What types of hysterectomy are recommended for cervical cancer treatment?

Types of Hysterectomy in Cervical Cancer Treatment

The type of hysterectomy recommended for cervical cancer depends on the disease stage, with extrafascial (simple) hysterectomy recommended for stage IA1 disease without lymphovascular space invasion (LVSI), modified radical hysterectomy for stage IA1 with LVSI, and radical hysterectomy for stages IA2 through IIA1. 1

Classification of Hysterectomy Types

The Querleu and Morrow surgical classification system describes the degree of resection and nerve preservation for radical hysterectomy in three dimensions:

• Type A: Simple/Extrafascial Hysterectomy - Removal of the uterus and cervix without significant parametrial tissue
• Type B: Modified Radical Hysterectomy - Partial parametrial resection
• Type C: Radical Hysterectomy - Complete parametrial resection to the pelvic sidewall 1

Hysterectomy Recommendations by Stage

Stage IA1

• Without LVSI:

  • Extrafascial (simple) hysterectomy without lymphadenectomy 1
  • Ovarian preservation is appropriate 1

• With LVSI:

  • Modified radical hysterectomy with pelvic lymph node dissection 1

Stage IA2

• Without LVSI:

  • Extrafascial hysterectomy (if fertility preservation not desired) 1

• With LVSI:

  • Radical hysterectomy with pelvic lymph node dissection 1

Stages IB1-IIA1

• Standard approach:
  • Radical hysterectomy with bilateral pelvic lymph node dissection 1
  • This is preferred over simple hysterectomy due to its wider paracervix margin of resection that includes aspects of the cardinal and uterosacral ligaments, upper vagina, and pelvic nodes 1

Stages IB2-IIA2

• In the United States, definitive chemoradiation is typically preferred over radical surgery 1
• Some centers may consider radical hysterectomy or neoadjuvant chemotherapy followed by radical hysterectomy 1

Stages IIB-IVA

• Primary surgical management is not recommended
• Standard treatment is concurrent chemoradiation with cisplatin 1, 2

Fertility-Sparing Options

For young patients desiring fertility preservation:

• Stage IA1: Cone biopsy with or without pelvic lymph node dissection 1
• Stage IA2: Radical trachelectomy with pelvic lymph node dissection 1
• Stage IB1 (small tumors): Radical trachelectomy may be considered in select cases 1

Surgical Approach Considerations

• Open radical hysterectomy remains the gold standard surgical approach 3, 4
• Minimally invasive surgery (MIS) for radical hysterectomy has been associated with inferior oncologic outcomes compared to the open approach based on the LACC trial 3, 4

Recurrent Disease

• For recurrent or persistent cervical cancers confined to the central pelvis, pelvic exenteration may be a potentially curative surgical option 1

Important Considerations

• Lymph node assessment is critical in cervical cancer management, with the extent depending on disease stage and presence of LVSI 1
• Para-aortic node dissection is indicated for patients with known or suspected pelvic nodal disease 1
• Sentinel lymph node biopsy may be useful for decreasing the need for complete pelvic lymphadenectomy in early-stage disease 1, 4
• Adjuvant therapy (radiation ± chemotherapy) is recommended for patients with high-risk factors after surgery, including positive margins, positive nodes, or parametrial involvement 1

The choice of hysterectomy type should be guided by disease stage and risk factors to optimize oncologic outcomes while minimizing treatment-related morbidity.