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Treatment • Both primary lesion and potential sites of spread should be treated • Surgery, radiotherapy, chemoradiation • Radiation therapy can be used in all stage but surgery alone is limited (stage I or IIa) • Optimal therapy: radiation + surgery Surgery • Advantage (instead of radiotherapy) -conservation of the ovary -bladder and bowel problem: easily repair and without long-term complication -sexual dysfuntion이 덜 함 (radiation: vagina shortening, fibrosis, atrophy) -the epithelium does not become atrophic • Genenally, it is prudent not to operate on lesions than 4cm in diameter because these patients will require postoperative radiation therapy Radical hysterectomy and Pelvic node dissection Type II (modified) hysterectomy -medial half of the cardinal & uterosacral lig. selective removal of the enlarged LN Type III hysterectomy -cardinal & uterosacral lig. upper 1/3 of the vagina Radical hysterectomy and Pelvic node dissection Type IV hysterectomy -the periureteral tissue superior vesicle artery ¾ of the vagina Type V hysterectomy -distal ureter and bladder rarely performed because radiotherapy Radical hysterectomy and Pelvic node dissection • • The abdomen : midline incision low transverse incision -exposure of the lateral pelvis pelvic LN dissection wide resection of primary tumor Metastatic disease : liver omentum both kidney paraaortic LN Radical hysterectomy and Pelvic node dissection • Tumor extension, nodularity 확인 -vesicouterine fold rectouterine fold cervix cardinal ligment • The ovaries are conserved -younger than 40 yars of age Radical hysterectomy and Pelvic node dissection • Paraaortic lymph node evaluation -peritoneum is incised medial to the ureter and over the right common iliac artery -expose the aorta and the vena cava -any enlarged LNs are dissected -analysis by frozen section +: discontinue and use radiotherapy -: left side LN palpable through the IMA if heaithy, not sumitted for frozen section Radical hysterectomy and Pelvic node dissection • Development of the pelvic space -paravesical space umbilical artery : medial obturator internus : lateral sidewall cardinal lig. : posterior pubic symphysis : anterior -pararectal space rectum : lateral cardinal lig. : anterior hypogastric artery : lateral sacrum : posterior • The coccygeus muscle forms the floor of the pararectal space Radical hysterectomy and Pelvic node dissection • Pelvic lymphadenectomy -begin by opening the round lig. ureter elevated, expose the common iliac artery common iliac & ext. iliac node are dissected (avoid injuring the genitofemoral n.) -lateral chain of ext. iliac LN->median chain ->obturator LN 순으로 dissection 함 Radical hysterectomy and Pelvic node dissection • Dissection of the bladder -tumor extension to the base of the bladder not adequate mobilization -bladder off : the upper 1/3 of the vagina remove the tumor safely adequate margin Radical hysterectomy and Pelvic node dissection • Dissection of the uterine artery -usually arised from the sup. vesicle artery , is isolated and devided. and the vesicle artery are preserved • Dissection of the ureter -the ureter is dissected free from its medial peritoneal flap of the level of the uterosacral ligament Radical hysterectomy and Pelvic node dissection • Posterior dissection -across the cul-de-sac expose the uterosacral ligament the cardinal lig. separate from rectum Modified Radical Hysterectomy • The uterine artery is tansected at the level of the ureter, thus preserving the ureteral branch to the ureter • The cardinal ligment is not divided near the sidewall but instead is divided at about its midportion near the ureteral dissection • The anterior vesicouterine ligament is divided, but the posterior vesicouterine ligament is conserved Complications of Radical Hysterectomy • Acute complication -Blood loss ureterovaginal fistula vesicovaginal fistila Pulmonary embolus small bowel obstruction Febrile morbidity Complications of Radical Hysterectomy • Subacute complication -bladder dysfunction bladder vol. decreased filling pr. Increased the sensitivity to filling is diminished be unable to intiate voiding ->adequate bladder drainage during this time to prevent over distension Complications of Radical Hysterectomy • Subacute complication -lymphcyst formation (cause is uncertain) ureteral obstrustion partial venous obstruction thrombosis ->adequate drainage of the pelvis • Chronic complication -bladder hypotonia or atony result of bladder denervation