Radical vaginal hysterectomy with extraperitoneal pelvic lymphadenectomy in cervical cancer

Objective: The aim of this work was to examine three types of radical vagin al hysterectomy with different degrees of radicality, performed in order to reduce surgical complications and sequelae in different indications, and t o test the feasibility of a new simple and quick technique for extraperiton eal pelvic lymphadenectomy to be used in combination with radical vaginal h ysterectomy for treatment of cervical cancer. In this way the advantages of vaginal surgery (e.g.: unnecessary general anaesthesia, reduced surgical t rauma, applicability to obese and poor surgical risk patients, fast time-sa ving procedure) can be preserved. Methods: We compared retrospectively the long-term results of radical vagin al and radical abdominal operations in a large series of stage IB-IIA cervi cal cancer patients treated at our institution in Florence from 1968 to 198 3. Furthermore, we analysed the results of our experience from 1995 to 1998 , when we performed extraperitoneal pelvic lymphadenectomy, followed by rad ical vaginal hysterectomy, on 48 patients affected by cervical cancer. Extr aperitoneal pelvic lymphadenectomy was performed through two small abdomina l incisions (6-7 cm). Twenty-two patients (45%) were obese (BMI>30 kg/m(2)) and 20 were poor surgical risks, FIGO stage was: IB1 in 18 cases, IB2 in e ight, IIA in six, IIB in 12, IIIB in four. Neoadjuvant chemotherapy was giv en in 12 cases and preoperative irradiation was given in ten. General and r egional anaesthesia were used in 30 (62.5%) and in 18(37.5%) cases, respect ively. Results: As for past experience, in stage IB the five-year survival of 356 patients who underwent radical vaginal hysterectomy and that of 288 who had radical abdominal hysterectomy with pelvic lymphadenectomy were 81% and 75 %, respectively (p<0.05). Surgical complications were fewer with no mortali ty in the first group. in stage IIA, survival rates were 68% for radical va ginal hysterectomy and 64% for radical abdominal hysterectomy, in 76 and 64 cases, respectively (p=n.s.). As for the more recent experience, median op erative time for extraperitoneal pelvic lymphadenectomy was 30 minutes for each side (range 15-36). In each patient a median of 26 lymph nodes were re moved (range 16-48). Positive nodes were found in 12 cases (25%), Median op erative time for radical vaginal hysterectomy was 40 minutes (range 30-65). Extraperitoneal pelvic lymphadenectomy complications included: lymphocyst, five cases (10%) and retroperitoneal hematoma, one (2%); all occurred at t he beginning of the experience. Radical vaginal hysterectomy complications included: ureteral stenosis, one (2%) and uretero-vaginal fistula, one (2%) . All complications occurred in patients who received radiotherapy or chemo therapy preoperatively. Median hospital stay was ten days (range 6-20). Conclusions: The results of our work demonstrate that our technique for ext raperitoneal pelvic lymphadenectomy shows a good applicability to cervical cancer patients submitted to radical vaginal hysterectomy, which has a high rate of cure for stage IB and IIA as shown by our past experience. The pro cedure of extraperitoneal pelvic lymphadenectomy was quick, easy, and safe, and its realization was not detrimental to the advantages of radical vagin al hysterectomy. Our experience supports the continued use of this combined extraperitoneal and vaginal approach in the treatment of cervical cancer. Moreover, the three classes of radical vaginal hysterectomy allow tailoring the type of the operation to the clinical and physical characteristics of the patients.