RADICAL VAGINAL HYSTERECTOMY

The use of the radical vaginal hysterectomy (RVH) in the management of early stage cervical cancer marked an important stepping stone for gynecologic oncologists. Schauta¹⁰ began using the vaginal approach in the last decades of the nineteenth century, but it did not gain much favor in the gynecologic community. In 1898, Wertheim,¹² a former student of Schauta's, developed the radical abdominal hysterectomy (RAH), which rapidly gained wide acceptance.¹² Interestingly, Wertheim's data consistently showed a mortality rate of approximately 40%. In the early twentieth century, Schauta continued to advocate the use of the vaginal route, having achieved a mortality rate that was eightfold lower, with results in terms of survival similar to those for the RAH.¹⁰ In 1924, Amreich¹ reported on the use of RVH with several refinements to the original procedure, which has come to be known as the Schauta-Amreich RVH. Since that time, this procedure has received continued attention and has been the focus of many discussions.

Despite the numerous advantages of RVH over RAH, RVH never gained acceptance in the scientific community because it failed to incorporate lymph node removal. RVH was almost abandoned worldwide, except for several European centers, when Meigs⁷ introduced the concept of combining the RAH with pelvic lymph node dissection. Nevertheless, some investigators have demonstrated the effectiveness of RVH in the surgical management of stages IB and IIA infiltrative cervical cancer even after Meigs' modifications.⁴

By performing retroperitoneal pelvic lymphadenectomy using the advances in laparoscopy, Dargent³ gave a rebirth to the Schauta RVH. In Canada and the United States, Querleu et al⁹ and Childers et al² paved the way to complete laparoscopic staging of the pelvic and periaortic lymph nodes for gynecologic malignancies. High-risk patients can be managed with RVH and extraperitoneal lymphadenectomy using locoregional anesthesia.⁵

At the University of Miami School of Medicine, the vaginal approach was reintroduced recently. The first RVH was performed in Miami in 1998, shortly after one of the authors (RA) was trained by Massi in Florence. It has been concluded in Miami that RVH is the treatment of choice in selected patients. When pelvic and periaortic lymph node dissection is indicated, it is performed by laparoscopy.

RAH and RVH may be associated with a significant risk for complications and postsurgical sequelae depending on the extent of parametrial excision. Thus, individualized treatment protocols should be tailored to the specific needs of each patient. With respect to the vaginal route, it can be clearly deduced from the literature that the use of such an approach in the treatment of early stage cervical cancer is fully justified.