history of surgery for cancer cervix from BC era. includes pioneers of cancer surgery

1. Dr. Sakshi Mundra
Fellow
Dept. of Gynecologic Oncology
CHRI , Gwalior
HISTORY OF RADICAL
HYSTERECTOMY FOR CANCER
CERVIX

2.  The evolution of the radical hysterectomy
encompasses nearly 2500 years and is among the
most fascinating stories in surgical oncology.
 Hippocrates of Cos (460–370 BC) attempted
trachelectomy but noted that nothing he did could
eradicate the disease.
 In the mid-fifth century, Byzantine physician Aëtius of
Amida used vaginal irrigation with herbal compounds
to relieve pain caused by cervical cancer.
 In 1652, Tulipus performed cervical amputation.
 J. Marion Sims(1813-1883) used galvanocaustic
loops to amputate and cauterize a cervical cancer.

3. PIONEERING DEVELOPMENTS IN
GYNECOLOGIC ONCOLOGY
 Ephraim McDowell –
- Founder of Surgical Gynecology
- 1809 : first to successfully
remove an ovarian tumor.
- demonstrated feasibility of
elective abdominal surgery.
 Conrad Langenbeck : 1813 – 1st
successful vaginal hysterectomy.
 Charles Clay(1801- 1893) –
earliest successful practitioners of
abdominal hysterectomy in
Europe.

4. Pioneers of Radical
Hysterectomy
 Wilhelm Alexander Freund
(1813- 1917)
- German gynecologist
- 1878 : first abdominal
extirpation of a cancerous
uterus.
- developed a standardized
technique for total
abdominal hysterectomy.

5. Karl Pawlik
- Gynecologist from
Prague.
- 1880 : radical vaginal
hysterectomy
- 1886 – 1st described
blind ureteric cathete-
rization in females

6. John Clark (1867-1927)
 Resident in the Department of
Gynecology at John Hopkins Hospital
under Howard A. Kelly.
 Noted the spread of cervical cancer
to the tissues and lymph nodes
beyond the limits of excision of the
standard hysterectomy
 Assigned to develop a more radical
surgical approach for the treatment of
cervical cancer.
 Influenced by the surgical doctrines
of Halsted, he began considering an
en bloc radical hysterectomy for
cervical cancer.
 1895 – first radical hysterectomy

7. Ernst Wertheim(1864-1920)
 Austrian gynecologist
 November 16,1898 – his first
full-extended abdominal
radical hysterectomy.
 1912 - published a landmark
English-language manuscript
in the American Journal of
Obstetrics and Diseases of
Women and Children, in which
he detailed 500 cases of what
he termed “extended
abdominal operation for
carcinoma uteri,” now widely

8. Friedrich Schauta
 1901 – first extensive radical
vaginal hysterectomy .
 Mentor to Ernst Wertheim .
 Pioneer of radical vaginal
surgery.
 Schauta’s RVH technique
were later modified by
Amreich and Stoeckel in the
1920s.

9. Joe Vincent Meigs(1892-1963)
 American gynaecologist
 1930 - the problem of radiation
resistance and the recurrence of
cancer in previously irradiated
patients led him to reconsider and
reevaluate the role of surgery in
the treatment of cervical
carcinoma.
 Modified the Wertheim
hysterectomy by adding more
extensive pelvic
lymphadenectomy, as
recommended by Joseph Taussig.

10. Hidekazu Okabayashi
 1921 – Modified the Wertheim
operation and extended the radicality
of the operation by extensive
resection of the parametrium and
separation of the posterior leaf of the
vesicouterine ligament.
 1961 – Kobayashi, modified the
Okabayashi RH and identified the
principles for the prevention of
bladder dysfunction by preserving
the pelvic splanchnic nerves.
 1983 – Fujiwara emphasized the
importance of preserving the bladder
branch of the inferior hypogastric

11.  The Tokyo Method –
- described by Sakamato (student of Kobayashi) .
- modification of Okabayashi’s RH technique
- Noted that, after pelvic lymphadenectomy ,
cardinal ligaments could be seen as 2 main parts:
vascular and neural.
- Crucial component - cutting of the vascular part
of the cardinal ligament while preserving the
autonomic nerves within the neural part of the
cardinal ligament.
 All these nerve-sparing techniques are based on
the Okabayashi RH developed in Japan.

12. Alexander Brunschwig
 1948 –hypothesized that
ultraradical dissection of organs
in the pelvic area might
eradicate the disease as
cancer arising in the cervix and
endometrium was frequently
confined to the lower pelvis.
 His operations came to be
known as the‘‘Brunschwig
pelvic exenteration.’’

13. Daniel Dargent(1937-2005)
 Pioneer of both the conservative
surgical management of cervical
carcinoma and the use of the
sentinel node concept in the
management of cervical
carcinoma.
 1987 – combined the Schauta’s
RVH with a laparoscopic pelvic
lymphadenectomy.
 1994 – first successful radical
vaginal trachelectomy.

14. Subodh Mitra
 1951 – The Mitra technique
 2 stage operation : the first part
being a radical vaginal
hysterectomy and the second part
the extraperitoneal pelvic
lymphadenectomy.
- this technique ensures that the
regional lymph nodes are not
ignored in RVH.
 He modified his own technique by
initially starting with extraperitoneal
pelvic lymphadenectomy followed

15. Minimally Invasive and Robotic-assisted
Radical Hysterectomy
 Dargent was the first to record minimally invasive
technique in conjuction with radical hysterectomy.
 1992 – Nezhat published cases of the first
laparoscopic radical hysterectomies with pelvic and
para-aortic lymph node dissections.
 2006 – Sert published the first case of robotic-assisted
radical hysterectomy.
 2012 – Garrett and Boruta reported a novel technique
known as Laparoendoscopic single site (LESS) radical
hysterectomy.

16. Classification of Radical
Hysterectomies
 At present , there are three standard classification systems
–
1. Piver–Rutledge–Smith classification – 1974
 Five classes of Radical Hysterectomy –
 Class I – Extrafascial Hysterectomy
 Class II – Modified Radical hysterectomy (Wertheim)
 Class III - Classical radical hysterectomy (Meigs)
 Class IV
 Class V - addition of the excision of a portion of the
ureter or bladder which is involved by the tumour

17. 2. GCG-EORTC classification – 2007
 Type I - Simple hysterectomy
 Type II: modified radical hysterectomy
 Type III: radical hysterectomy
 Type IV: extended radical hysterectomy
 Type V: partial exenteration
GCG-EORTC - Gynecological Cancer Group of the European Organization for
Research and Treatment of Cancer

18. 3 . Querleu and Morrow (Kyoto) - 2008
- based only on the lateral extent of resection.
 Type A: minimum resection of paracervix
(extrafascial hysterectomy)
 Type B: transection of paracervix at the ureter
B1—Without removal of lateral paracervical lymph nodes
B2—With removal of lateral paracervical nodes
 Type C: transection of paracervix at junction with internal
iliac vascular system
C1—With nerve preservation
C2—Without preservation of autonomic nerves
 Type D: Laterally extended resection
D1—Resection of the entire paracervix along with the
hypogastric vessels
D2—Resection of the entire paracervix, along with the
hypogastric vessels and adjacent fascial or muscular

19.  Lymph node dissection has four levels:
Level 1—External and internal iliac
Level 2—Common iliac (including presacral)
Level 3—Aortic inframesenteric
Level 4—Aortic infrarenal
 This classification can be adapted for conservative
operations
(aiming for the procedure of fertilization) or in case of
vaginal or abdominal open surgery, laparoscopic or
robotic surgery.

20. Piver-Rutledge-
Smith
GCG-
EORTC
Querleu and
Morrow
CLASS I TYPE I TYPE A
Extrafascial
hysterectomy
• Identification of
ureters to avoid
injury
• Uterine vessels
are resected and
ligated close to the
uterine isthmus
• Uterosacral and
cardinal ligaments
are not removed
• No vaginal portion
Simple
Hysterectomy
Minimum resection of
paracervix
(extrafascial
hysterectomy)
• The position of ureters
are determined by
palpation or direct vision
without
freeing from their beds
• The paracervix is
transected medial to the
ureter but lateral to the
cervix
• The uterosacral and
vesicouterine ligaments
are not transected at the
distance

21. Piver-Rutledge-
Smith
GCG-EORTC Querleu and Morrow
CLASS II TYPE II TYPE B
Modified radical
hysterectomy
(Wertheim)
• Ureters are dissected in
the paracervical tissues but
are not separated from the
pubovesical ligament
• Uterine arteries are
resected and ligated beside
and medial the ureter
• Uterosacral and cardinal
ligaments are excised up to
the medial half portions
• Vagina is excised up to the
upper third level
• Pelvic lymphadenectomy
Modified radical
hysterectomy
• The uterus, paracervix
and upper vagina (10-20
mm) are removed after
dissection
of the ureters to the point
of their entry to the
bladder
• Uterine arteries are cut
off and ligated
• Medial half of
parametria and proximal
uterosacral ligaments
are transected
Transection of paracervix at
the
ureter
B1
• Ureters are unroofed
and dissected laterally,
permitting
transection of the
paracervix at the level of
the ureteral tunnel
• The posterior and deep
neural component of the
paracevix
caudal to the deep uterin
vein is not resected
• At least 10 mm of the
vagina from the cervix or
tumour is
excised

22. Piver-Rutledge-
Smith
GCG-EORTC Querleu and
Morrow
CLASS III TYPE III TYPE C
Classical radical
hysterectomy
(Meigs)
•Complete dissection of
ureters from the
pubovesical ligament
except for the small
part where the umbilical
bladder artery is located
to the level of their
penetration into
the bladder
• Uterine arteries are cut
off at the origin
• Uterosacral and
Radical
hysterectomy
•En bloc removal of the
uterus with the upper
third of the vagina along
with the paracervical
and paravaginal tissues
• Uterine arteries are cut
off and ligated at their
origin
• The entire width of the
parametria is resected
bilaterally
• The entire uterosacral
Transection of paracervix
at junction with internal
iliac vascular system
C1
• Uterosacral ligament
is transected at the
sacral insertion
• Vesicouterine
ligament is transected
at the bladder
• Ureters are
mobilised completely
• Vagina is excised at
least 15-20 mm from
the tumour and
the corresponding
paracolpos is resected
routinely
• WITH the

23. Piver-Rutledge-
Smith
GCG-EORTC Querleu and
Morrow
CLASS IV TYPE IV TYPE D
Class IV differs from
the Class III
according to the
following issues:
• Complete
dissections of the
ureters from the
pubovesical ligament
• Umbilical artery is
sacrificed
• Vagina is removed
Extended radical
hysterectomy
•Differs from Type 3,
as three-quarters of
the vagina and
paravaginal tissues
are
resected
Laterally extended
resection
D1
• Resection of the
entire paracervix at the
pelvic side wall along
with the hypogastric
vessels, exposing the
roots of the sciatic
nerve
• Total resection of the
vessels of the lateral
part of the paracervix
D2
As described in D1
plus resection of the
entire paracervix with
the hypogastric
vessels and adjacent
fascia and muscles

24. Piver-Rutledge-Smith GCG-EORTC Querleu and
Morrow
CLASS V TYPE V
Class V differs from
Class IV with the
addition of the excision
of a portion of the
ureter
or bladder which is
involved by the
tum.our
Partial
exenteration
Terminal ureters or
segments of
bladder or rectum
are resected along
with the
uterus and
parametria.

25. Fig. 1 Difference between type II and type III radical hysterectomy
(anterior view)

26. Fig. 2 Difference between type II and type III radical
hysterectomy (posterior view)

27. Conclusion
 Remarkable progress has been made in the surgical
treatment of cervical cancer in the century following
Ernst Wertheim's pioneering operation.
 A disease once considered to be uniformly fatal to its
bearer, early-stage cervical cancer is now treatable via a
number of surgical approaches, including nerve-sparing,
fertility sparing, and minimally invasive procedures
designed to improve quality of life.
 As disease process and patterns of disease spread are
further elucidated, focus in the coming years will likely
be directed toward
identifying patients appropriate for conservative surgical
therapy in an effort to further reduce operative

28. THANK YOU