Radical Hysterectomy for Carcinoma Cervix: A Clinical Analysis of 160 Cases

Background: In this study an attempt was made to study the following  Advantage and disadvantage of different approaches of radical Hysterectomy with special reference to abdominovaginal approach  Complications and side effects of the procedure with special reference to post CTRT (Chemo Therapy and Radio Therapy treated) cases Method: It is a prospective clinical study. It was conducted between December 1990 and August 2016 in different institutions of Silchar, Guwahati and Barpeta situated in ssam (North East India). It included 160 carcinoma cervix cases of stage Ia to stage IIb, operated by three different approaches of Radical Hysterectomy. Results: Maximum numbers of cases in the series were in stage IIa (51.25%). Most of the cases (50%) were performed by the Abdominovaginal approach wound gapping was the commonest (5%) complications followed by ureteric fistula (0.625%) secondary haemorrhage (2.50%) etc. Out of 90 cases in 5 years follow up there were 20 cases (12.50%) recurrences. Conclusion: Different approaches of radical hysterectomy have their own advantages. Abdominovaginal approach is more useful for stage II a carcinoma cervix where more liberal excision of vagina is helpful. It is also useful in obese patients, where abdominal approach is more difficult for vaginal dissection. In this method damage to the urinary bladder and its innervations is minimum which the reason for less post operative morbidity. Post CTRT cases are technically difficult but if performed carefully give similar result.

In this series an attempt was made to study the following 1.
Advantage and disadvantage of different approaches of radical Hysterectomy with special reference to abdominovaginal approach.

2.
Complications and side effects of the procedure with special reference to post CTRT (Chemo Therapy and Radio Therapy treated) cases.

Study design:
It is a prospective clinical study.

Materials and Methods
This study was conducted during December 1990 to August 2016 and consists of 160 cases. It consists of carcinoma cervix cases of stage Ia to stage IIb including 50 cases post CTRT (Chemo Therapy and Radio Therapy treated cases). The cases included in the study were operated by the author himself in different institutions of Silchar, Guwahati and Barpeta situated in Assam (North East India) 3 Different approaches were followed for radical hysterectomy in this series as follows:

Results and Observations
Out of total 160 cases most of the cases were of stage 2 a (51.25%) Though there were cases (7.50%) in stage 2 b preoperatively another 5 cases (3.12% ) were found to be in this stage postoperatively Most of the cases (50%) in this series were performed by the Abdominovaginal approach. Wound gapping was the commonest complication in this study happened in 8 (5%) cases 1 patient (0.625%) also developed Burst abdomen in 2 cases (1.25%). There was inadvertent injury to the ureter which was repaired primary by ureterovesical implantation successfully. 1 patient (0.625%) developed ureteric fistula postoperatively which was successfully repaired after 3 months. In one patient (0.625%) there was inadvertent injury of the ileum which was successfully repaired in the same sitting this was a post CTRT case.

Discussion
In this study 80 cases (50%) were done by abdomino vaginal Technique. This technique popularly known as modified Schauta technique has the advantage of vaginal dissection for liberal removal of vagina wherever indicated. It also allows precise dissection with least damage to the urinary bladder and its innervations leading to minimum post operative morbidity, specially urological. Only limitation of the procedure is extra time required for 2 stage procedure. In the present series average time taken for the complete procedure was 120 minutes to 160 minutes. It was advantageous to choose the abdominovaginal procedure in stage II (a) cases. Indwelling catheter was maintained for 5 days in most cases. Because of early ambulation other post operative morbidities were also less.
In post CTRT cases due to radiation effect on the normal and diseased tissues there are lot of fibrotic changes in the pelvis leading to anatomical deformitiesadhesion to the surrounding viscera and tissues, lack of cleavage etc. This lead to difficulty in dissection. Chances of injury to the viscera increase due to all these effects. To avoid injury to the structures a specially innovated technique of hydro dissection (by the author himself) was used in this series [6]. In this technique good amount of Ringer lactate or Normal saline is pushed with a 10 ml syringe, some time with the help of a small feeding tube around the structure to be dissected. This method is helpful in completing the dissection and completes the surgery without damage vital structure in most cases.
Only in 1 case (o.5%) there was urinary bladder injury and ileal injury in another case. Both the cases were repaired primarily Cetina et al. (2009) in their study of 80 patients showed that radical hysterectomy has a great role in the treatment of post EBRT-CT cases in the FIGO stage IB2 to IIb [7]. Da. Vinci Robotic system has revolutionised the cancer surgery by offering more precise surgery with minimal blood loss and minimal physical strain to the surgeon [8] Of course this approach is not affordable to all unlike the approaches used in the present series.

Conclusion
In treatment of Carcinoma Cervix Radical hysterectomy is a well established method of treatment for which different approaches of surgery have their own advantages. Especially in Stage I (a) cases where more vaginal excision will be helpful and in obese patient where abdominal approaches may be more difficult, abdomino vaginal approach is more advantageous. This approach is helpful in minimizing damage to the urinary bladder and support leading to less post operative morbidity Post CTRT cases are technically difficult but if performed carefully give similar result to the conventional primary surgery.