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Extended Radical Vaginal Hysterectomy for Cancer of the Cervix EXTENDED RADICAL VAGINAL HYSTERECTOMY FOR CANCER OF THE CERVIX 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 & Gynaecology, 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 hysterectomies 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 radiation therapy 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) 3 L 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.
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