HISTEREKTOMIA VAGINALE – PERSPEKTIVA TE REJA “RADICAL VAGINAL HYSTERECTOMY – NEW PERSPECTIVE”
Prof. Dr. Danilo DODERO Introduction – Historical outline On April 21st, 1893, Karl August Schuchardt made the first enlarged vaginal hysterectomy in a patient suffering from cervical cancer. The incision of vagina, perineum and anus elevator, from then on called after his name, allowed what the Hamburg gynecologist Staude (1908) defined “top opening” of the vaginal fornix in order to remove the structures of the connective tissue. This also allowed to solve the ureter problem two years before solving it via abdomen. Before dying of surgical infection in 1901, Schuchardt showed unprecedented percentages of operation and remission. In the same year, in June, a gynecologist from Vienna, Shauta (1891, 1911) worked on Schuchardt’s idea and further developed its surgical technique. Shauta, therefore, opened a breach for Schuchardt’s forerunning (pionieer) idea. However 25 years elepsed before Schuchardt and Staude’s operation could find an enthusiastic supporter in its own country: Stocker (1928). Stockel championed (followed) a systematical (methodical) technique. His pupil (student) Amreich (1924, 1960) described the surgical anatomy in detail and developed the operation (technique) following a methodical anatomic procedure. In the following years only a few schools cultivated the tradition of vaginal surgery in the oncologic field (Ingiulla, Navratil, van Bowdijk, McCal). Shauta-Amreich’s operation, though criticized for not allowing lymphoadenectomy, was proving remarkably efficient in treating (curing) cervical cancer and its results were not lower than those obtained through the abdominal operation including pelvic lymphoadenectomy. In 1958, Mitra introduced a new technique in gynecology, the pelvic limphoadenectomy via extra-peritoneal, which had already been described by Nathanson in 1950 and had been applied in the urologic field. Mitra’s procedure, which aimed at completing the vaginal histerectomy, found limited applications and was systematically employed only by the Dutch school (van de Graaf) with very satisfactory results. The relative technical difficulty in the performance of the vaginal operation, which, due to the narrowness of the operationali field requires uncommon manual dexterity and experience, limited its spread: in fact, cases of cervical cancer, with a high surgical risk and unsuitable for vaginal surgery, used to be treated with radiotherapy. In the last years, the increasing interest in an accurate prognostic estimation has previleged surgical treatment rather than radiotherapy in all forms of uterine cervical cancer. In fact, the role of surgery, which at first had been merely therapeutic, has changed dramatically: diagnostic aspects have been pointed out and attempts have been made to integrate clinic elements of stadiation with accurate anatomy-surgical considerations. If on the one hand all this has allowed to personalize the therapy, employing intergrated treatments in risk cases, on the other hand it has raised problems in the application of such a procedure in patients who, due to consitutional or pathological characteristics (obsity, cardiopathy, etc.) are at high risk for surgery anesthesia. In this light, vaginal surgery, thanks to the favourable balance cost/benefit (swift execution, reduced surgical trauma, local anesthesia, ect.) plays a crucial role in all the obese and high risk patients. Directions Radical vaginal hysterectomy for cervical cancer is curently employed only occasionally in a limited number of centres. Directions are represented by: obesity, initial invasive disease, cervical cancer in patients with prolapsus. What at the beginning of the century was considered advantageous in this procedure, compared to the abdominal operations, i.e. reduced mortality rate and surgical morbidity, is no longer valid nowadays, as abdominal operations and perioperational assistence have considerably improved. One disadvantage of the vaginal 82