根治性宫颈切除术（图文演示）

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.