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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
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
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
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
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 dissection5
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 dissection6
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 dissection7
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 dissection8
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 dissection9
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

radical hysterectomy and pelvic node dissection11
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 dissection12
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 dissection13
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 dissection14
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
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
Complications of Radical Hysterectomy
  • Acute complication

-Blood loss

ureterovaginal fistula

vesicovaginal fistila

Pulmonary embolus

small bowel obstruction

Febrile morbidity

complications of radical hysterectomy18
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 hysterectomy19
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