EXTENDED RADICAL VAGINAL FOR CANCER OF THE

BY SuBODH MITRA, M.B. (Cal.), DR. MEn. (Berlin), F.R.C.S. (Edin.), F.R.C.O.G., F.A.C.S., Professor-in-charge, Department of Obstetrics & , R. G. Kar Medical College; Director, Chittaranjan Cancer Hospital, Calcutta.

There is an old saying that ''in the treated rather indifferently till, to­ history of science . . . . , the past is wards the end of the 19th century never past but continues and is very and the beginning of the 20th cen­ active in every form and at every tury, Wertheim and Schauta (both manifestation of the present" ( Costi­ from Vienna) took up the surgical glioni). The same is equally true in work with scientific prec1s10n and the progress of the scientific treat­ started doing radical ment of cancer of the cervix. With­ abdominally and vaginally. out going much into details, the pro­ During this era, the investigation gress of the treatment can be divi­ was s:arted to assay the results of ded into different eras, namely, Pre­ cancer treatment on a statistical Wertheim, Wertheim-Schauta, radio­ basis. I think, it would not be out therapy and the modern era. In 1878 of place here to state clearly a few surgical interference was introduced fundamental rules of cancer statistics. in the treatment of cancer of the In order to assess the surgical cervix by Freund and Czerny, i.e. achievement of a series of cancer about a quarter of a century before cases, it is essential to know the Wertheim and Schauta came in the surgeon's operability rate, i.e. the field. Freund started abdominal re­ percentage of patients selected for moval of the cancerous uterus in operation out of every 100 cases exa­ January, 1878, and had to face a pri­ mined. If the patients live free from mary mortality of 72 per cent. Eight recurrence after treatment for a mini­ months later, Czerny started the mum period of 5 years and up to an vaginal operation and the primary optimum period of 10 years, they are mortality came down to 32 per cent. declared cured or salvaged. Because of this high mortality and The percentage of cured cases is poor end results, cancer cases were differentiated into relative cure rate and absolute cure rate according as Paper read at the Seventh All-India th2 percentage of cured cases out of Obstetric and Gynaecological Congress the total number of cases operated, held at Calcutta in December, 1952. which is relative cure rate, and the 16 JOURNAL OF OBSTETRICS AND GYNAECOLOGY OF INDIA percentage of cured cases out of the ment, not only survival rate of the total number of cases seen and :qumber of cases operated are requir­ examined, which is absolute cure ed, but also the operability rate is rate. essential. 1 The whole idea of this cancer sta­ Judging from the above mentioned tistics is to get a clear-cut unambi­ criteria, we find the results of Wer­ guous figure of salvaged cancer cases theim and Schauta are as follows: depending on surgeon's operability there were 500 cases operated by rate. Wertheim, having an operability rate To make it more explicit, let us, of 50 per cent, primary mortality for example, consider the achieve­ rate of 18.6 per cent and 5-year rela­ ments of two surgeons, A and B. If tive cure rate of 42.4 per cent, surgeon A has operated on 10 cases whereas in Schauta's series 698 cases of whom 4 are alive after 5 years, he were operated, having an operability has a relative cure rate of 40 per rate of 51.3 per cent, primary morta­ cent. If surgeon B has also operated lity rate of 7.3 per cent and 5-year re­ on 10 cases .of which 8 are alive after lative cure rate of 39.7 per cent. In 5 years, he has a relative cure rate 1910 Schauta had only 1 death in 50 of 80 per cent. Surgeon B should be operations (Table I). considered a definitely more success­ It is thus obvious that both the ful operator provided the operability radical abdominal and radical vagi­ rate of both surgeons is the same. If nal methods gave almost identical on the other hand, surgeon A ope­ results in the hands of experts. rates on 10 out of 20 cases seen, i.e. During the latter part of the W er­ having an operability rate of 50 per theim-Schauta era, radium treatment cent, and surgeon B operates on 10 came into the field. The introduc­ out of 100 cases seen, i.e. an oper­ tion of radiation thereby had a strik­ ability rate 10 ji , the absolute survi­ ing effect on the gynaecologists, and val rate will be 20 per cent and 8 it was thought at one time that per cent instead of 40 per cent and will entirely re­ 80 per cent respectively. Thus for place the surgical treatment for can­ l proper assessing the r : sults of treat- cer of the cervix. Radiation therapy

TABLE I

Operability Primary 5-year relative rate mortality cure rate Wertheim (500 cases) 50 % 18.6% 42.4 ~~ Schauta (698 cases) 51.3 % 7.3 % 39.7% (in 1910 only 1 death in 50 cases) 1 ------·------RADICAL VAGINAL HYSTERECTOMY 17

reigned supreme for a quarter of a staking in learning the technique century when it was noticed that 'all more thoroughly and applying it was not well with the radiation front. more precisely. Surgery, however Proper application of radium along ultraradical it may be, will never be with accurate planning and the esti­ able to entirely replace radiation mation of isodose curve with a view therapy, which will always remain to supplement deep x-ray therapy to the most useful adjunct in the treat­ areas partially exposed to rad!ium ment of cancer of the cervix. gamma rays is as difficult to learn as During the radiotherapy era, the the surgical technique. Complica­ surgical practice was kept alive by ) tions of the nature of perforation of a few gynaecologists of exceptional the uterus, severe haemorrhage, in­ merits, most outstanding of them tractable sepsis, vesico-vaginal and being Victor Bonney and Stoeckel. recto-vaginal fistulae, rectal telan­ Here again, Victor Bonney follow­ giectasis and ulceration and even ed the abdominal technique and necrosis of the small intestines are Stoeckel the radical vaginal tech­ not infrequently encountered. Pri­ nique. Their results show that, mary mortality ranged from 1.2 per operability rate remaining more or cent (Heyman) to as high as 7.7 per less the same, there is a definitely re­ cent (Schlink). Further, it is to be duced primary mortality and an in­ noted, that although the primary creased 5-year cure rate after radical growth of the cervix can be cured by vaginal method (Table II). Even radium, metastatic cancer cells of the worst critic will have to admit pelvic glands cannot be sterilised even from the foregoing results that radical by supervolt x-ray therapy. vaginal hysterectomy is as much In spite of the defects mentioned a standard operation for cancer of above, it must be admitted that the cervix as the radical abdominal radium treatment has proved itself to hysterectomy. be the most successful treatment for In the modern era, there is an at­ cancer of the cervix. tempt to integrate radiotherapy and Radiation therapy could have been surgery on a rational basis. Radio­ more effective if the gynaecologists at therapy is still the method of choice large would have been more pam- 'in most of the clinics all over the

TABLE II

5-year No. of cases Operability Primary relative operated rate mortality cure rate

Victor Bonney (abdominal) 500 63'/t 14/{ 39'/{ Stoeckel (radical vaginal) 1200 76.6 jl,, 4-9 '/u 50 /u (1910-1920)

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I 18 JOURNAL OF OBSTETRICS AND GYNAECOLOGY OF INDIA world, but the gynaecologists are abdominal hysterectomy. We get a getting more and more conscious of much favourable report from Frank the limitations of radiotherapy. There Cook's and Charles Read's combined is a definite group of radio resis­ series of 205 cases with a primary tent cases, where surgery will yield mortality rate of 2.9 per cent. There ...I better results. Besides, there are was no mention about the oper­ certain associated conditions, namely, ability rate in this series, which may fibroids, tubo-ovarian masses and be due to "careful selection of cases" pregnancy, which should prompt operated in different hospitals and one to take up surgery rather than nursing homes. radiother;apy in these complicated During the years 1932 to 1950, I cases. did 209 radical vaginal hysterec­ During this radiotherapy age, we tomies having a primary mortality are experiencing certain difficulties in rate of 2.8 per cent. There was no assessing our operability rate. operative death in the last 105 cases Although after careful analysis of our of this series (Table III). cases, I thought that I could have Charles Read has also given 5-year taken up 57.7 per cent of them for relative cure rate of cases at Chelsea operation, I actually operated on 17 Hospital, during the year 1936 to per cent of patients belonging to 1941, as 44.4 per cent. In all, there different stages. The rest of the were 54 cases, of which 34 belonged patients had to be treated with to Stage I and 20 to Stage II. Ana­ radiation therapy either by patients' lysing my 79 operated cases, between own choice or due to circumstances 1932 and 1938, I find 8 belonged to favouring radiotherapy. Stage I, 36 to Stage II, 35 to Stage Although at Chelsea Hospital for III. If all the cases are taken to­ Women good surgery for . cancer of gether, there is a relative 5-year cure the cervix, has been the tradition, rate of 39 per cent, and if only Stages even at this place the operability rate I and II cases are calculated there is I has been reduced to 14 per cent. a relative 5-year cure rate of 50 per l] Operations referred to meant radical cent (Table IV).

TABLE III

No. of cases Operability Primary operated rate mortality

Chelsea Hospital for Women 96 14% 8.3% F rank Cook and Charles Read (Personal Series) 205 ? 2.9 % S ubodh Mitra 209 17 % 2.8 % (Chittaranjan Seva Sadan & Cancer Hospital) Last 105 0% cases

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I RADICAL VAGINAL HYSTERECTOMY' 19

TABLE IV patients and positive cancer nodes were found in 9 of them, i.e. inci­ No. of cases 5-year dence of 40 per cent. operated relative An ideal operation should aim at cure rate removing not only the cancerous Chelsea 54 44 % uterus but also an extensive amount Hospital of vaginal and paravaginal tissue to ( 1936-1941 (St. I & II) prevent local recurrence, and prac­ Mitm 79 39% tically the whole of the parametrial 1932-1938 (St. I, II & III) tis-sue and pelvic nodes to avoid gla­ 44 50 % ndular metastases. Although I am (St. I & II) more than conscious that the ideal of the total removal of all the pelvic lymphatics and ·the lymph nodes Taking all these facts into conside­ cannot be reached, the method fol­ ration it can be definitely pronounced lowed by extraperitoneal lympha­ that the radical vaginal hysterectomy denectomy leaves practically very yields as good results as the radical little chance for any lymph glands abdominal hysterectomy; and fur­ to be left behind. Not only the ther, if Wertheim's operation is a lymph glands but also the whole of standard operation for cancer of the the fibro-areolar sheaths of the blood cervix, Schauta's operation is equally vessels containing the lymphatics as a standard operation. well as adiposo-areolar tissue con­ In spite of what is said and done, tained in the lateral fossae of the there cannot be any denying of the pelvic basin are removed en masse, fact that regional lymph glands are thus reducing the chance of leaving ignored in radical vaginal hysterec­ behind any suspected lymph node to tomy and this was rightly pointed the minimum. out by Frank Cook in 194 7, This two stage operation satisfies while I presented my results of all the conditions which are essen­ radical vaginal hysterectomy at the tial for radical surgery in cancer of Royal Society of Medicine. Since the cervix. then, I have designed a two stage operation, the first part being radical I have worked further to make vaginal hysterectomy and the second this operation simpler and more part ( 3 weeks later), the extraperi- radical and a new technique has 1Joneal pelvic lymphadenectomy. I been designed to do this operation made an official statement of this of extended radical vaginal hysterec­ modification at the 12th British Con­ tomy at one sitting. gress of Obstetrics and Gynaecology This operation is started with the held in London in 1949, and later, extraperitoneal · exposure of the at the International and Fourth gland-bearing area of the pelvis American Congress of Obsterics and (Fig. 1). Skin with subcutaneous Gynaecology in New York in 1950. fat is cut by an inguinal incision and I did this composite operation on 22 the apponeurosis of the external ob- 20 JOURNAL OF OBSTETRICS AND GYNAECOLOGY OF iNDIA lique slit open upto subcutaneous ing the massive removal of the para­ inguinal ring. Then after blunt dis­ metrium. The uterine artery is section of the inguinal falx, a tunnel ligatured and cut near its origin from is made by ,insinuating the finger the internal iliac artery (Fig. 3). beneath the fascia transversalis thus Usually the uterine veins are not separating the internus obliqus and found accompanying the artery at transversus muscles and the fascia this place. These veins meet the .. I transversalis from the loose connec­ artery at an angle medial to the I tive tissue of the lateral pelvic wall. as seen from the lateral as­ These muscles and fascia are cut pect. along the skin incision and the peri­ Next, the lower part of the ureter, toneum thus exposed is pushed as it passes th~ough the Macken­ medially. The ureter being attached rodt's ligament, is dissected up to its to the peritoneum is thus pushed entrance into the bladder thus expos­ away from the gland bearing area ing the frontal part of the parametri­ and the whole field is exposed for um. the removal of the glands beginning The paravesical and pararectal from the common iliac to the ob­ fossae are next exposed by blunt dis­ turator gland. The whole range of section thus defining the lower and glands along with fibro-areolar upper border of the parametrium. sheaths of iliac vessels and fibro­ The index finger is then insinuated adipose tissue of the obturator fossa down wards through the pararectal are removed en masse (Fig. 2). fossa along the sacrospinous liga­ The next step of the operation is ment until it reaches the paravesical to ligature the ovarian vessels as fossa. This should be done carefully they are found crossing the ureter as the rectal, uterine and vesical near the pelvic brim. This will ob­ plexus of veins are encountered. viate ligaturing the infundibulopelvic The finger thus insinuated will sepa­ ligament while the uterus is removed rate the parametrium from the pelvic vaginally. Next, the uterine artery floor to which it is loosely attached. is dissected. When exposed extra­ 'I'he parametrium thus dissected is peritoneally, the uterine artery is cut from the lateral pelvic wall found to be overlapped by the (Fig. 4). As the lateral part of the superior vesical artery which should parametrium contains the inferior be well dissected out and kept away vesical artery and the plexus of veins from the field of operation. Distally with varying directions, it is better the superior vesical artery is attach­ to ligate the stump in 2 or 3 stalks ed to the obliterated hypogastric for good haemostasis. The detached artery which may be cut during parametrium is dissected further mobilisation of the bladder to open medially and left as such for mass re­ the paravesical space. The superior moval vaginally. vesical artery is to be specially pre­ Ensuring proper haemostasis, the served as the inferior vesical artery wound is closed layer by layer. The being embedded in the utero-vesical same process is repeated on the op­ plexus of veins is invariably cut dur- posite side. RADICAL VAGINAL HYSTERECTOMY

,. The vaginal portion of the opera­ the parametrial attachment to the tion is then taken up. After the adjacent structures as well as the left-sided Schuchardt's incision, the paracervical and the paravaginal vaginal cuff is made taking as much tissues are cut as far laterally as pos­ vaginal and paravaginal tissue as sible, and the uterus is taken out thought proper according to the ex­ with its appendages and with whole tent of the growth. The bladder is of the parametrial tissue. There dissected up and the ureter is ex­ will be certain amount of bleeding posed after cutting through • the due to venous stasis. It will be vesico-uterine ligaments (bladder checked either by a few haemostatic pillars) (Fig. 5). As the ureter was stitches or by tamponade. After already dissected partially, it will be closure of the peritoneal opening the very easy to deflect the ureter further cystocele is repaired by a purse­ away from the parametrium. string suture and the cut margin of The pouch of Douglas is next open­ the vaginal opening is partially ed and, after retracting the uterus stitched up. This anterior colpor­ upwards and the rectum downwards, rhaphy is an additional advantage of the utero-sacral ligaments are made this operation adding comfort to the taut and along with the so-called patient's future life. vosterior parametrium cut close i c;, I shall end this by presenting the the rectum. pictures of two of my operated speci­ The uterovesical -pouch is next mens. Fig. 6 is from a patient of Stage II cancer cervix. She was "'pened. Pulling out the fundul> treated with radium and deep x-ray with the tubes and , the in­ therapy about a year ago. There fundibulopelvic ligament is cut with­ out ligature as the ovarian vessels are was a recurrence of the growth of the cervix and radiotherapy would have already ligatured; next the round ligament with the upper part of the been of no use. The picture shows the massive removal of the cancer­ broad ligament is cut. affected organ along with a complete At this stage the uterus is pulled dissection of the pelvic nodes. The to the opposite side by giving trac­ patient was discharged well after 3 tion to the fundus upwards and weeks. The next picture (Fig. 7) is J laterally, and to the cervix down­ fa-om a patient clinically diagnosed wards and laterally. At the same as a Stage I cancer cervix case. Dur­ time the bladder and the ureter are ing the dissection of the vaginal and kept away by lateral retractors thus paravaginal tissue and the making exposing the parametrium to its full of the vaginal cuff, the endocervical length. The uterine vessels do not portion was found to be completely require any ligature vaginally as infiltrated with soft proliferated can­ they have been already ligatured and cer tissue so much so that on slight cut. The bulk of the parametrium traction to the vaginal cuff, the whole does not require to be excised here of the cervix came off from the body as it has already been cut extraperi­ of the uterus. It would have been toneally. The remaining portions of most difficult to do a radical opera- L joURNAL OF OBSTETRiCS AND GYNAECOLOGY OF INDIA tion in this case by Wertheim's abdo­ 3. Doededein-Kroenig: Operative minal method. Gynaekologie Verlag von Georg It was possible for me to make a Thime Leipzig, 1924. complete dissection and remove the 4. Heyman H. V. James: Jour. Obst. whole uterus with extensive para­ & Gyn., Brit. Emp.; Vol. 31, No. 1, metrial and paravaginal tissues along Spring, 1924. l I with the whole block of pelvic nodes 5. Mitra, Subodh: Proceedings of by this new method of extended Roy. Soc. of Med.; XL, 14, 907, radical vaginal hysterectomy. 1947. In conclusion, I would like to sub­ 6. Mitra, Subodh: Amer. Jour. Obst. mit that we are determined to make and Gyn.; 55, 293, 1948. an all-out attempt to :fight cancer 7. Mitra, Subodh: Archiv. f. Gynak.; with knowledge. It is not our inten­ Bd. 179, 1951. tion to fight for the supremacy of one 8. Mitra, Subodh: Zentralblatt f. method of treatment over the other. Gynak.; 73 Jahragang, Heft 5 (a) Our yardstick would be to see how 1951. many cancer cases we can cure out 9. Read, Charles D.: Edin. Med. of every hundred cases seen and Jour.; 55, 675, 1948. examined by us, no matter whidh 10. Schauta: Die erweiterte vaginale method we follow. He will get the Totale:x.tirpation des Uterus bei laurel who can salvage more cases Collumcarcinom. Wien-Leipzig, out of his every hundred cases initial­ 1908. ly examined. 11. Schlink, Herbert H.: Gynaecology; Angus and Robertson Ltd., Sydney References. & London, 1939. 12. Stoeckel: Zentralblatt f. Gynak.; 1. Adler, L.: Amer. Jour. Obst. and Nr. 1, 53, 1931. Gyn.: 23, 332, 1932. 13. Stoeckel: Lehrbuch der Gynaeko­ 2. Bonney, Victor: Amer. Jour. Obst. logie S. Herzel Verlag, Leipzig, and Gyn: 30, 815, 1935. 1947.

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I Figure 1 Exposure of the gland-bearing area

Figure 2 Pelvis after dissection and removal of lymph glands J

Figu re 3 Ligature of ovarian and uterine .vessels. Dis­ section of the parametrium

Figure 4 ------"""""' "'"1-i_'"l.,.... ,.... ~ f.l.. a P o _.. ... /.-!..,_~-- Figure 5 Vaginal cuff, dissection of the bladder and ureter

Figure 6 Mass removal of the Uterus, parametria and pelvic nodes by Extended Radical Vaginal Hysterectomy 4 . I

Figur e 7 Mass removal of the uterus, parametria and pelvic nodes by Extended Radical Vaginal Hysterectomy

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