Treatment
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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)

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Treatment l.jpg
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 l.jpg
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


Slide3 l.jpg


Radical hysterectomy and pelvic node dissection l.jpg
Radical hysterectomy and Pelvic node dissection in diameter because these patients will require postoperative radiation therapy

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 dissection5 l.jpg
Radical hysterectomy and Pelvic node dissection in diameter because these patients will require postoperative radiation therapy

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 dissection6 l.jpg
Radical hysterectomy and Pelvic node dissection in diameter because these patients will require postoperative radiation therapy

  • 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


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Radical hysterectomy and Pelvic node dissection in diameter because these patients will require postoperative radiation therapy

  • 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 dissection8 l.jpg
Radical hysterectomy and Pelvic node dissection in diameter because these patients will require postoperative radiation therapy

  • 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 dissection9 l.jpg
Radical hysterectomy and Pelvic node dissection in diameter because these patients will require postoperative radiation therapy

  • 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


Slide10 l.jpg


Radical hysterectomy and pelvic node dissection11 l.jpg
Radical hysterectomy and Pelvic node dissection in diameter because these patients will require postoperative radiation therapy

  • 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 dissection12 l.jpg
Radical hysterectomy and Pelvic node dissection in diameter because these patients will require postoperative radiation therapy

  • 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 dissection13 l.jpg
Radical hysterectomy and Pelvic node dissection in diameter because these patients will require postoperative radiation therapy

  • 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 dissection14 l.jpg
Radical hysterectomy and Pelvic node dissection in diameter because these patients will require postoperative radiation therapy

  • Posterior dissection

    -across the cul-de-sac

    expose the uterosacral ligament

    the cardinal lig. separate from rectum


Modified radical hysterectomy l.jpg
Modified Radical Hysterectomy in diameter because these patients will require postoperative radiation therapy

  • 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 l.jpg
Complications of in diameter because these patients will require postoperative radiation therapyRadical Hysterectomy

  • Acute complication

    -Blood loss

    ureterovaginal fistula

    vesicovaginal fistila

    Pulmonary embolus

    small bowel obstruction

    Febrile morbidity


Complications of radical hysterectomy18 l.jpg
Complications of in diameter because these patients will require postoperative radiation therapyRadical 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 hysterectomy19 l.jpg
Complications of in diameter because these patients will require postoperative radiation therapyRadical 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


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