[醫如往常] Senior Clerkship Day 3: Ob/Gyn Grand Round: Nerve-sparring radical hysterectomy

NSRH/CRH for cervical cancer

Nerve-sparring radical hysterectomy

Conventional radical hysterectomy

Outcome 沒有顯著差異

Quality of life 有顯著差異

Surgery Indication: 1B to 2A

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Cardinal lig. dissection is the key element

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Sympathetic T10-L2 Para-aortic nerve → Sup. Hypogastric plexus

Parasympathetic L2-4 Pelvic splanchnic nerve→Inf. Hypogastric plexus (IHP)

(uterosarcral lig.)

Bladder br. of IHP save part of vesicouterine lig.

Hypogastric nerve lat. Border of mesoderm

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F. Mota: EORTC Classification of radical hysterectomy

Classification of radical hysterectomy adopted by the Gynecological Cancer Group of the European Organization for Research and Treatment of Cancer

1. Simple hysterectomy (type I).

2. Modified radical hysterectomy (type II): Theuterus, paracervical tissues, and upper vagina (1–2 cm) are removed after dissection of the uretersto the point of their entry to the bladder. The uterine arteries are ligated, and the medial half of the parametria (there was no consensus in this concept) and proximal uterosacral ligaments are resected.

3. Radical hysterectomy (type III): En bloc removal of the uterus with the upper third of the vagina along with the paravaginal and paracervical tissues. The uterine vessels are ligated at their origin, and the entire width of the parametria is resected bilaterally. Removal of as much of the uterosacral ligaments as possible.

4. Extended radical hysterectomy (type IV): Differ from the type III procedure—three fourths of the vagina and paravaginal tissue are excised.

5. Partial exenteration (type V): The terminal ureteror a segment of the bladder or rectum is removed along with the uterus and parametria (supralevatorial).

A) Types II–V hysterectomies are completed witha systematic bilateral pelvic lymphadenectomy,half the way along the common iliac artery downto the femoral ring, including the presacral, bothexternal, internal, and interiliac and the obturatornodes (at least to the level of the obturator nerve).

B) Removal of the tubes and ovaries is not part ofradical hysterectomy per se.

F. MOTA, Int J Gynecol Cancer 2008, 18, 1136–1138

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FIGO stage

Endometrial cancer, Figo stage II

Primary tumor (T)
TNM	FIGO	Surgical-Pathologic Findings
Categories	Stages
TX		Primary tumor cannot be assessed
T0		No evidence of primary tumor
Tis		Carcinoma in situ (preinvasive carcinoma)
T1	I	Cervical carcinoma confined to the cervix (disregard extension to the corpus)
T1a	IA	Invasive carcinoma diagnosed only by microscopy; stromal invasion with a maximum depth of 5.0 mm measured from the base of the epithelium and a horizontal spread of 7.0 mm or less; vascular space involvement, venous or lymphatic, does not affect classification
T1a1	IA1	Measured stromal invasion ≤ 3.0 mm in depth and ≤ 7.0 mm in horizontal spread
T1a2	IA2	Measured stromal invasion > 3.0 mm and ≤ 5.0 mm with a horizontal spread ≤ 7.0 mm
T1b	IB	Clinically visible lesion confined to the cervix or microscopic lesion greater than T1a/IA2
T1b1	IB1	Clinically visible lesion ≤ 4.0 cm in greatest dimension
T1b2	IB2	Clinically visible lesion > 4.0 cm in greatest dimension
T2	II	Cervical carcinoma invades beyond uterus but not to pelvic wall or to lower third of vagina
T2a	IIA	Tumor without parametrial invasion
T2a1	IIA1	Clinically visible lesion ≤ 4.0 cm in greatest dimension
T2a2	IIA2	Clinically visible lesion > 4.0 cm in greatest dimension
T2b	IIB	Tumor with parametrial invasion
T3	III	Tumor extends to pelvic wall and/or involves lower third of vagina and/or causes hydronephrosis or nonfunctional kidney
T3a	IIIA	Tumor involves lower third of vagina, no extension to pelvic wall
T3b	IIIB	Tumor extends to pelvic wall and/or causes hydronephrosis or nonfunctional kidney
T4	IV	Tumor invades mucosa of bladder or rectum and/or extends beyond true pelvis (bullous edema is not sufficient to classify a tumor as T4)
T4a	IVA	Tumor invades mucosa of bladder or rectum (bullous edema is not sufficient to classify a tumor as T4)
T4b	IVB	Tumor extends beyond true pelvis
Regional lymph nodes (N)
NX	Regional lymph nodes cannot be assessed
N0	No regional lymph node metastasis
N1	Regional lymph node metastasis
Distant metastasis (M)
M0	No distant metastasis
M1	Distant metastasis (including peritoneal spread; involvement of supraclavicular, mediastinal, or para-aortic lymph nodes; and lung, liver, or bone)

http://emedicine.medscape.com/article/2006486-overview

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台灣40% 都要 RT

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Hydronephros when pregnancy is mostly at the right side due to right Ureter angulation

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