1. 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

2. 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

3. Genenally, it is prudent not to operate on lesions than 4cm in diameter because these patients will require postoperative radiation therapy

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. The coccygeus muscle forms the floor of the pararectal space

11. 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

12. 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

13. 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

14. Radical hysterectomy and Pelvic node dissection
Posterior dissection
-across the cul-de-sac
expose the uterosacral ligament
the cardinal lig. separate from rectum

16. 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

17. Complications of Radical Hysterectomy
Acute complication
-Blood loss
ureterovaginal fistula
vesicovaginal fistila
Pulmonary embolus
small bowel obstruction
Febrile morbidity

18. 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

19. 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