306 Obstetrics and Gynecology Board Review •••
❍ What are the classifications of radical hysterectomy?
- Class I: Extrafascial hysterectomy: incised pubocervical fascia allowing lateral deflection of ureter allowing for
complete excision of cervix.- Indication: CIN/CIS cervix.
- Class II: Modified radical: Uterus, upper third of vagina, cervix, paracervical-parametrial tissue, lymph node
dissection, washings, biopsies allowing for removal of paracervical tissue, while preserving blood supply to
ureters and bladder.- Indication: Microinvasive cervical cancer.
- Class II: Meigs-Wertheim radical: Same as Class II but wider excision of parametrial/cervical tissue allowing
uterine artery to be ligated at it’s origin from the internal iliac artery.- Indication: Stage Ib and IIa cervical cancer.
- Class IV: Complete removal of periureteral tissue and ¾ of vagina while preserving the bladder.
- Class V: Removal of ureter (reimplantation-ureteroneocystostomy) and/ or bladder.
❍ When is hysterectomy indicated in the management of endometrial hyperplasia?
Adenomatous hyperplasia with cytologic atypia is considered a precancerous lesion, and should be treated with
hysterectomy except under very special circumstances. Less severe forms of hyperplasia, without cytologic atypia,
can be managed medically. Hysterectomy for hyperplasia may be done vaginally or abdominally.
❍ What type of hysterectomy is done for endometrial cancer?
Systematic surgical staging for endometrial cancer requires TAH with BSO, peritoneal washings, biopsies of
any suspicious lesions, and pelvic +/- paraaortic lymphadenectomy. If papillary serous or clear cell carcinoma is
present, then omental biopsy is required for full staging.
❍ What procedures are used in the treatment of uterine sarcoma?
TAH, BSO, pelvic washings, and pelvic and paraaortic lymphadenectomy make up the appropriate surgical
treatment and staging of uterine sarcoma. Postoperative radiation and chemotherapy may be of benefit, but this is
an evolving area.
❍ When is hysterectomy used in the treatment of gestational trophoblastic disease (GTD)?
In women who have completed their childbearing, hysterectomy performed during the first cycle of chemotherapy
can reduce the total amount of chemotherapy required to achieve complete remission. Recurrence rates after
successful treatment in these cases (with or without hysterectomy) are <5%.
Early hysterectomy is of no benefit in women with high-risk metastatic GTD with any of the following:
- hCG >40 k.
- Brain or liver metastases.
- Antecedent term pregnancy.
4 months since last pregnancy, or prior chemotherapy).
❍ Is hysterectomy always part of the surgical management of ovarian cancer?
Systematic surgical staging and debulking is required for ovarian cancer. The staging procedure includes TAH,
BSO, pelvic washings and cytology, inspection of all peritoneal surfaces with debulking of any visible tumor,
bilateral pelvic and paraaortic lymphadenectomy, omentectomy, and peritoneal biopsies. In younger women
desiring fertility who at the time of operation are found to have ovarian cancer that is low grade and confined to
one ovary, the staging procedure may be modified to leave the uterus and uninvolved ovary in place.