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Radical hysterectomy differs from simple hysterectomy in that additional surrounding soft tissue is resected to achieve negative tumor margins. The operation involves wide radical excision of the parametrial and paravaginal tissues in addition to removal of intervening pelvic lymphatics.

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The five “types” of extended hysterectomy are discussed in Chapter 30. Of these, type III (radical) hysterectomy is chiefly indicated for stage IB1 to IIA cervical cancer or small central recurrences following radiation therapy, or for clinical stage II endometrial cancer when tumor has extended to the cervix (Greer, 2011a,b).

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Type III radical hysterectomy is increasingly being performed by a minimally invasive approach (Sections 44-3 and 44-4). With these approaches, the principles of the abdominal operation are still applied. Radical hysterectomy is a dynamic operation that always requires significant intraoperative decision making. Every step requires a focused, consistent surgical approach. In many ways, radical abdominal hysterectomy initially defined the field of gynecologic oncology. Familiarity with its concepts continues to be critically important in developing expertise in complex pelvic surgery.

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Preoperative

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Patient Evaluation

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Radical hysterectomy is not appropriate for women with higher-stage cancers. Thus, accurate clinical staging is critical prior to selection of this surgery. Pelvic examination under anesthesia with cystoscopy and proctoscopy is not mandatory for smaller cervical cancer lesions, but the clinical staging described in Chapter 30 should be completed before proceeding surgically. For most patients with grossly visible cervical tumors, an abdominopelvic computed-tomography (CT), magnetic resonance (MR) imaging, or positron emission tomography (PET) scan is indicated to identify clinically obvious metastases or undetected local tumor extension (Greer, 2011a). Unfortunately, there are limitations in what can be reliably detected preoperatively (Chou, 2006).

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Consent

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Radical abdominal hysterectomy can result in significant morbidity and potentially unforeseen short- and long-term complications. These complications may develop more frequently in women with obesity, prior pelvic infections, and prior abdominal surgery, which may add difficulty to safely performing radical hysterectomy (Cohn, 2000). In addition, differences in patient morbidity rates among surgeons do exist and may be of significant magnitude (Covens, 1993).

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Of potential intraoperative complications, the most common is acute hemorrhage. Blood loss averages 500 to 1000 mL, and transfusion rates are variable, but high (Estape, 2009; Naik, 2010). Subacute postoperative complications may include ureterovaginal or vesicovaginal fistula (1 to 2 percent), symptomatic lymphocyst formation (3 to 5 percent), and significant postoperative bladder or bowel dysfunction (20 percent) (Franchi, 2007; Hazewinkel, 2010; Likic, 2008). Additionally, long-term effects on sexual function, loss of fertility, and other body functions should be candidly reviewed (Jensen, 2004; Serati, 2009).

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The tone of the consenting process should reflect the extent of the operation required to ideally cure or at least begin treatment of ...

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