перельмана.pdf
Radical Hysterectomy
MitchelHoman, NadimBouZgheib,
MonicaAvila, andJing-YiChern
33
Introduction
Radical hysterectomy is an extended hysterectomy that is intended to remove the uterus as well
as a variable amount of soft tissue, for the purpose of achieving appropriate oncologic resection of a pelvic malignancy. While mainly utilized
as primary surgical treatment of early stage cervical cancer, this operation may also be incorporated into the surgical management of extended
operations for ovarian, colorectal or urologic
malignancies.
When utilized to treat cervical cancer, radical
hysterectomy includes surgical assessment of the
pelvic and sometimes paraaortic lymph nodes.
Pelvic and paraaortic lymphadenectomy is covered in Chap. 32. When performed as a primary
operation for cervical cancer, the oncologic margins include the endopelvic fascia ventrally, the
lymph node-bearing tissue associated with the
uterine vessels as well as the paravaginal portion
M. Hoffman (*) · M. Avila · J.-Y. Chern
Department of Gynecologic Oncology, Moftt
Cancer Center, USF Morsani College of Medicine,
Tampa, FL, USA
e-mail: mitchel.hoffman@moftt.org; Monica.
Avila@moftt.org; Jing-Yi.Chern@moftt.org
N. B. Zgheib
Department of Oncology, Edwards Comprehensive
Cancer Center and Joan C.Edwards School of
Medicine, Huntington, WV, USA
e-mail: nadim.bouZgheib@chhi.org
of the cardinal ligament laterally, the uterosacral
and rectovaginal ligaments dorsally, and the
upper vagina distally. Resection of this addition
soft tissue requires extensive mobilization of the
distal ureters and bladder from the cervix and
upper vagina. The upper rectum must be separated from the upper vagina. Variations of this
operation are performed to resect other pelvic
malignancies, depending on their extent. Radical
hysterectomy may be performed by open or laparoscopic surgery.
Major complications of radical hysterectomy
include urinary tract injury, bladder dysfunction,
rectal injury, colorectal dysfunction, vaginal
dehiscence, surgical site infection and sexual
dysfunction.
Ureteral Injury
Background
Freeing the ureter from its course through the
parametria (Fig.33.1) is a major part of the effort
in performing a radical hysterectomy. The extent
of ureteral dissection varies according to the radicality of the operation, but invariably results in
some loss of ureteral vasculature.
The incidence of ureteral injury (immediate
and delayed) is reported to be 1–2% [1–17]. The
risk is much higher in those who have received
prior pelvic radiotherapy [18, 19].
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Hoffman et al. (eds.), Major Complications of Female Pelvic Surgery,
https://doi.org/10.1007/978-3-031-66772-5_33
363
364
s
ureter
Fig. 33.1 Course of the
ureter through the
parametrium
M. Homan et al.
Ureter
Uterine
vessel
Prevention
Thorough knowledge of the surgical anatomy of
the pelvic ureter is a critical factor in the safe performance of a radical hysterectomy. There must
be gentle, meticulous dissection of the ureter
with avoidance of thermal energy in proximity to
this structure. It is the opinion of the authors that
stents may have a deleterious effect during radical hysterectomy by making the ureters stiff and
more susceptible to shearing of feeder vessels
and the adventitia.
The degree of ureteral dissection will vary
according to the radicality of the hysterectomy,
which should be tailored to an oncologically
appropriate resection (Fig.33.2). Regardless, it
is of paramount importance that the integrity of
the ureteral adventitia be preserved and that dissection lateral to the distal most aspect of the
ureter be avoided (Fig. 33.3) [1]. Finally, for
Course of
women who have received prior full dose radiotherapy, radical hysterectomy that will involve
anything beyond minimal ureteral dissection
should only be considered in highly selected
cases [18, 19].
Recognition
During radical hysterectomy, the surgeon must
maintain a high level of vigilance with the ureters, both during dissection and resection.
Thermal damage may not be readily appreciable
and any concern regarding this possibility must
be managed accordingly. Loss of adventitia is
equally concerning. Clear uid appearing in the
operative eld must be investigated with careful
inspection, aided by intravenous injection to dye
the urine. Cystoscopy with the passage of a stent
and/or retrograde pyelography are also options.
(par
e
33 Radical Hysterectomy
365
Vascular porton
s vacsulosa)
Fibrous portion
(pars nervosa)
Fig. 33.2 Extent of radical hysterectomy. Right lateral
line represents Class III and left line represents Class II
radical hysterectomy. “Zigzag” line on right represents a
hybrid or Class II/III radial hysterectomy. The latter oper-
Unrecognized complete transection or ligation
of a ureter is highly unlikely given that the ureter
is dissected out and in direct view of the surgeon.
At the completion of surgery, the operative eld
should always be carefully inspected for injuries
and hemostasis.
Following surgery, a ureteral injury may present within days or weeks depending on the
mechanism of the insult. Thermal injury tends to
be more delayed. With unilateral obstruction
there may be a transient rise in the serum creatinine during the rst several days after surgery. A
large volume of clear uid from a drain or the
vagina is concerning and is initially evaluated by
sending a sample for creatinine and dying the
urine. A CT urogram is the denitive test to evaluate for and identify the location of a ureteral
Lymph nodes
2-3 Procedur
ation includes resection of the entire vascular cardinal
ligament but spares the lateral and deep portions of the
brous, nerve-containing ligament
injury, as well as to look for the presence of a
urinoma. Unfortunately, the silent death of a kidney secondary to obstruction is a well-known
phenomenon.
Management
This is covered in detail in Chap. 17. Briey, the
vast majority of ureteral injuries that are recognized intraoperatively are managed with a ureteroneocystostomy. For minimal damage (loss of
a small area of adventitia) or suspected mild
injury (questionable mild thermal insult), ureteral
stenting alone may be considered. For management of an injury diagnosed postoperatively,
please refer to Chap. 17.
366
Renal artery
M. Homan et al.
a
Fig. 33.3 Blood supply of the ureter
Bladder Injury
Ovarian artery
Internal iliac
artery
Superior
vesical artery
Inferior
vesical artery
b
Ureteral mucosa
Prevention
AdventitiaMuscularis
Background
During radical hysterectomy, the bladder must be
mobilized to a much greater extent than required
for a simple hysterectomy. This is necessary to
achieve adequate vaginal and parametrial margins.
The incidence of bladder injury associated with
radical hysterectomy is up to 4% [17, 20, 21].
Signicantly, some of these injuries are close to the
trigone due to the need for more distal dissection.
Due to the oncologic importance of maintaining
the integrity of the endopelvic fascia with the specimen, it is not appropriate to direct dissection away
from the bladder and into the cervix or vagina.
Prevention of injury requires cautious dissection,
including the lateral aspects of the bladder that
might otherwise be damaged during paravaginal
resection. Backlling the bladder is occasionally
useful in challenging cases. Minimal and judicious
use of thermal injury is important here.
33 Radical Hysterectomy
367
Recognition
As with the ureters, the surgeon must maintain a
high level of vigilance with the bladder, both during dissection and resection. Similarly, thermal
damage may not be readily appreciable and any
concern regarding this possibility must be
managed accordingly. Clear uid appearing in
the operative eld must be investigated with careful inspection, aided by backlling the bladder
under observation.
Following surgery, a bladder injury may present within days or weeks depending on the mechanism of the insult. As with the ureter, thermal
injury tends to be more delayed. Large volume
clear drainage from the vagina is concerning and
is initially evaluated by backlling the bladder
with a dyed solution while observing the vaginal
cuff with a speculum. A CT urogram is the denitive test to evaluate for and dene the location of
a bladder injury, and to look for a concomitant
ureteral injury and/or urinoma.
Management
This subject is covered in detail in Chap. 12.
Following a radical hysterectomy, bladder sensation is often impaired. An overdistended bladder
may lead to failure of repair of even a minor
injury. This requires special consideration when
determining the length of time for postoperative
bladder rest.
Prevention
Identication and incision of the rectal reection
must be accomplished, followed by maintaining
the correct path of dissection in the rectovaginal
space and off of the rectovaginal ligaments. This
may be challenging in cases of Pouch of Douglas
obliteration (endometriosis, diverticulitis). An
instrument in the rectum such as an EEA sizer
may occasionally be useful in challenging cases.
Judicious use of thermal energy is a must when in
proximity to the rectum.
Recognition
As with the previously discussed urinary tract
injuries, constant vigilance is required during dissection and resection if the surgeon is to recognize this uncommon intraoperative complication.
Stool in the eld or noting the rectal lumen makes
the injury apparent. Sudden loss of resistance
during development of the rectovaginal space
should lead to prompt investigation for this possibility. When any level of concern exists, the “air
bubble” or “at tire” test is useful in ruling a rectal injury in or out.
With delayed injury, the patient will almost
always present with stool per vagina. Examination
and a contrast enema will be conrmatory.
Management
Rectal Injury
Background
During radical hysterectomy, it is necessary to
mobilize the rectum from the upper vagina and
medial aspect of the rectovaginal ligaments in
order to obtain appropriate margins. Injury of the
rectum may occur during dissection or resection.
Injury of the rectum (immediate or delayed) is
uncommon and underreported. However, it is
presumed to be comparable to benign hysterectomy where it has been shown to occur in less
than 1% of cases [17, 22, 23].
A rectal injury identied at the time of surgery is
temporarily closed to reduce contamination while
the hysterectomy is completed. After controlled
irrigation, the defect is closed in two layers as
described in several other chapters.
When presenting as a delayed rectal injury,
diversion is required followed by later repair.
Bladder Dysfunction
Background
Radical hysterectomy partially denervates the
bladder (Fig. 33.4). Following radical hysterec-
368
Cervix
ligament
c
Fig. 33.4 Neuroanatomy
clinically relevant to
radical hysterectomy
M. Homan et al.
Sympatheti
nerve fibers
Bladder
branches
Vascular portion
tomy, a majority of patients experience some
degree of lower urinary tract dysfunction,
although the reported incidence varies greatly in
the literature [15, 24–39]. The most common
morbidity related to the extent of radicality is
lower urinary tract dysfunction [12, 15, 40–44].
This is mainly a short-term difference (rst
3months) although the infrequent occurrence of
long-term (greater than 6–12 months) severe
voiding dysfunction also appears to be greater
with the Class III operation (Fig.33.2) [13, 14].
The pathophysiology of lower urinary tract dysfunction after radical hysterectomy is not clearly
understood. Plausible theories include direct surgical trauma, subsequent perivesical brosis,
interruption of afferent sensory, parasympathetic
and sympathetic autonomic motor nerves
(Fig.33.4), and an impaired detrusor reex [15,
24–26, 28–35]. Overall, the likelihood of chronic
urinary tract dysfunction following a radical hysterectomy may be related to preoperative function, the degree of surgical neurological injury,
and subsequent injury by bladder overdistention.
Better case selection, an improved understanding of contributing surgical factors, appropriate oncologic surgical modications, extended
bladder rest in some cases, and highly selective
use of adjuvant radiotherapy have all contributed
of cardinal
Pelvic nerve
plexus
Parasympathetic
nerve fibers
to a reduction in both the incidence and severity
of this problem.
A smaller percentage of patients will develop
stress or mixed urinary incontinence, especially
when adjuvant radiotherapy has been administered [28, 32, 33, 43, 44]. Prevention and management of these types of voiding dysfunction
are less clear, but probably follow the same principles outlined for the denervation-related dysfunction described.
Prevention
Prevention of postoperative bladder dysfunction
begins with careful case selection. Large tumors
require more extensive resection. These and
deeply invasive tumors are more likely to have
indications for postoperative adjuvant radiotherapy and are better managed primarily with
chemoradiotherapy [45].
Modications of radical hysterectomy markedly reduce the incidence and severity of subsequent bladder dysfunction (Fig.33.2) [12–15, 26,
28, 40–42, 46–61]. The specic modications
include avoiding very lateral and caudal resection
of the paravaginal, vesicovaginal and rectovaginal
ligaments as well as limiting the extent of bladder
33 Radical Hysterectomy
369
mobilization and vaginal resection [45]. These
modications are consistent with an appropriate
oncologic resection [62–65]. A recent study has
suggested that radicality involving less extensive vaginal resection (<3cm) will minimize the
need for ongoing postoperative catheterization
[66]. Therefore, larger vaginal resections should
be limited as they can cause more damage to the
pelvic oor. If resection leaves only the urethral
vagina, the posterior urethro-vesical angle may
be lost, which will predispose to lower urinary
tract symptoms or LUTS (especially incontinence) [67]. Another recent study (prospective,
randomized) concluded that simple hysterectomy is non-inferior to radical hysterectomy for
women with low-risk cervical cancer (lesions of
≤2 cm with limited stromal invasion) [68].
Minimizing the use of postoperative adjuvant
pelvic radiotherapy to appropriate indications is
also an important factor in reducing the incidence
of postoperative bladder dysfunction.
Postoperative bladder overdistention is a
major contributing factor to short and especially
long-term bladder dysfunction. The length of recommended bladder rest following radical hysterectomy varies among studies and practices. Prior
to discontinuation, an active voiding trial should
be performed. Additionally, given the potential
decrease in bladder sensation, the patient should
be instructed to “void by the clock” in order to
avoid bladder overdistention. Counseling on
using Valsalva to aid in bladder emptying is also
reasonable. When difculty with bladder emptying persists during the rst 6weeks after surgery,
having the patient perform intermittent selfcatheterization (ISC) is more likely to result in a
degree of bladder recovery than further complete
bladder rest.
Recognition
After an initial period of bladder rest, failure to
pass an active voiding trial alerts the surgeon that
more time for bladder recuperation is needed. If
the patient is still not able to empty her bladder
(<100cc post-void residual [PVR]) after 6weeks,
then consideration should be given to instituting
ISC until the PVR is consistently <100 cc.
Additional recovery of bladder function may
occur over the next 6months, but beyond that, the
problem is likely to be permanent [69].
An initially successful voiding trial may occasionally be followed, usually within days to
weeks, by incomplete voiding. The problem
accumulates until the patient presents with overow incontinence or inability to void, with a
markedly overdistended bladder.
Management
For women with persistent inability to adequately
void following radical hysterectomy, the mainstay of management is some form of catheterization. It is important to avoid both acute and
chronic bladder overdistention, which will lead
to infection and further decompensation of bladder function. Pharmacologic agents may be tried
but have been met with limited success. Catheter
options are an indwelling Foley, ISC, or a suprapubic tube.
Colorectal Dysfunction
Background
As with the bladder, extensive pelvic resection
during radical hysterectomy may denervate the
rectosigmoid colon. Unlike voiding dysfunction,
this problem appears to be very uncommon [12,
56, 57]. Subsequent to surgery, the patient has a
segment of the rectosigmoid colon with poor
peristaltic function.
Risk factors are unclear but likely include the
extent of resection and associated pelvic nerve
plexus denervation (as previously described) and
preexisting chronic constipation and/or defecatory dysfunction. Whether specic aspects of the
radical hysterectomy radicality, such as more
extensive rectovaginal ligament resection, contribute to the development of this problem is not
known. Survivorship studies suggest that the
long-term effects of bowel dysfunction tend to be
mild in isolated radical hysterectomy and are not
370
M. Homan et al.
signicantly impacted by the need for a radical
procedure [70]. However, other studies comparing surgical radicality suggest that a more extensive procedure such as total mesorectal excision
tends to have higher rates of dysfunction than
radical hysterectomy alone [71].
Prevention
As with the prevention of bladder dysfunction,
case selection that precludes the oncologic necessity of an extensive wide and deep resection of
the paravaginal tissues would likely prevent most
instances of signicant colorectal dysfunction
following radical hysterectomy. Regardless,
extensive resection of the uterosacral and rectovaginal ligaments for cervical cancer does not
have an oncologic basis [49, 62–65].
During the weeks following a radical hysterectomy, there is a tendency toward bowel dysfunction and constipation. It is good practice to
maintain these patients on a bowel regimen that
will help avoid severe constipation, which may
be an additional contributing factor to the development of colorectal dysfunction.
Recognition
Women with signicant colorectal dysfunction
following radical hysterectomy present in a manner similar to those who have undergone colorectal anastomosis, although the problem may involve
a longer bowel segment and be more severe and
persistent. There is a “functional obstruction”,
with the ineffective passage of stool past this area
resulting in chronic and severe constipation [72].
The problem persists despite conservative measures. The combination of a colon transit study and
defecography helps conrm the diagnosis.
Management
When women initially present postoperatively
following radical hysterectomy, the mainstay of
management is a good bowel regimen that
includes a bulking agent combined with adequate
hydration and supplemented by a combination of
laxatives and stool softeners. If studies conrm a
defect in transition across the rectosigmoid colon,
consideration is given to intensifying this regimen. A small case series reported good results
with segmental resection [73]. This should only
be considered in severe, recalcitrant cases and
after informed consent regarding both the potential for a major complication (leak) and failure to
improve the problem.
Vaginal Dehiscence
andEvisceration
This topic is covered in Chap. 6. The incidence of
vaginal cuff dehiscence with or without evisceration does not appear to be signicantly different
with radical versus simple hysterectomy.
Surgical Site Infection
Background
Surgical site infection (SSI) is the most common
complication of gynecologic surgery and has
been associated with mortality, prolonged hospitalization, increased readmission rate, and longterm disability. SSIs are dened as “an infection
related to an operative procedure that occurs at or
near the surgical incision within 30 days” [74,
75]. With the implementation of routine preop-
erative antibiotics along with bundled surgical
site infection preventions there have been
decreased infection rates in gynecologic cancer
surgery [74]. There are several risk factors that
contribute to SSIs such as obesity, hyperglycemia, poor nutritional status, tobacco use, steroid
use, and untreated infections. These are modiable risk factors and should be evaluated and
addressed prior to surgery, which may impact the
outcome [75, 76].
Radical hysterectomy is classied as a cleancontaminated operation due to entry into the
vagina. Cervical tumors may become infected,
adding to the eld contamination. Following
33 Radical Hysterectomy
371
radical hysterectomy, surgical site infection
may take the form of urinary tract infection
(UTI), abdominal wound infection, pelvic cellulitis, or pelvic abscess. The pathogens that are
attributed to SSIs are endogenous microbes of
the skin, vagina, and gastrointestinal tract.
When considering antimicrobial agents for
gynecologic procedures, it is important to consider the three sites of infection: supercial incisional- involves the skin and subcutaneous
layer, deep incisional- involves the deeper soft
tissues of the incision such as muscle or fascia,
and organ/space which involves any part of the
anatomy other than the incised body layer [75,
77]. During a radical hysterectomy, the surgical
site is exposed to gram- positive, gram-negative,
and anaerobic organisms. To effectively prevent
SSIs, interventions are directed at broadly covering these sites. Current studies and intervention strategies demonstrate a multi-modal
approach has provided the greatest benet in
decreasing complications.
Prevention
The most effective method of preventing SSIs is
incorporating a bundled approach of administering effective preoperative antibiotics and thorough preoperative surgical sterile measures. The
components of this bundling method include
patient factors such as optimization of modiable
risk factors as briey mentioned above. Personal
skin preparation prior to surgery includes avoiding hair removal (ie. shaving) and preoperative
shower with 4% chlorhexidine gluconate. If hair
removal is deemed necessary, this should be done
in the operating room prior to surgery using hair
clippers.
Generally, the routine use of intravenous
cefazolin and metronidazole is recommended at
least 1hour prior to skin incision and redosing of
cefazolin at four hours or blood loss >1500mL,
with increased dosing of cephalosporin for obese
patients [74, 78, 79]. The addition of metronidazole additionally addresses the common problem
of bacterial vaginosis which occurs in a third of
patients [74, 78, 80]. Preoperative treatment can
decrease the rate of vaginal cuff infections after
hysterectomy.
Skin preparation prior to surgical incision
should be with chlorhexidine gluconate and isopropyl alcohol 70%. The vaginal tract should be
prepped with either a povidone-iodine solution or
chlorhexidine gluconate with 4% of isopropyl
alcohol.
Wound infections are less common with active
maintenance of intraoperative normothermia by
pre-warming patients and avoiding a decrease in
body temperature.
In a radical hysterectomy, there can be disruption of autonomic innervation of the bladder
which can cause voiding dysfunction. Prior to
starting the procedure, a urethral catheter is
placed into the bladder and historically the catheter is maintained into the postoperative period.
Unfortunately, catheter-associated urinary tract
infections (CAUTI) are common and carry serious morbidity. CAUTIs are urinary tract infection
symptoms with no other source of infection and
with bacteriuria diagnosed within 48hours of a
catheter left in situ. Preventative measures such
as prophylactic antibiotics have not been shown
to decrease CAUTIs [81, 82]. One of the most
notable postoperative factors related to urinary
tract infections is the duration of catheterization,
and early catheter discontinuation should be considered depending on the radicality of the surgery
and the judgment of the surgeon.
Surgery should be meticulous, including
avoidance of excess thermal damage to tissues
and attention to hemostasis, while operating with
pace. Abdominal wound closure should include
subcutaneous layer approximation for obese
women. Placing a vacuum device on the closed
wound may be considered in high-risk cases, but
the benet in terms of preventing wound infection remains unclear.
Recognition
CAUTI is the most common hospital-acquired
condition following gynecologic surgery, more
so after a radical hysterectomy. While an indwelling urinary catheter is in place, symptoms of uri-
372
M. Homan et al.
nary tract infection (UTI) may not be apparent.
Hematuria, although not uncommon secondary
to mild trauma, may be a sign of infection cystitis. Following removal of the catheter, the patient
may develop clinical UTI days to weeks later,
which at times is chronic and difcult to eradicate. Fever, ank pain, costovertebral angle tenderness, and leukocytosis are suggestive of
pyelonephritis.
Following radical hysterectomy, clinically
apparent pelvic cellulitis may develop days to
weeks following surgery. The diagnosis is somewhat subjective and made largely on clinical
impression. Lower abdominal or pelvic discomfort, tenderness on lower abdominal and especially pelvic exam, fever, and leukocytosis may
all be present. Vaginal discharge and/or a partially disrupted vaginal cuff may be present.
Findings on imaging are nonspecic.
Abdominal wound infection (a common occurrence in obese women) typically presents
1–2 weeks after surgery with tender, red, warm
surrounding skin. Initially, there may be cellulitis
with surrounding induration. This may progress to
or initially present with uctuance or even purulent drainage. Imaging may be helpful in selected
cases when the presence of a drainable abscess is
unclear. Fever and leukocytosis may be present.
A pelvic abscess may develop in a small percentage of patients, usually within 2–3 weeks
postoperatively. The common presentation is
lower abdominal or pelvic discomfort, fever,
malaise, purulent vaginal drainage, leukocytosis,
and an abscess found on imaging.
Management
Fevers in the rst 48hours are conservatively managed as this is most often related to cytokine release
from tissue injury or atelectasis. The patient should
be encouraged to ambulate, use incentive spirometry, and respiratory toilet. After this time period if a
fever persists, a thoughtful work-up should be
completed for a postoperative patient.
When it is the clinical impression that an early
abdominal wound infection has been identied
(cellulitis only), then management with antibiotics and warm compresses is initiated. If there is
progression to or presentation with a wound
abscess (or drainage with subcutaneous dehiscence), then the wound should be opened. This
can usually be done in the clinic or bedside setting but occasionally needs to be done in the
operating room, especially when extensive
debridement is required. After thorough drainage
and washout of the wound, care may consist of
moist-to-dry dressings or a wound vacuum system. Some patients are candidates for subsequent
secondary closure.
UTI that is clinically conned to cystitis is
treated, ideally, with a culture-directed antibiotic
in addition to a urinary anesthetic. Pyelonephritis
with signs of systemic infection requires initial
hospitalization for supportive care and intravenous antibiotics. Ureteral obstruction should be
ruled out in such cases.
Clinically diagnosed pelvic cellulitis is treated
with broad-spectrum antibiotics. Hospitalization
may not be necessary.
Pelvic abscess that develops following radical
hysterectomy requires antibiotics and drainage.
The route of drainage is individualized and generally can be accomplished percutaneously by
interventional radiology or transvaginally.
Sexual Dysfunction
Background
A standard part of a radical hysterectomy is the
removal of a portion of the upper vagina. The
length of the vagina removed depends on the radicality of the operation, varying from approximately 2–4cm. The loss of this portion is rarely
of clinical signicance in terms of sexual function, likely due to the distensibility of the vagina
and its ability to stretch. Associated factors that
may impair vaginal health and function include
concomitant removal of the ovaries in premenopausal women, adjuvant radiation therapy (more
so if this includes vaginal brachytherapy), and the
radicality of the operation [38, 70, 71].