Chapter 3: Radical Hysterectomy With En Bloc Vaginectomy or Pelvic Lymphadenectomy

BACKGROUND

Radical hysterectomy with en bloc total vaginectomy is rarely performed in gynecologic oncology; however, both radical hysterectomy and vaginectomy are separately considered classic procedures. The first hysterectomy with resection of lateral parametria was described in 1895 by Clark.¹ However, lymphadenectomy was not part of this procedure. Three years later, Wertheim performed the first radical hysterectomy in combination with pelvic lymphadenectomy in Austria.² Wertheim’s early mortality rate was about 30%, but this decreased quickly in time, with a cumulative experience of 10% in his report of 500 operations published in 1911.³ In parallel to the abdominal approach to radical hysterectomy, Schauta developed a vaginal technique, which was first published in 1908.⁴ Both approaches, abdominal and vaginal, form the current basis for the radical surgical treatment of cervical cancer. The surgical principles were modified during the twentieth century by many other surgeons; Amreich made meaningful contributions to the vaginal approach, while Wertheim’s abdominal procedure has been expanded upon by Latzko, Okabayashi, and Meigs.⁵

INDICATIONS AND CLASSIFICATION

Indications

The most frequent contemporary indication for radical hysterectomy with en bloc vaginectomy is early-stage (FIGO I–II) vaginal cancer, provided the disease is localized to the proximal part of the vagina and is invading into the paracolpium and parametrium.^6,7 This procedure is also indicated for the clinical scenario with combined pathology consisting of early-stage cervical cancer (FIGO I-IIA) and vaginal intraepithelial neoplasia (VaIN). VaIN is often multifocal, and an underlying invasive cancer is reported in nearly one-third of cases.⁸ Although more conservative treatment modalities are usually preferred, especially in patients who are younger, partial or total vaginectomy is a treatment of choice in women who are not sexually active, in recurrent lesions, or in multifocal dispersive lesions involving the entire vagina. Less common indications described in the literature include cervical embryonal rhabdomyosarcoma,⁹ recurrent endometrial cancer in the upper vagina,¹⁰ or clear cell carcinoma of the cervix or vagina.^11-13

Considering radical hysterectomy as an individual procedure, the indications are not entirely uniform. One commonly accepted indication for radical hysterectomy is the treatment of cervical cancer stage IB1, in which radical hysterectomy has been associated with excellent oncologic outcomes. Primary surgical treatment is also feasible and has a satisfactory oncologic outcome, according to available data, for locally advanced cervical cancer tumors of stages IB2, IIA, and selected patients with stage IIB disease.^14,15 However, the major limitation of the surgical approach in locally advanced stages is the high proportion of patients with lymph node involvement, which may be as high as 40% for patients with stage IIB disease, and is a requirement for adjuvant radiotherapy.¹⁶ The requirement for 2 treatment modalities—extensive surgical procedure and adjuvant radiotherapy—is associated with a substantial increase in the risk of postoperative morbidity. An alternative treatment modality for bulky cervical tumors or tumors with ...