Laparoscopic Radical Hysterectomy (Type III)
With Aortic and Pelvic Lymphadenectomy

Nick M. Spirtos, M.D., John B. Schlaerth, M.D, Ronald E. Kimball, M.D., Victoria M. Leiphart, M.D., and Samuel C. Ballon, M.D.

Women's Cancer Center of Northern California, Palo Alto, California

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Condensation

Type III radical hysterectomies were performed in ten patients incorporating a wide range of operative laparoscopic techniques with minimal morbidity.

Objective

The purpose was to incorporate a wide range of operative laparoscopic techniques in order to complete a Type III radical hysterectomy with aortic and pelvic lymphadenectomy.

Study Design

A Type III radical hysterectomy with bilateral aortic and pelvic lymph node dissection was separated into eight component parts: 1) right and left aortic lymphadenectomy; 2) right and left pelvic lymphadenectomy; 3) development of the paravesical and pararectal spaces; 4) ureteral dissection; 5) ligation and dissection of uterine artery; 6) development of the vesicouterine and rectovaginal spaces; 7) resection of the parametria; and, 8) resection of the upper vagina. The adequacy of the component parts was determined and documented on video.

Results

Complete aortic and pelvic lymphadenectomy and a Type III radical hysterectomy were performed by operative laparoscopy. Argon beam coagulation (Birtcher, USA) and countertraction facilitated pelvic and aortic lymph node dissection including the removal of nodal tissue lateral to the iliac vessels. Ureteral dissection with resection of the cervicovesical fascia ("the tunnel") was completed using right angle dissectors, vascular clips, and argon beam coagulation. Resection of the cardinal and ureterosacral ligaments was successful using Endo-GIA stapling instruments (US Surgical, USA).

Conclusion

A complete pelvic and aortic lymphadenectomy and Type III radical hysterectomy were performed laparoscopically. This approach could potentially decrease morbidity historically associated with radical hysterectomy and lymphadenectomy performed either abdominally or vaginally. Only prospective randomized trials will allow for the evaluation of potential benefits associated with this surgical technique.

Key Words: Laparoscopy Radical Hysterectomy Pelvic and Para-Aortic Lymphadenectomy

Laparoscopic Radical Hysterectomy (Type III) With Aortic and Pelvic Lymphadenectomy Operative laparoscopy in the care of patients with gynecologic cancer has evolved rapidly. In 1991, Querleu et al reported on the use of laparoscopic techniques to perform pelvic lymph node sampling. (1) Within four years, large series demonstrated the adequacy of laparoscopic bilateral aortic and pelvic lymphadenectomy. (2,3) The Gynecologic Oncology Group has four open protocols evaluating the feasibility of laparoscopic techniques in staging gynecologic cancers. (4) Improved laparoscopic techniques have led to the evaluation of the feasibility of performing a radical hysterectomy (Type III) in addition to pelvic and aortic lymphadenectomy for patients with cancer of the cervix.

Materials and Methods

From July 1, 1994 to June 30, 1995, ten nonconsecutive patients underwent laparoscopic bilateral therapeutic aortic and pelvic lymph node dissection and Type III radical hysterectomy. All patients undergoing this procedure underwent complete history and physical and had a Quetelet index of <30 (5) The average age of the patients was 36.7 years (range 26 to 52). The study population characteristics are seen in Table I.

The operation was separated into eight component parts: 1) right and left aortic lymphadenectomy; 2) right and left pelvic lymphadenectomy; 3) development of the paravesical and pararectal spaces; 4) ureteral dissection; 5) ligation and dissection of the uterine artery; 6) development of the vesicouterine and rectovaginal spaces; 7) resection of the parametria; and, 8) resection of the upper vagina. Adequacy of the component parts of this operation was determined and documented on video.

Using previously described techniques, the aortic and pelvic lymphadenectomy were performed with an argon beam coagulator (ABC) (Conmed, USA) and countertraction. In all cases, the paravesical, pararectal, and rectovaginal spaces, were developed, thereby delineating the ureterosacral ligaments and the parametria. A laparoscopic "peanut" was used on occasion to assist in dissection of the urinary bladder from the upper vagina. The ligation of the uterine artery at its origin from the internal iliac artery was accomplished with Endo-clips (U.S. Surgical Corp., USA). The artery was clipped twice both proximally and distally and then transected with Endo-shears (U.S. Surgical Corp., USA). A similar procedure was undertaken to transect the uterine vein. Small perforating venules and arteries were coagulated with the argon beam. Once the uterine artery was transected, the uterosacral ligaments were cut with an Endo-GIA (U.S. Surgical Corp., USA) approximately 2-3 cm from the cervix. It usually required one to two reloads per side to resect the uterosacral ligaments. The Endo-GIA stapler also was used to transect the parametrial tissues. The uterine arteries were dissected from the ureters with the argon beam coagulator and small vascular clips. The ureteral dissection lateral to the uterosacral ligament was accomplished with the blunt tip of a 10 mm ABC. Ureteral dissection proceeded to the point that the ureter passed under the vesicouterine ligament. Using short bursts of argon gas, an excellent plane is created allowing Endo-clips to secure the ligament prior to transection with the ABC. As often as not, the ligament was simply coagulated and transected. The ABC was used for hemostasis as the urinary bladder was dissected inferiorly and the ureters laterally. This allowed for excellent exposure to the proximal paracervical tissues which were transected with the Endo-GIA stapler. At the point the vaginal fornices were encountered bilaterally, the vagina was transected with argon beam coagulation set at approximately 100 watts and the specimen removed vaginally. The vaginal cuff was then closed either vaginally or laparoscopically. When closing the cuff laparoscopically, it is our current preference to use an Endo-stitch (U.S. Surgical, USA) with 0-polysorb suture.

Adequacy of this procedure was determined by visual confirmation of a complete bilateral aortic and pelvic lymphadenectomy which included resection of all lymph node-bearing tissue beginning at the inferior mesenteric artery and extending distally to the external iliac artery at the level of the circumflex iliac vein; laterally to the pelvic sidewall; medially to the patient's midline; and inferiorly to the level of the obturator nerve. Aortic and pelvic lymph nodes were counted. The adequacy of the ureteral dissection was determined visually, and the paracervical and vaginal tissues were then measured to assess the lateral and inferior margins.

(Figure 1 - Surgical specimen with margins measured not available)

Results

All operations were completed laparoscopically. The average aortic lymph node count was N=6.5 (range 4 to 9) and average number of pelvic lymph nodes resected, N=18.3 (range 15 to 26). The average parametrial width measured 3.3 cm (range 1.0 cm to 5.0 cm). The average vaginal margin measured 2.15 cm (range 1.0 cm to 3.5 cm).

The average operative time was 253 minutes (range 200 to 430). The average length of hospitalization was 3.2 days (range 2.0 to 5.0). The average blood loss was 300 cc (range 100 cc to 700 cc) (Table II). No patient was transfused and there were no intra- or postoperative complications.

Discussion

Using the argon beam coagulator, Endo-GIA staplers, and Endo-Clips, a Type III radical hysterectomy and bilateral aortic and pelvic lymphadenectomy were completed in ten consecutive patients who agreed to undergo this procedure in a non-randomized situation. The first two procedures were the most time-consuming. By operating as a team and standardizing operative techniques, operating time decreased. At this point, operative times of three to four hours compare favorably with the amount of time required to perform this procedure by laparotomy. It should be noted, however, that these patients were limited to Quetelet indexes of <30. Our average blood loss approximated 300 cc and no patient required transfusion. This compares favorably to the blood loss reported by Sedlacek et al when performing laparoscopic radical hysterectomy. (6) Historically, 40 to 75 percent of patients undergoing abdominal radical hysterectomy receive blood. (7-11) Additionally, Querleu reported that 2/8 (25%) patients undergoing laparoscopically-assisted radical vaginal hysterectomy required transfusion. (12) It is our opinion that blood loss is minimized because of the ability to identify small vessels with the magnification provided by the laparoscopic optics, and the use of the argon beam coagulator. This instrument allows for resection of lymph node-bearing tissue overlying the pelvic vasculature without a deeply penetrating current.

The Endo-GIA stapler provided excellent hemostasis when used to resect the uterosacral and cardinal ligaments. There was no instance of uncontrolled bleeding along the pelvic sidewall or in the area of the deep uterosacral ligament.

We present measurements of the parametrial tissues and vagina as a means to allow future comparisons in other series of laparoscopic radical hysterectomy or laparoscopically-assisted radical vaginal hysterectomy. These measurements have not typically been reported in series of patients undergoing traditional laparotomy, but are of some interest in the sense that we are reporting a new surgical technique. We measured the parametria at its widest dimension and it should clearly be noted that the width of the parametrial tissues is not uniform throughout the length of the specimen. The average number of lymph nodes resected using the described surgical techniques averaged 24.8 with a range of 19 to 35. In a series of patients operated on in part by at least two of the authors in this series (NMS, SCB), the average number of lymph nodes resected in un-transfused patients undergoing Type III radical hysterectomies was 31 as reported by Eisenkop et al. If there is a difference in the lymph node yield based on the surgical technique, it is not readily evident. (7)

The gas stream of the argon beam coagulator completed the ureteral dissection without incident in all ten patients. The argon gas separates tissue planes in much the same way as hydrodissection, but without the disadvantage of a wet operative field. The vaginal cuff initially was closed from below. More recently, an Endo-stitch is used to complete vaginal closure from above. Three to four 7 inch interrupted sutures were typically used to close the vagina. No drains were used. The abdominal wall was closed in two layers using 0 polysorb for the anterior abdominal wall and 4-0 polysorb or clips for the skin. There have been no herniations through any of the laparoscopy incisions.

The average hospital stay of 3.2 days (range 2.0 to 5.0) is much shorter than that of a recent experience by Benjamin et al which averaged ten days. (10) This short hospital stay is attributed to early ambulation and early return of intestinal function secondary to a decreased manipulation and packing of the small intestine and stomach.

There have been no intra- or postoperative complications. Contrast this to Sedlacek et al, performing laparoscopic radical hysterectomy as opposed to laparoscopically-assisted radical vaginal hysterectomy, who reported that 4/14 (28%) of patients had ureteral injuries or vesicovaginal fistulae and another 4/14 (28%) had bladder injuries (5) The lack of ureteral injury is attributed to the argon beam coagulator as opposed to unipolar cautery. With the argon beam coagulator, the electrical current penetrates between 0.3 and 0.9 mm (less than 1 mm) as opposed to 3 mm with standard unipolar cautery. Also, the argon beam coagulator is insulated in such a way as to decrease the chance of secondary electrical injury. To date, there are no other series published describing an experience treating patients with early stage carcinoma of the cervix with laparoscopic radical hysterectomy. Querleu reported on a series of eight patients undergoing laparoscopically-assisted radical vaginal hysterectomy. In that series, the lymph node dissection was limited to the intra-iliac area in the majority of cases and, more specifically, nodes located lateral to iliac vessels were not resected. Querleu describes a technique using bipolar cautery to divide the uterine vessels. After dissecting the uterine arteries anterior to the ureter and dividing the cephalic portion of the vesicouterine ligament, t he remainder of the operation is performed vaginally. The mean operative time in Querleu's series was 283 minutes and the average postoperative stay was 5.25 days. There were no complications reported in this series. One significant difference in this series, as compared to our experience at the Women's Cancer Center of Northern California, relates to the fact that 75 percent of the patients reported by Querleu underwent Type II, as opposed to Type III radical hysterectomies. (13)

Querleu proposes that the transection of the cardinal ligaments can be accomplished laparoscopically, but "feels that this could be done in a much shorter period of time vaginally." Clearly, our experience does not bear this out. Although both aortic and pelvic lymphadenectomy with lymph nodes being resected both medial and lateral to iliac vessels was performed, in addition to Type III radical hysterectomies, our mean operative time is less than that reported by Querleu et al by a mean of 28 minutes. It should also be noted that if other laparoscopic experiences hold true, it is only reasonable to expect that the time required to perform this procedure will decrease as our experience increases. (14) It is not clear to our group that comparison of laparoscopic radical hysterectomy versus laparoscopically-assisted vaginal hysterectomy is one that is terribly important. Certainly both techniques have been demonstrated to be technically feasible with acceptable morbidity.

The operative procedure as designed was completed in reasonable time and associated with low morbidity in this small series of patients. Further evaluation in a prospective randomized trial is required to evaluate both quality of life issues, as well as outcome.

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