Wertheim's Radical Hysterectomy
Definition and Surgical Extent
Wertheim's radical hysterectomy (also called Type III or radical hysterectomy) is an extensive operation that removes the uterus, cervix, parametrial tissue, cardinal and uterosacral ligaments, upper vaginal cuff (1-2 cm), and includes bilateral pelvic lymph node dissection with optional para-aortic lymph node sampling. 1
- The procedure was pioneered by Austrian gynecologist Ernst Wertheim in 1898 and involves removal of appropriate parametrium and tissues surrounding the upper vagina along with pelvic lymph nodes 2, 3
- Modern classification systems (Piver-Rutledge) categorize this as a Type III radical hysterectomy, representing extensive parametrial resection 3, 4
Primary Indications
Radical hysterectomy is indicated for early-stage cervical cancer (FIGO stages IA2 through IIA1) with tumors ≤4 cm that are confined to the cervix/pelvis. 1
Stage-Specific Indications:
- Stage IA2: Microscopic stromal invasion >3 mm but ≤5 mm depth 5, 1
- Stage IB1: Clinically visible lesion ≤2 cm 5, 1
- Stage IB2: Clinically visible lesion >2 cm but ≤4 cm 5, 1
- Stage IIA1: Upper two-thirds vaginal involvement without parametrial invasion, tumor ≤4 cm 5, 1
Additional Surgical Requirements:
- Bilateral pelvic lymph node dissection is mandatory for all stages requiring radical hysterectomy 5, 1
- Para-aortic lymph node sampling is indicated for larger tumors and when pelvic nodal disease is suspected or confirmed 5, 1
- Sentinel lymph node mapping is an acceptable alternative to complete pelvic lymphadenectomy in apparent uterine-confined disease 5, 1
Absolute Contraindications (Surgery NOT Recommended)
Primary concurrent chemoradiation is the standard treatment instead of radical hysterectomy for the following scenarios: 1
- Stage IB3 tumors >4 cm (high risk of occult nodal metastasis) 1
- Stage IIA2 tumors >4 cm with vaginal involvement 1
- Stage IIB or higher disease with parametrial invasion 5, 1
- Stage III-IV disease with pelvic side-wall, lower vaginal, or adjacent-organ invasion 5, 1
- Confirmed distant metastases 1
- Medical comorbidities precluding major surgery 5, 1
Relative Contraindications and Special Considerations
- Poor performance status favors primary chemoradiation over surgery 5, 1
- Positive para-aortic nodes on preoperative imaging (CT, MRI, or PET/CT) should prompt consideration of extended-field chemoradiation rather than radical hysterectomy 1
- For patients desiring fertility preservation, radical trachelectomy with pelvic lymph node assessment is an alternative for stage IA2-IB1 tumors <2 cm 5, 1
Surgical Procedure Details
Preoperative Workup:
- History and physical examination focusing on tumor size, vaginal extension, and parametrial involvement 5
- CBC including platelets, liver and renal function tests 5
- Imaging: CT, MRI, or combined PET/CT to rule out extrapelvic disease and assess nodal involvement 5
- Cystoscopy and proctoscopy only if bladder or rectal extension is suspected 5
Operative Technique:
- Traditional approach: Open abdominal radical hysterectomy via laparotomy 6, 3
- Minimally invasive options: Laparoscopic or robotic-assisted radical hysterectomy are acceptable alternatives with appropriate patient selection and surgeon experience 5, 7
- Average lymph node yield: approximately 15 nodes removed during pelvic lymphadenectomy 3
Intraoperative Considerations:
- Some surgeons perform pelvic lymph node dissection first; if positive, the hysterectomy is abandoned and the patient proceeds to chemoradiation 5
- Para-aortic node dissection is performed when pelvic nodes are positive or when tumors are large with suspected nodal disease 5
Surgical Risks and Complications
Intraoperative Complications:
- Ureteral injury: Accidental transection occurs in approximately 1.5% of cases and requires immediate surgical correction 6
- Bladder injury: Rare with experienced surgeons 7
- Bowel injury: Rare 7
- Blood loss: Median blood loss ranges from 300-500 mL depending on surgical approach (laparoscopic approaches have significantly lower blood loss) 7
Postoperative Complications:
- Wound complications: Occur in approximately 12-34% of patients, including infection, dehiscence, and hematoma 6, 3
- Urinary fistulas: Historically significant but now reduced to near 0% with modern technique 3
- Bladder dysfunction: Temporary urinary retention is common; median time to bladder recovery varies 7
- Lymphocele or lymphedema: Related to extensive lymph node dissection 4
- Nerve injury: Can cause bladder, bowel, and sexual dysfunction; nerve-sparing techniques reduce this risk 4
Mortality:
- Perioperative mortality: Near 0% in modern series at experienced centers 6, 3
- 5-year survival: Approximately 92% for stage IB disease treated with radical hysterectomy 3
Postoperative Care
Immediate Postoperative Period:
- Hospital stay: Median 5-7 days for open approach; shorter (3-5 days) for laparoscopic/robotic approaches 7
- Bladder management: Foley catheter remains in place until bladder function recovers, typically 7-14 days 7
- Wound care: Monitor for infection, dehiscence, and hematoma formation 6
- Thromboprophylaxis: Low-dose heparin or other anticoagulation to prevent venous thromboembolism 6
Pathology-Directed Adjuvant Therapy:
Category 1 recommendation: Patients with positive pelvic nodes, positive surgical margins, or positive parametrial tissue MUST receive postoperative pelvic external-beam radiation therapy with concurrent platinum-based chemotherapy. 5, 1
- Intermediate-risk features (large tumor size, deep stromal invasion, lymphovascular space invasion) require pelvic radiation ± vaginal brachytherapy based on Sedlis criteria 5, 1
- Positive para-aortic nodes require extended-field radiation with concurrent platinum chemotherapy ± brachytherapy 1
Long-Term Surveillance:
- Follow-up schedule: Clinical examination every 3-6 months for the first 2 years, then every 6-12 months 1
- Recurrence detection: 46-95% of recurrences are detected by physical examination and history alone 1
- Imaging: Reserved for patients with symptoms or clinical suspicion of recurrence 1
- Recurrence timing: Most recurrences occur within 0.5-3 years 1
Critical Pitfalls to Avoid
Performing radical hysterectomy on tumors >4 cm or with parametrial invasion leads to high rates of positive margins, necessitating adjuvant chemoradiation and resulting in trimodality therapy with increased morbidity and potentially inferior outcomes. 1
- Using simple hysterectomy instead of radical hysterectomy for stage IA2-IIA1 disease results in inadequate parametrial margins and higher risk of local recurrence 1
- Omitting systematic pelvic lymph node dissection or sentinel node mapping compromises staging accuracy and impairs selection of appropriate adjuvant therapy 1
- Failure to consider fertility-preserving options (radical trachelectomy) in eligible young patients with tumors <2 cm forfeits valuable quality-of-life opportunities 5, 1
- Performing unnecessary radical procedures for benign disease increases surgical morbidity without oncologic benefit 5, 1
Alternative Treatment Options
Primary concurrent chemoradiation (pelvic external-beam radiation + weekly cisplatin + intracavitary brachytherapy) is oncologically equivalent to radical hysterectomy for early-stage disease and may offer superior therapeutic index when adjuvant radiation would otherwise be required. 5, 1