Radical trachelectomy

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摘要

The description of the radical trachelectomy covers all aspects of the surgical procedure used for the management of cervical cancer.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: vaginal incision, dissection posterior steps, dissection anterior steps, treatment of ureter, treatment of paracervix, exeresis/reconstruction.
Consequently, this operating technique is well standardized for the management of this condition.

媒體類型

刊物

2001-11

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最愛

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數位出版

WeBSurg.com, Nov 2001;1(11).
URL: http://www.websurg.com/doi-ot02en223.htm

Radical trachelectomy

1. Introduction

Radical trachelectomy was developed by Dargent (Dargent et al., 2000) as an alternative surgical treatment for cervical cancer. Other surgical teams have recently published reports on their experience in using this new technique(Covens et al., 1999; Plante and Roy, 2001).
The technique is performed by the vaginal route, in the same way as a vaginal radical hysterectomy or Schauta operation (Dargent and Mathevet, 1995), but only the cervix is removed. In Greek, the word for ''cervix'' is ''trachelos'', from which the name ''trachelectomy'' is derived. The adjective ''radical'' is used to indicate the fact that tissue surrounding the cervix and the upper third of the vagina are removed along with the cervix.
The objective of the procedure is to leave the body of the uterus, and consequently the ability to conceive, intact.

2. Anatomy

• Uterus

1. Uterine artery
2. Cervical artery
The anatomical fundamentals of the operation are the same as those for all radical hysterectomies, and knowledge of the anatomy of the ureter is essential for vaginal surgery.
Blood is supplied to the uterus via the uterine artery, which branches into a cervical artery. The uterine artery must be preserved, and the cervical artery is divided.

• Paracervix

1. Paracervix
The paracervix links the uterus and the vagina to the pelvic wall. Its superior border is situated caudal to the arch formed by the uterine artery and the ureter; its inferior border joins the vagina as a transverse ligament, which is visible when the vaginal approach is used.

• Ureter

1. Ureter
Thorough knowledge of the position of the ureter is the key to uterine surgery. The ureter courses posteriorly to anteriorly below the uterine artery, above the paracervix, and passes through the bladder pillar.

• Surgical spaces

1. Bladder
2. Uterus
3. Rectum
4. Paravesical fossae
5. Pararectal fossae
6. Bladder pillars
The vesicovaginal and vesicouterine spaces, and the paravesical and pararectal fossae are useful landmarks for the surgeon in the pelvis. The paravesical fossa is separated from the vesicouterine space by the bladder pillar or vesicouterine ligaments. The pararectal fossa is separated from the rectovaginal space by the rectovaginal and uterosacral ligaments. The paracervix separates the pararectal and paravesical fossae.

3. Indications

Radical trachelectomy is used to treat cervical cancer which:
- involves a small tumor (less than 20 mm);
- is on the external surface of the cervix;
- does not involve lymph node metastases;
- is present in young women who desire preservation of fertility.

It is always preceded by an endoscopic pelvic lymphadenectomy to make sure that the cancer has not spread to the lymph nodes.

4. Operating room set-up

• Patient

1. Slight Trendelenburg
The operation is performed under general anesthesia. Prophylactic antibiotics to protect against Gram-negative bacteria and anaerobes are recommended.
The patient is placed in a low lithotomy position.
A slight Trendelenburg position causes the intestinal loops to slide away from the operative field, and centers the light on the axis of the vagina.

• Team

1. Surgeon
2. First assistant
3. Second assistant
4. Scrub nurse
The surgeon is either seated or standing (the latter being the preferable position for the assistants).
Two assistants and a scrub nurse are required for this procedure. The surgeon is placed between the 2 assistants, who should have adequate shoulder room and a good view of the procedure. The scrub nurse stands behind and to the right of the surgeon.

• Equipment

1. Anesthetic unit
2. Operating table with stirrups
3. Instrument table

5. Instruments

• Mangiagalli retractor

1. Retractor in rectouterine pouch
A self-retaining retractor must be placed in the rectouterine peritoneal pouch (of Douglas) and should remain in place without hindering the operative field; the ideal retractor for this is the Mangiagalli retractor with a 45° angle.

• Breisky vaginal retractors

1. Breisky retractor reflecting the bladder
Their bayonet shape enables the retraction of organs without the operative field being blocked by the assistant’s hand. These retractors are available in many widths (ranging from 15 mm to 40 mm) and lengths, all of which are useful in adapting to the successive needs of the operative steps. For this procedure, a minimum of 2 of these devices is required (one 28 x 80 mm retractor and one 32 x 90 mm retractor).

• Graspers

1. 8 Kocher clamps for vaginal retraction
2. Chrobak forceps to isolate vaginal cuff
Kocher or Allis clamps are used for the traction on the vaginal wall. Eight are required. For radical vaginal hysterectomies, wide and powerful toothed forceps are needed to retract and isolate the vaginal cuff; a set of 6 Chrobak forceps is indispensable.

• Others

1. Surgical knife
2. Bipolar scissors
3. Allis clamp
4. Kelly forceps
5. Suction device

6. Major principles

Principles
The procedure is defined as radical due to the removal of the paracervix. When the external boundary of the exeresis is at the base of the ureter, within the origin of the “external crus”, the procedure is called a proximal radical hysterectomy.
The exeresis is usually combined with a colpectomy limited to the vaginal cul-de-sac.

Common general strategy
It includes the following steps:
1. incision of the vagina at an adequate level suitable for constituting the vaginal cuff;
2. opening the paravesical and pararectal fossae;
3. identifying and dissecting the ureter;
4. identifying the paracervix.

Specific strategy for trachelectomy
It involves:
1. division of the cervical arteries;
2. incision of the cervix 5 mm below the isthmus;
3. anastomosis of the vagina to the remaining uterus.

7. Vaginal incision

• Placement of the clamps

Exposure is achieved with the clamps.
If vaginal access is made difficult by a narrow inferior vaginal opening, a limited median episiotomy is performed.
The vaginal cuff, fashioned by a circular incision, must be at least 2 cm from the lesion.
The vaginal wall is retracted by a set of Allis or Kocher clamps placed immediately inside the chosen vaginal incision line (six to eight clamps positioned in a circular pattern).
Anterior and posterior incisions are made more easily than lateral incisions, because the lateral pouches are very shallow and more difficult to access. For this reason, surgeons always end with the lateral incisions.

• Xylocaine infiltration

The traction on the clamps forms a protruding ring from the vaginal wall into which lidocaine with epinephrine (or saline) is administered. Mechanical detachment, combined with the effect of hemostasis, aids in the identification of this plane during the separation of the vaginal cuff.

• Vaginal incision

1. Anterior vaginal incision
2. Posterior vaginal incision
The vaginal wall is placed under tension by traction on the forceps and on the clamp placed opposite.
The incision involves the entire external wall of the evaginating ring, anteriorly and posteriorly. It is less deep laterally, to avoid separating the vaginal portion of the paracervix from the vaginal cuff.

• Vaginal cuff

1. Chrobak clamps trap the tumor
2. Operative specimen is guided
By slightly detaching the deep surface of the vagina, the edge of the incision is turned over and closed with 5 to 6 Chrobak clamps which trap the tumor in the upper third portion of the vagina. One of the assistants can then firmly pull and guide the operative specimen.

8. Dissection/Posterior steps

• Posterior steps

1. Dissection of posterior spaces
The rectovaginal, vesicouterine, paravesical and pararectal spaces must be dissected and the ligaments between these spaces are divided.
We have chosen to proceed counterclockwise, beginning with the posterior steps to bring down the uterus, and then continuing with the anterior steps.
The posterior steps include opening the rectouterine pouch and the right pararectal fossa, exposing the right uterosacral ligament which is then divided, opening the left pararectal fossa and dividing the left uterosacral ligament.

• Opening the rectouterine pouch

1. Rectouterine pouch
2. Dissection of rectouterine pouch
Upward traction on the cuff with the Chrobak clamps reveals the rectouterine pouch. It is (widely) opened with scissors at the level of the dorsal surface of the uterus.

• Opening the right pararectal space

1. Kocher clamp at 8 o’clock
2. Kocher clamp at 9 o’clock
3. Opening toward sciatic spine
To open the right pararectal space, 2 Kocher forceps are placed on the edge of the vagina. If compared to the hands on a clock, a forceps is positioned at 9 o’clock and the other at 8 o’clock. The entrance to the pararectal fossa is situated between these 2 forceps, at the level of the deep surface of the vagina. The fossa is opened with scissors, and developed in the direction of the sciatic spine.

• Division of right rectovaginal ligament

1. Opening with bipolar scissors
The rectovaginal ligament is situated between the rectouterine pouch and the pararectal fossa. The ligament is cut with bipolar scissors as high as possible, exposing the dorsal surface of the right paracervix. This is repeated symmetrically on the left.

9. Dissection/Anterior steps

• Anterior steps

1. Dissection of anterior spaces
Each step is performed symmetrically on the right and on the left. The steps include freeing the vesicouterine pouch, opening the left paravesical fossa, freeing the left ureter, opening the right paravesical fossa and freeing the right ureter.

• Preparation of vesicovaginal pouch

The operative specimen is now reflected downward with firm traction on the Chrobak clamps. The tissue connecting the bladder and the deep surface of the vagina must be cut midway between these 2 organs. The vesicouterine space must be opened widely and extended until the broad ligaments are reached and the anterior surface of the uterine arteries are identified.

• Left paravesical space

1. Kocher clamp at 2 o’clock
2. Kocher clamp at 3 o’clock
3. Formation of small opening
4. Closed scissors inserted
The Chrobak clamps are now positioned downward and to the right.
Two large forceps are placed on the vaginal wall, one in a 2 o’clock position and the other in a 3 o’clock position. Traction on these forceps forms a small opening through which penetration into the space is possible.
Closed scissors are introduced laterally(with respect to the uterus) towards the pelvic wall, against the deep surface of the vagina, going through about 5 cm of the aponeurosis of the levator muscle.
The scissors are replaced by a forefinger which widens the space. A narrow Breisky clamp, and then a large one, is then placed in the space.
The lateral surface of the bladder pillar is revealed.

• Difficulties

The bladder forms a larger anterior recess in cases of colpectomy as compared with total abdominal hysterectomy.
Opening of the vesicouterine space can be difficult, particularly in patients who previously underwent a cesarean. To clearly identify the bladder before and during this dissection, it is helpful to place a rigid catheter into the organ.

10. Treatment/ureter

• Dissection of the ureter

Freeing the ureter is the most difficult part of the procedure. At this point, the bladder pillar situated between the paravesical fossa and the vesicouterine space has been defined. The following steps describe the procedure as it is performed on the left side.

• Palpation of the ureter

The ureter is situated in the bladder pillar.
Identification of the ureter is achieved by palpation:
- with a finger placed in the vesicouterine space;
- with the clamp placed in the paravesical space.
The finger is placed deep into the vesicouterine space and is bent outward. It runs along the pillar, crushing it against the clamp. A bulge, and often a characteristic snapping sound, localizes the intertrigonal portion of the ureter.

• Division

1. Ureter
2. Distal fibers of pillar are divided
The portion of the crus situated below the angle of the ureter is perforated with a curved dissector and the distal fibers of the pillar are divided.

11. Treatment/paracervix

• Definition of paracervix

1. Ureter
Once the 2 ureters have been freed, the paracervix is treated on the left side, and then on the right. The operative steps for the left side are described in the following:
The paracervix has 2 surfaces and 2 edges. The anterior surface is exposed with the freeing of the ureter, and the posterior surface is prepared with the division of the rectovaginal and rectouterine ligaments.

• Freeing the edges of the paracervix

1. Ureter
2. Para-isthmic window
The inferior edge of the paracervix is defined by a 1 to 2 cm posterolateral detachment of the vagina.
It is limited superiorly by a zone situated outside of the isthmus below the uterine artery loop, which is referred to as the para-isthmic window.
A dissector, whose open tips define the limits of the paracervix, is passed through the para-isthmic window posteriorly (rectouterine pouch) to anteriorly (vesicouterine space).

• Division of the paracervix

1. Division performed between 2 graspers
2. Parietal stump is ligated
All preparatory steps are carried out in order to safely divide the paracervix below the angle of the ureter. A grasper is placed 10 mm from the cervix. It pulls more of the paracervix towards the operative field, allowing for a second, more lateral, grasper to be positioned. The division is performed between the 2 graspers, and the parietal stump is ligated. All steps must be performed on the left and then on the right.
Frequently, uterosacral attachments persist after this division. They must be divided with bipolar scissors or between 2 graspers; the uterus remains attached only by its superior pedicles.

12. Exeresis/Reconstruction

• Division of the cervical artery

From this step onwards, radical trachelectomy differs from radical vaginal hysterectomy.
After identifying the loop of the uterine artery, care is taken to preserve it.
After division of the paracervix at the base of the ureter, a grasper is placed perpendicular to the cervix at the level of the uterine isthmus, below the loop of the uterine artery, on one side and then on the other.

• Division of the cervix

After dividing the cervical artery on both sides, the cervix is divided 8 to 10 mm below the isthmus. A frozen section of the upper aspect of the cervix should confirm clear margins. If this is not the case, the operation is immediately completed by further resection or by a hysterectomy. The surgeon should warn the patient of this eventuality before undertaking the surgery.

• Cerclage of the isthmus of the cervix

A permanent prophylactic cerclage of the cervix (non-absorbable 8.0 suture) is placed around the isthmus and knotted against its posterior surface.

• Reconstruction of the cervix

Four Sturmdorf sutures, one at each cardinal point, are placed on the cervical cuff, leaving a crown of about 5 mm around the cervical orifice.
It is essential to avoid invagination of vaginal mucosa into the uterine canal which would compromise colposcopic surveillance of the vaginal and endocervical margins.

13. Complications

Complications
Some of the complications are also related to radical vaginal hysterectomy.
Injuries to the rectum are rare.
Injuries to the bladder are more frequent.
Lateral injuries of the ureter are sutured over a catheter; in cases of division of the ureter, reimplantation via an abdominal approach is mandatory.
Classic postoperative complications (infections, thromboses) are more frequent than in simple hysterectomy.
Postoperative bleeding requires reoperation in about 1% of cases.
Rectovaginal fistulas are rare.
A risk of vesicovaginal fistula exists.
Prolonged postoperative urinary retention is the result of vesical denervation and its frequency is proportional to the radicality of the operation.
Long-term sequelae involve the urinary tract and could lead to dysuria or incontinence.

Specific complications
Some of the complications are specific to trachelectomy.
Stenosis of the cervix and cervical sterility are both specific to trachelectomy.
Recurrence of cancer in the uterus is theoretically possible but has never been reported.
Gravidic complications include spontaneous abortion or hyperprematurity. Cesarean delivery is mandatory due to the permanent cerclage.

14. Reference

Covens A, Shaw P, Murphy J, DePetrillo D, Lickrish G, Laframboise S et al. Is radical trachelectomy a
safe alternative to radical hysterectomy for patients with stage IA-B carcinoma of the cervix? Cancer
1999;86:2273-9.
Dargent D, Martin X, Sacchetoni A, Mathevet P. Laparoscopic vaginal radical trachelectomy: a
treatment to preserve the fertility of cervical carcinoma patients. Cancer 2000;88:1877-82.
Dargent D, Mathevet P. Schauta's vaginal hysterectomy combined with laparoscopic
lymphadenectomy. Baillieres Clin Obstet Gynaecol 1995;9:691-705.
Plante M, Roy M. New approaches in the surgical management of early stage cervical cancer. Curr
Opin Obstet Gynecol 2001;13:41-6.
Querleu D, Childers JM, Dargent D. Laparoscopic surgery in gynecologic oncology. Blackwell Science,
Oxford, 1999.

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