Radical hysterectomy

Question 1

Radical hysterectomy vs simple hysterectomy

Answer 1

Simple: Just uterus and cervix

Radical:
Extent of radicality tailored according to disease characteristics

Ovaries
Fallopian tubes
Uterus
Parametrium (anterior, posterior and lateral)
Cervix
Upper vaginal cuff

Question 2

Steps of abdominal radical hysterectomy

Answer 2

1. Develop rectovaginal space
2. Develop pelvic spaces
3. Develop Okabayashi space
4. Develop Yabuki space Bladder dissection
5. Ligation of uterine artery at IAA origin
6. Resection of parametrium
7. Open vagina with 2cm margin
8. Pelvic lymph node dissection/close vaginal vault

Question 3

Why open Rectovaginal space

Answer 3

1. Locate posterior vaginal wall and posterior resection margin
2. Protect rectal wall
3. Locate hypogastric nerves

Question 4

Pararectal space boundaries

Answer 4

Medial: ureter/posterior leaf of broad
Lateral: Internal iliac artery
Anterior: uterine artery
Posteriorly: sacral fascia

Contains: hypogastric nerve

Question 5

Paravesical space boundaries

Answer 5

Medially: superior vesical artery
Laterally: by the iliac vessels
Anteriorly: by the pubic bone
Posteriorly: by the cardinal ligament

Question 6

Where can you locate the hypogastric nerve?

Answer 6

The surgeon can identify the hypogastric nerve approximately 4 to 5 cm below the uterine artery and attached to the posterior leaf of broad ligament

3-4cm below ureter

Connects superior hypogastric plexus to inferior hypogastric plexus

it tracks toward the bladder, passing behind and below the deep uterine vein, where together with splanchnic fibers it forms the inferior hypogastric plexus

sympathetic innervation to block bladder contraction and contract the internal urethral sphincter.

Question 7

Latzko space

Answer 7

Pararectal space lateral to ureter

Question 8

Okabayashi space

Answer 8

Pararectal space medial to ureter and lateral to medial leaf of broad ligament

Question 9

Yabuki space

Answer 9

Medial: the lateral vaginal wall
Lateral: ureter as it enters the bladder
Anterior: bladder
Posterior: endocervical fascia and the uterine vessels entering into the uterus at its isthmus

Question 10

Uterine artery ligation and unroofing of ureter

Answer 10

Uterine artery ligated at origin on IAA
UA drawn medially to deroof ureter
then anterior parametrium is ligated.

Question 11

Parametrial resection

Answer 11

1. anterior parametrium is ligated as previous
2. Lateralize hypogastric nerve
3. Ligate uterosacral ligaments
4. Resect lateral parametrium with hypogastric nerve as the inferior margin

Question 12

Intraoperative complications of radical hysterectomy

Answer 12

Injury of bladder, bowel, vascular structures, or nerves is a very rare event.

The most common intraoperative complication of radical hysterectomy is bleeding

The majority of blood loss during a radical hysterectomy occurs in general in the dissection of the anterior and lateral parametria

Question 13

Postoperative complications of radical hysterectomy

Answer 13

1. Lower urinary tract dysfunction:
   - inability to empty the bladder
   - dysuria
   - increased frequency of urination
   - increased micturition urgency
   - nocturia
   - bladder sensory loss
   - abdominal straining on micturition
   - urge incontinence
   - stress incontinence

Spontaneous recovery of bladder function is typically expected within 6 to 12 months after operation.

Vesicovaginal and ureterovaginal fistulas after radical hysterectomy have been reported in 0.9% to 2.7% of patients.

2. The incidence of urinary tract infections after radical hysterectomy ranges from 11% to 20%.
3. Pelvic lymphocyst formation is another postoperative complication than may occur after lymphadenectomy. The reported incidence is 6% to 22%
4. lower limb lymphedema. The risk of developing this complication ranges from 5% to 20%.

Question 14

Management of a vesicovaginal fistula

Answer 14

Conservative treatment by placement of a bladder catheter for several weeks is one option, because spontaneous closure of a vesicovaginal fistula after continuous bladder drainage occurs in 15% to 20% of patients

surgical repair if conservative management fails

If fails - urinary diversion