Early Stage Carcinoma Cervix - Surgical Management

Introduction

FIGO 2018 Staging (Early Stages)

Surgical Management by Stage

1. Stage IA1 (No LVSI)

• Simple (extrafascial) hysterectomy (Piver-Rutledge type I) is adequate
• Lymph node dissection is NOT required (risk of nodal disease < 1%)
• Fertility-sparing option: Large loop excision of transformation zone (LLETZ/LEEP) or cold knife conization (CKC) with clear margins

2. Stage IA1 (With LVSI) and Stage IA2

• Modified radical hysterectomy (Type II) + pelvic lymph node dissection (PLND)
• Sentinel lymph node (SLN) mapping is an accepted alternative to full PLND for small tumors
• Fertility-sparing option: Radical trachelectomy (vaginal or abdominal) + PLND/SLN mapping

3. Stage IB1 (≤ 2 cm)

• Radical hysterectomy (Type III/Wertheim-Meigs procedure) + bilateral PLND
• This remains the gold standard
• Equally effective as chemoradiation, but surgery avoids long-term radiation morbidity (bowel, bladder, sexual dysfunction)
• Fertility-sparing: Radical trachelectomy is recommended for lesions ≤ 2 cm in patients desiring future fertility (FIGO IA1 with LVSI, IA2, or IB1)

4. Stage IB2 and IIA1

• Radical hysterectomy (Type III) + bilateral PLND ± para-aortic lymph node sampling
• Surgery or concurrent chemoradiation (CCRT) - outcomes are equivalent
• Surgery is preferred in younger patients to preserve ovarian function
• Ovaries can generally be spared in premenopausal patients as ovarian metastasis risk is low

Radical Hysterectomy - Piver-Rutledge-Smith Classification

• Developing paravesical and pararectal pelvic spaces
• Dividing uterine arteries and veins at their origin from internal iliac
• Dissecting the bladder and ureters off the anterior cardinal ligament (ureter "unroofed")
• Dissecting rectum off the posterior cardinal ligament
• Dividing cardinal and uterosacral ligaments fully
• Removing the upper 1-2 cm of vagina with an adequate margin
• Bilateral pelvic lymphadenectomy

Fertility-Sparing Surgery: Radical Trachelectomy

• FIGO stage IA1 with LVSI, IA2, or IB1
• Lesion ≤ 2 cm diameter (most experts' consensus)
• Desire for future fertility
• No lymph node involvement on imaging or SLN biopsy

Pelvic Lymphadenectomy

• External iliac nodes (lateral and medial)
• Obturator nodes (between external iliac vein and obturator nerve)
• Nodes from common iliac bifurcation down to deep circumflex iliac vein

• Accepted alternative for small early-stage tumors
• Avoids full lymphadenectomy morbidity (lymphedema, lymphocyst)
• ICG (indocyanine green) is most commonly used with excellent detection rates

Minimally Invasive vs. Open Surgery - Critical Update

• Minimally invasive radical hysterectomy (laparoscopic/robotic) had significantly worse disease-free survival (91.2% vs. 97.1% at 3 years) and overall survival (93.8% vs. 99% at 3 years) compared to open surgery
• Hazard ratio for recurrence: 3.74 (95% CI 1.63-8.58)
• No difference for tumors < 2 cm
• Open (abdominal) approach is now the standard of care for radical hysterectomy in cervical cancer
• Studies are ongoing to identify patients who may safely undergo minimally invasive surgery

Adjuvant Therapy Post-Surgery

• Positive pelvic lymph nodes
• Positive parametrial margins
• Positive surgical margins

• LVSI + deep stromal invasion + large tumor
• Combination determines need for adjuvant pelvic radiation

Complications of Radical Hysterectomy

Summary Algorithm

Early Carcinoma Cervix
        |
        ├── IA1, no LVSI → Simple hysterectomy (or conization if fertility desired)
        |
        ├── IA1+LVSI / IA2 → Type II radical Hx + PLND (or radical trachelectomy)
        |
        ├── IB1 (≤2cm) → Type III radical Hx + PLND (open approach)
        |              [Trachelectomy if fertility-sparing desired]
        |
        └── IB2 / IIA1 → Type III radical Hx + PLND (or CCRT - equivalent)
                        ↓
               Adjuvant CCRT if Peters criteria met

Conclusion

Management of Locally Advanced Carcinoma Cervix

Definition and Staging

Pre-Treatment Workup

• Clinical examination - bimanual and rectovaginal examination
• MRI pelvis - gold standard for local staging (tumor size, parametrial/vaginal/bladder/rectal involvement)
• PET-CT - for nodal staging (pelvic, para-aortic, supraclavicular) and distant metastasis
• CT chest/abdomen/pelvis if PET unavailable
• Cystoscopy and sigmoidoscopy if bladder or rectal invasion suspected
• Renal function tests (hydronephrosis assessment), CBC, LFTs

Standard of Care: Concurrent Chemoradiation (CCRT)

• GOG 85 (IIB-IVA): Cisplatin + 5-FU + RT vs. hydroxyurea + RT - cisplatin arm had significantly superior PFS and OS
• GOG 120 (IIB-IVA): Weekly cisplatin + RT vs. cisplatin/5-FU/hydroxyurea + RT vs. hydroxyurea + RT - both cisplatin arms were superior
• GOG 123 (Bulky IB): Cisplatin + RT (+ adjuvant hysterectomy) vs. RT alone - 3-year OS 83% vs. 74%
• RTOG/SWOG Intergroup trial: 5-year OS 73% with CCRT vs. 58% with RT alone

CCRT Regimen

Brachytherapy - The Non-Negotiable Component

• Brachytherapy inclusion: CSS 64.3% vs. 51.5% without (P < 0.001)
• OS 58.2% vs. 46.2% without (P < 0.001)

• LDR (Low Dose Rate) brachytherapy (classical) - tandem and ovoids/ring
• HDR (High Dose Rate) brachytherapy - now standard; several minutes per fraction
• Total dose to Point A: ~80-90 Gy equivalent (EQD2) combining EBRT + brachytherapy

Extended Field Radiation (EFRT) - Para-Aortic Nodes

• Indicated when para-aortic LN involvement is confirmed (Stage IIIC2) or suspected
• Extends radiation field from pelvis up to L1-L2 (level of inferior mesenteric artery)
• Pelvic CCRT was shown superior to extended-field RT alone (RTOG trial)
• IMRT for para-aortic fields: associated with low GI toxicity (6.5% acute and late)
• Prophylactic EFRT is NOT recommended due to high GI toxicity without proven survival benefit in absence of documented nodal disease

Surgical Staging Before CCRT

• Extraperitoneal laparoscopic lymphadenectomy is preferred (transperitoneal approach has 16-33% radiation enteritis mortality)
• Positive para-aortic nodes: upgrade treatment to extended field CCRT
• PET-CT has largely replaced surgical staging in modern practice, though histologically positive nodes can be missed on imaging

Management of Grossly Positive Para-Aortic Nodes

• Extraperitoneal debulking lymphadenectomy before CCRT improves survival to levels comparable to microscopic nodal disease
• Patients with supraclavicular node involvement (5-30% of para-aortic positive cases) should receive palliative chemotherapy rather than extended CCRT

Neoadjuvant Chemotherapy (NACT) Followed by Surgery

• Paclitaxel + cisplatin or cisplatin + vincristine x 3 cycles, then radical hysterectomy
• The Indian ERCC trial (Gupta et al.) compared NACT + radical surgery vs. CCRT in stage IB2-IIB:
  • No superior survival benefit of NACT-surgery over CCRT
  • CCRT remains the standard
• NACT + surgery may be considered where radiotherapy resources are limited or in selected stage IIB patients in specialized centers
• A 2025 systematic review and meta-analysis (PMID 40408847) found that induction chemotherapy followed by CCRT improved progression-free and overall survival vs. CCRT alone in LACC

Adjuvant Hysterectomy After CCRT

• GOG 123 included adjuvant hysterectomy after CCRT for bulky IB disease
• No improvement in survival was demonstrated with adjuvant hysterectomy
• Not routinely recommended; CCRT alone is standard

Stage IVA (Bladder/Rectal Invasion)

• Primary CCRT remains standard - may achieve complete response in selected patients
• Bladder/rectal fistula may be palliative issue requiring diversion
• If residual or persistent central disease after CCRT: consider pelvic exenteration in highly selected, fit patients with no distant spread (cures 25-50%)

Recurrent/Persistent Disease After CCRT

Central Pelvic Recurrence (Previously Irradiated)

• Pelvic exenteration - anterior (bladder), posterior (rectum), or total
• Cures 25-50% in carefully selected patients
• Requirements: no pelvic sidewall or distant disease, adequate PS, resectable
• Laterally Extended Endopelvic Resection (LEER) - for selected lateral recurrences

Systemic/Metastatic Recurrence

• Chemotherapy: Paclitaxel + cisplatin/carboplatin ± bevacizumab (GOG 240 trial)
• Bevacizumab (anti-VEGF): Adds ~3.7 months OS benefit (GOG 240, NEJM 2014)
• Pembrolizumab (anti-PD-1): FDA-approved for PD-L1 positive recurrent/metastatic cervical cancer; can be combined with chemotherapy ± bevacizumab
• A 2024 meta-analysis (PMID 39351236) confirmed benefit of chemoradiation + immune checkpoint inhibitors in LACC

Complications of Radiation Therapy

Prognosis (5-year OS by Stage - CCRT Era)

Summary Algorithm

LACC (FIGO IB3 - IVA)
          |
    PET-CT / MRI staging
          |
    ┌─────┴─────┐
Para-aortic      Pelvic-only
nodes +ve        disease
    |                |
Extended-field   Pelvic CCRT
CCRT (45 Gy)   (45-50 Gy EBRT
                + weekly cisplatin)
          |
    Mandatory intracavitary
    BRACHYTHERAPY boost
    (total EQD2 ~80-90 Gy)
          |
    Assess response (MRI at 3 months)
          |
    ┌─────┴──────┐
Complete        Residual/
response        Recurrence
(surveillance)      |
             Central only → Exenteration
             Metastatic → Chemo ± Bev ± Pembrolizumab

Sentinel Lymph Node Biopsy in Cervical Cancer

Introduction and Rationale

NCCN Guidelines (Version 2.2026) - Current Recommendations

• SLN mapping is now included in the primary treatment recommendations for early-stage cervical cancer (added following SENTIX trial final results, published 2025)
• Recommended for FIGO stage IA1 (with LVSI), IA2, IB1, and IB2 (tumor ≤ 4 cm, clinically node-negative)
• Preferred tracer: ICG (indocyanine green) with near-infrared fluorescence imaging
• Standard bilateral cervical injection at 3 and 9 o'clock positions, both superficially and deeply
• Ultrastaging is a mandatory component of SLN evaluation
• If SLN mapping fails on one side: side-specific lymphadenectomy is required on the non-mapped side
• Any suspicious node must be removed regardless of mapping status

Anatomy: Where are Sentinel Nodes Found?

Tracer Techniques

1. Blue Dye (Isosulfan Blue / Patent Blue V)

• Oldest technique; purely visual
• Detection rate: ~60-80%
• Disadvantage: cannot use laparoscopy effectively; anaphylaxis risk (1-2%)
• Injection site per FILMS study protocol: deeply + superficially at 3 and 9 o'clock

2. Technetium-99m Radiocolloid (99mTc)

• Requires preoperative lymphoscintigraphy
• Intraoperative gamma probe detection
• Detection rate: ~80-90%
• Not widely available; radiation handling required

3. Indocyanine Green (ICG) - PREFERRED (NCCN 2026)

• Detected via near-infrared (NIR) fluorescence camera
• Detection rate: 93-100% - highest sensitivity
• Superior to blue dye and comparable to or better than 99mTc
• Works excellently laparoscopically and robotically
• No radiation; minimal allergy risk
• Dose: 1-4 mg diluted in sterile water; 1 mL per quadrant

4. Combination Techniques

• Blue dye + 99mTc has historically been the gold standard (superior to either alone)
• ICG ± blue dye is now preferred in most centers

Injection Technique

1. Patient under general or spinal anesthesia
2. Inject superficially and deeply at cervical stroma
3. Standard: 3 and 9 o'clock (or 12, 3, 6, 9 o'clock quadrants)
4. Volume: 0.5-1 mL per injection site; total 2-4 mL
5. No prior conization affects detection rates (cold knife cone biopsy does NOT reduce SLN detection)
6. Allow 5-10 minutes after injection before starting dissection

The NCCN SLN Algorithm (Cervical Cancer)

Inject tracer (ICG/blue dye/99mTc) into cervix
              ↓
      Bilateral mapping?
     ↙              ↘
   YES                NO (unilateral or failed)
     |                        |
Excise all mapped        Side-specific PLND on
SLNs bilaterally        unmapped/failed side
     |                + excise mapped SLNs
     ↓
Remove ALL suspicious nodes regardless of mapping
              ↓
     PATHOLOGICAL ULTRASTAGING of all SLNs
              ↓
    ┌─────────┴─────────┐
SLN negative           SLN positive
(omit PLND)       (complete treatment/
                   adjuvant therapy)

Pathological Ultrastaging - The Critical Step

1. Bisect the node along the longest axis
2. H&E staining of all sections
3. Cytokeratin immunohistochemistry (IHC) (AE1/AE3 or MNF116) on all levels
4. Serial sections at 200-500 μm intervals

Classification of SLN Metastases:

Key Landmark Trials

SENTICOL I & II (France)

• Prospective multicenter studies establishing SLN feasibility in cervical cancer
• SENTICOL II: 206 patients; bilateral detection rate 97%; sensitivity 82%; NPV 97%
• Demonstrated that SLN biopsy with ultrastaging detects low-volume metastases missed by standard H&E

SENTIX Trial (International, NCT02494063) - 2025 Final Results

• 47 centers, 18 countries; FIGO IA1/LVSI+ to IB2; n=731 enrolled, n=594 intention-to-treat
• 12.5% of patients had node-positive disease (81/647)
• 44% of N1 cases detected exclusively by ultrastaging (would have been missed by standard assessment)
• Intraoperative frozen section detected only 56.1% of positive nodes
• At 2 years: recurrence rate 6.1% (within noninferiority threshold of 7%)
• 2-year DFS: 93.3%; 2-year OS: 97.9%
• Conclusion: SLN biopsy without systematic PLND does NOT increase recurrence risk in early-stage cervical cancer
• This trial formed the basis for NCCN v2.2026 adding SLN mapping to primary treatment recommendations

Systematic Reviews on Survival (2023)

• Parpinel et al., IJGC 2023 (PMID 37696646) - Meta-analysis of 6 studies: 5-year DFS 94-98%; 5-year OS 99% after SLN biopsy alone - comparable to full PLND
• Mauro et al., IJGC 2023 (PMID 37586759) - 4 studies, 2226 patients: 3-year recurrence-free survival 93.1% (SLN alone) vs. 92.5% (PLND) - no significant difference (p=0.773)

Performance Characteristics (Berek & Novak, NCCN)

Predictive Factors for SLN Mapping Failure

Appropriate Candidates (NCCN 2026 Criteria)

• FIGO stage IA1 with LVSI, IA2, IB1, IB2
• Tumor ≤ 4 cm (strongest evidence for ≤ 2 cm)
• No suspicious nodes on preoperative imaging (MRI/PET-CT)
• No prior pelvic radiation
• No prior pelvic surgery likely to disrupt lymphatic drainage
• Planned radical hysterectomy or trachelectomy

• Tumor > 4 cm
• FIGO stage IIB and beyond
• Clinically suspicious or imaging-positive lymph nodes
• Prior radiotherapy to pelvis
• Failed bilateral mapping without side-specific PLND completion

Advantages of SLN Biopsy Over Full PLND

Current Status and Guidelines Summary

Conclusion

Nerve-Sparing Radical Hysterectomy (NSRH)

Introduction and Historical Background

• Kobayashi (1961): First described preservation of the hypogastric nerve in radical hysterectomy
• Okabayashi radical hysterectomy: The original Japanese technique emphasizing anatomical tissue plane dissection
• Sakuragi (2005): Described a systematic NSRH technique for preserving postsurgical bladder function
• Raspagliesi (2004): European adaptation with anatomic nerve identification
• Fujii (2007): Defined the Nerve-Sparing Okabayashi procedure with functional outcomes

Anatomy of Pelvic Autonomic Nerves - The Surgical Basis

Sympathetic Component

• Originates from T11-L2 spinal segments
• Forms the Superior Hypogastric Plexus (SHP) below the aortic bifurcation at the sacral promontory
• SHP divides into left and right Hypogastric Nerves (HN) which descend along the lateral pelvic wall
• Functions: bladder neck continence, orgasm, ejaculation (in males), uterine/vaginal tone

Parasympathetic Component

• Originates from S2, S3, S4 sacral nerve roots
• Forms Pelvic Splanchnic Nerves (PSN) - also called "nervi erigentes"
• Runs along the pelvic sidewall within the cardinal ligament (deep uterine vein region)
• Functions: detrusor contraction (bladder voiding), rectal motility, vaginal lubrication, clitoral engorgement

Inferior Hypogastric Plexus (IHP) = Pelvic Plexus

• Formed by convergence of: Hypogastric Nerve (sympathetic) + Pelvic Splanchnic Nerves (parasympathetic) + Sacral Sympathetic Trunk
• Located in the retroperitoneal space lateral to the rectum, vagina, and cervix
• Situated within the "pars nervosa" of the parametrium (posterior-lateral portion)
• Gives rise to branches to: bladder (vesical branches), uterus, vagina, and rectum

The Three Critical Nerve Groups at Risk in Radical Hysterectomy

Parametrium: Surgical Anatomy (Okabayashi Division)

Indications for NSRH

• FIGO 2018 stage IA2, IB1 (< 2 cm) - strongest evidence
• Stage IB2, IIA1 in selected cases (tumor ≤ 4 cm, no parametrial involvement)
• Clinically negative lymph nodes on preoperative MRI/PET-CT
• No parametrial invasion on imaging
• Good performance status; younger patients (quality of life priority)

• Bulky tumors > 4 cm
• Imaging-suspicious parametrial involvement
• Lymph node metastases on preoperative imaging
• Prior pelvic surgery altering anatomy

Surgical Technique - Step-by-Step

Step 1: Retroperitoneal Development and Nerve Identification

• Open the retroperitoneum bilaterally
• Identify the superior hypogastric plexus at the sacral promontory (below aortic bifurcation)
• Trace the hypogastric nerves bilaterally as they descend along the pelvic sidewall (medial to the internal iliac artery)
• Gentle blunt dissection exposes the nerve as a "stretched string" lateral to the rectum

Step 2: Medial Rectal Space Development

• Develop the mesorectal plane (rectovaginal space)
• This allows skeletonization of the uterosacral ligament, separating its nerve component from the ligament itself
• The hypogastric nerve is traced down to the IHP, preserved medially, while the uterosacral ligament is divided only at its uterine insertion

Step 3: Paravesical and Pararectal Space Development

• Standard development of paravesical space (medial to obliterated umbilical artery)
• Standard pararectal space (medial to hypogastric vessels)
• These spaces define the lateral limits of the parametrium

Step 4: Uterine Artery Ligation - Selective

• Uterine artery ligated at its origin from the internal iliac artery (standard)
• The deep uterine vein complex (where PSN runs) is carefully identified
• PSN is identified BENEATH the deep uterine veins and preserved while the veins are ligated above the nerve

Step 5: Cardinal Ligament Division - The Critical Step

• The cardinal ligament is divided in two phases:
  1. Pars vasculosa: ligated and divided (uterine artery, lymphatic tissue)
  2. Pars nervosa: the IHP and its bladder branches are lateralized and preserved
• The bladder branches of IHP run within the vesico-uterine ligament medial to the ureter
• After "unroofing" the ureter, the bladder pillars are divided while staying medial to the nerve branches

Step 6: Vesico-uterine Ligament (Bladder Pillar) Division

• The vesico-uterine ligament (anterior parametrium) is divided in two layers:
  • Ventral layer: divided close to the bladder
  • Dorsal layer: contains bladder branches of IHP - preserved by sharp dissection and lateral retraction
• This is the most technically demanding step

Step 7: Uterosacral Ligament Division

• The uterosacral ligament contains the upper portion of the IHP
• The ligament is divided at its cervical/vaginal insertion
• The hypogastric nerve running along its posterior surface is dissected free and preserved

Step 8: Vaginal Resection and Specimen Removal

• Standard 1-2 cm vaginal cuff removed
• Specimen checked for adequacy of parametrial margins

The "T-Shaped Nerve Plane" Concept

Superior Hypogastric Plexus (sacral promontory)
              ↓
      Hypogastric Nerve (descends on pelvic wall)
              ↓
    Inferior Hypogastric Plexus (lateral to cervix)
       ↙ (horizontal bar of "T")
  Pelvic Splanchnic     Bladder Branches
  Nerves (S2-S4)        (to vesical plexus)

Classification / Types of NSRH

• Type C1: Nerve-sparing radical hysterectomy (preserves autonomic nerves)
• Type C2: Classical non-nerve-sparing radical hysterectomy

Functional Outcomes: Evidence Summary

Bladder Dysfunction

• NSRH associated with significantly less urinary retention vs. classical RH
• HR 1.78 (95% CI 1.37-2.31, p < 0.001) in favour of NSRH
• HR 2.49 (95% CI 1.43-4.33, p = 0.001) in subgroup analysis

Sexual Function

• Nerve-sparing RH associated with significantly improved sexual function vs. standard RH (Berek & Novak, 4th ed.)
• Improved vaginal lubrication, arousal, and orgasm due to preservation of parasympathetic fibers
• A meta-analysis of NSRH for cervical cancer: no worsening of prognosis + improved sexual function vs. non-nerve-sparing surgery

Anorectal Function

• Reduced constipation (sympathetic preservation maintains rectal tone)
• Less defecatory urgency and straining
• Improved anorectal transit times

Oncologic Outcomes: Is Radicality Compromised?

• Parametrial clearance is maintained: provided the correct tissue planes are respected, pars vasculosa resection is complete
• No significant difference in local recurrence rates between NSRH and classical RH in multiple retrospective series
• 5-year OS and DFS are equivalent (Sakuragi 2005; Fujii 2007; Yin 2018)
• Berek & Novak (Robotic NSRH): "No differences with recurrence and survival" compared to non-nerve-sparing robotic RH
• 2024 systematic review (PMID 38438182 - Viveros-Carreño et al.): NSRH is one component of the overall de-escalation strategy - oncologic safety maintained

Minimally Invasive NSRH

• Robotic NSRH technique has been described and validated (Berek & Novak)
• Robotic platform advantages: 3D magnified visualization, tremor filtration, precise dissection in narrow pelvic spaces
• Comparison with open robotic NSRH: No differences in operating time, blood loss, complications, hospital stay
• However: The LACC trial caveat applies - open approach remains standard of care for radical hysterectomy in cervical cancer; MIS NSRH should be performed in specialized centers with careful patient selection (tumors < 2 cm)

Complications and Learning Curve

• Longer operative time (+30-90 minutes vs. standard RH)
• Steeper learning curve: requires detailed retroperitoneal anatomy training
• Risk of inadequate nerve dissection (nerve preserved anatomically but functionally disrupted by thermal spread)
• Para-rectal hematoma if hypogastric nerve dissection is overzealous

• Ureteral fistula (< 2%)
• Lymphocyst, lymphedema
• Bladder injury

Summary Comparison Table

Conclusion

Radical Hysterectomy

Definition and Historical Background

• 1895 - Ernst Wertheim (Vienna): Pioneered the abdominal radical hysterectomy with selective lymph node removal; less extensive than modern Type III
• 1944 - Joe Vincent Meigs (Boston): Standardized the radical hysterectomy with systematic bilateral pelvic lymphadenectomy - the operation most performed in the USA
• Okabayashi (Japan): Described a more extensive parametrial dissection technique
• 2008 - Querleu & Morrow: Published the modern anatomical classification (updated 2017) now widely used in Europe and internationally

Indications

• FIGO 2018 Stage IA2 (stromal invasion 3-5 mm) - Type II
• FIGO 2018 Stage IB1 (≤ 2 cm) - Type III (gold standard)
• FIGO 2018 Stage IB2 (2-4 cm) - Type III (surgery or CCRT - equivalent outcomes)
• FIGO 2018 Stage IIA1 (< 4 cm vaginal extension) - Type III
• Adenocarcinoma - preferred over radiotherapy to avoid bowel complications
• Younger patients - to preserve ovarian function (ovaries conserved if premenopausal)
• Patients who are unlikely to need adjuvant radiation (to avoid combined modality morbidity)

• Stage IIB and beyond (parametrial invasion)
• Bulky tumors > 4 cm (relative - high risk of needing adjuvant RT)
• Positive para-aortic nodes (CCRT preferred)
• Poor surgical candidate (medical comorbidities)
• Obesity or severe pelvic adhesions (relative)

Classification Systems

1. Piver-Rutledge-Smith Classification (1974) - Most Widely Used

2. Querleu-Morrow Classification (2008, Updated 2017) - European Standard

Surgical Anatomy: Pelvic Spaces

Operative Steps - Type III Radical Hysterectomy (Meigs)

Pre-Operative Preparation

• Bowel preparation (low residue diet, mechanical prep if needed)
• DVT prophylaxis (compression stockings + LMWH)
• Foley/suprapubic catheter placement
• Ureteral stenting (optional, in difficult cases)
• Informed consent: fistula risk, bladder dysfunction, lymphedema

Incision

• Midline infraumbilical incision (most common) - provides excellent exposure
• Low transverse incision (Maylard or Cherney): requires division of rectus muscles - superior lateral pelvic exposure, preferred for wider pelvis

Step 1: Abdominal Exploration

• Inspect peritoneal surfaces, liver, omentum for metastases
• Palpate para-aortic lymph nodes transperitoneally
• Inspect ovaries and fallopian tubes
• Palpate cardinal ligaments for lateral tumor extension
• Palpate the cervix between thumb and fingers to assess extent

Step 2: Retroperitoneal Entry and Lymphadenectomy

• Open round ligament at pelvic sidewall bilaterally
• Develop paravesical and pararectal spaces with blunt and sharp dissection
• Pelvic lymphadenectomy (bilateral):
  • External iliac nodes (lateral and medial chains from common iliac bifurcation to deep circumflex iliac vein)
  • Obturator nodes (between external iliac vein and obturator nerve; beware aberrant obturator vein in 10%)
  • Internal iliac nodes
  • Hemoclips applied distally to reduce lymphocyst
  • Drains NOT used (increase complications without benefit)
• Inspect/palpate para-aortic nodes; send frozen section if suspicious
• If frozen section confirms nodal metastases: consider abandoning RH in favour of CCRT

Step 3: Para-Aortic Node Assessment

• Indicated if: bulky cervical tumor, grossly positive pelvic nodes, suspicious imaging
• Peritoneum incised medial to ureter, over right common iliac artery
• Nodes removed up to level of inferior mesenteric artery

Step 4: Bladder Mobilization

• Critical early step - done before uterine artery ligation
• Peritoneum over vesicouterine fold incised
• Bladder mobilized off anterior cervix and upper vagina
• Tumor extension into bladder base (undetectable by cystoscopy) may require abandonment
• Must mobilize to lower 1/3 of vagina for adequate margin

Step 5: Uterine Artery Dissection and Ligation

• Superior vesical artery identified and preserved
• Uterine artery isolated where it arises from the superior vesical artery or directly from internal iliac
• In Type III: ligated at its origin from the internal iliac artery (sacrificing the ureteral branch)
• In Type II: ligated at the level of the ureter (preserving ureteral branch)
• Uterine vein ligated; occasionally passes under ureter

Step 6: Ureteral Dissection ("Unroofing")

• Ureter identified on medial peritoneal flap at level of uterosacral ligament
• Traced into the vesicouterine ligament tunnel (ureteral tunnel)
• Consistent arterial branch from uterine artery to ureter: sacrificed in Type III, preserved in Type II
• Ureter "unroofed" from the vesicouterine ligament using a right-angle clamp
• This is the most critical step for avoiding ureteral injury

Step 7: Posterior Dissection

• Peritoneum across the cul-de-sac (rectouterine pouch) incised
• Rectum rolled free from the uterosacral ligaments
• Type III: Uterosacral ligaments divided midway to the sacrum
• Type II: Uterosacral ligaments divided near the rectum
• Cardinal ligament isolated from rectum

Step 8: Cardinal Ligament Division

• Type III: Surgical clamp placed at lateral pelvic sidewall - full parametrial resection
• Type II: Clamp placed at level of the ureteral bed (midportion)
• Specimen-side clamp maintains traction to ensure complete parametrial excision
• Right-angle clamp placed across paravaginal tissues

Step 9: Vaginal Resection and Specimen Removal

• Vagina entered anteriorly with adequate margin of proximal vagina (at least 1-2 cm cuff)
• More vagina excised if colposcopy showed lower disease
• Vaginal edge: sutured hemostatic and either left open with pelvic drain, or closed with suction drain

Step 10: Closure

• Pelvic peritonization (optional - some leave open)
• Suprapubic catheter placed (preferred for postoperative bladder management)
• Abdominal closure in layers

Surgical Approach: Open vs. Minimally Invasive

The LACC Trial (NEJM 2018) - Practice-Changing Evidence

De-escalation: SHAPE Trial (NEJM 2024) - Critical Update

• Low-risk cervical cancer: stage IB1 (2009 FIGO), tumor ≤ 2 cm, limited stromal invasion
• Compared simple hysterectomy vs. radical hysterectomy + LN assessment
• Results: 3-year pelvic recurrence: 2.17% (RH) vs. 2.52% (SH) - noninferiority confirmed (difference 0.35%, 90% CI -1.62 to 2.32)
• Urinary retention: RH 11% vs. SH 0.6% (p < 0.001) - dramatically lower with simple hysterectomy
• Implication: For low-risk stage IB1 (≤ 2 cm, limited stromal invasion, node-negative), simple hysterectomy is now a valid alternative to radical hysterectomy with equivalent oncologic outcomes and significantly less morbidity

Postoperative Management

• Suprapubic catheter for bladder drainage (preferred over urethral)
• Cystometrography at 3-4 weeks postoperative
• Criteria for catheter removal: sense bladder fullness + initiate voiding + residual urine < 75-100 mL
• DVT prophylaxis continued postoperatively
• Early ambulation, nutrition
• Wound care and monitoring for febrile morbidity

Adjuvant Therapy Post-Radical Hysterectomy

High-Risk Features (Peters/GOG 109 Criteria) - Any ONE = Concurrent CCRT

1. Positive pelvic lymph nodes
2. Positive parametrial margin
3. Positive surgical margins

Intermediate-Risk Features (Sedlis Criteria) - Combination = Pelvic RT

1. Lymphovascular space invasion (LVSI) + large tumor
2. Deep stromal invasion (outer 1/3)
3. Tumor size > 4 cm

Complications

Acute Complications (Berek & Novak, p. 2248)

Subacute Complications

• For first days postoperatively: decreased bladder volume, increased filling pressure, diminished sensation, inability to initiate voiding
• Suprapubic catheter preferred for management
• Patients continue voiding trials at home; catheter discontinued when residual < 75-100 mL

• Cause uncertain; routine drains do NOT reduce incidence
• Can cause ureteral obstruction, venous obstruction, thrombosis
• Treatment: percutaneous drainage; if failed, surgical marsupialisation with omentum interposition

Chronic Complications

• Most common chronic effect - occurs in ~3% regardless of drainage method
• Likely due to bladder denervation
• Management: voiding every 4-6 hours, Credé's maneuver, intermittent self-catheterization

• Uncommon in absence of adjuvant RT or recurrent disease
• With lymphocyst: treat lymphocyst first
• After RT: ureteral stenting
• Without clear cause: suspect recurrent cancer - CT + FNA, then stenting if negative

Oncologic Outcomes

• Both modalities achieve equivalent 5-year survival (~85%) for Stage I disease
• Surgery preferred in younger women: ovarian conservation, avoids late radiation morbidity (bowel/bladder fibrosis, sexual dysfunction, secondary malignancy)
• Radiation preferred: poor surgical candidates, locally advanced, parametrial involvement

Advantages of Surgery Over Radiotherapy (Berek & Novak)

Summary