522

THE PLACE OF SURGERY IN THETREATMENT OF CARCINOMA

OF THE CERVIXBy JOHN HOWKINS, M.S., M.D., F.R.C.S., F.R.C.O.G.

Gynaecological Surgeon to St. Bartholomew's Hospital, Hampstead General and the Royal Masonic Hospitals

To understand the evolution of the treatment ofcancer of the cervix, it is profitable to glance backover the last fifty years. At the turn of the century,the great master of pelvic surgery, Victor Bonney,watched Wertheim perform his operation anddecided to embark on a series that ultimatelyexceeded five hundred. His initial mortality of14 per cent. must have proved an incontrovertibledeterrent to a less courageous man but it must beremembered that he knew no anaesthetic perfec-tion such as we enjoy, that blood transfusion inthose days was almost a major operation, thatwater and electrolyte balance was little understoodand that there was no chemotherapy, let alone anyantibiotic. The criticism of its high initial mor-tality gradually undermined the Wertheim opera-tion and the spectacular advances in radiotherapywith a negligible operative danger convincedalmost all but Bonney that surgery played no partin the treatment of this disease. The universalacclamation of radiotherapy soon thinned the ranksof those surgeons who were willing and capable ofperforming the Wertheim operation and only thosefortunate enough to have worked with Bonney andhis pupils continued the lonely struggle. To himand them we owe the principles which are nowaccepted in the surgical treatment of carcinoma ofthe cervix.A brief consideration of some of these prin-

ciples is important for the proper understandingof the place for surgery in this disease:

i. Kottmeier of Stockholm1 has recently repor-ted a go per cent. cure rate for stage I carcinomaof the cervix, the best figure so far obtained by pureradiotherapy. The immediate question that arisesfrom these figures is why the cure rate is not Iooper cent. Dobbie of Birmingham2 has suppliedthe answer by showing that the incidence of glandinvolvement in a small series in stage I is I5 percent., and stage II 47 per cent. It is an axiomstressed by Meigs that radiation cannot sterilizean involved lymphatic field and, if this is true, it

explains the loss of ten out of every hundredpatients treated by radiation. In stage II cancer,the radiation cure rate falls to 65 per cent., thepercentage of involved glands in this stage beingthe comparable figure of 35 per cent. The logicalconclusion is that if we knew which patients instage I and II had involved glands, they shouldhave at least a pelvic lymphadenectomy or, asadvocated by Schlinck3 and Currie4, preliminaryradiation followed by a Wertheim operation.Although surgery will only cure a percentage ofpatients with involved glands, it will cure morethan pure radiotherapy.

2. In certain cancers of the cervix adequatelytreated by radiotherapy, a number fail to respondto it. This can be proved by serial surface biopsyand a study of the tumour cells and bed afterradiation (Glucksmann and Way5). Failure torespond to radiation provides an incontrovertibleindication for surgical extirpation.

3. For certain technical reasons, for examplestenosis of the vaginal vault, it may be impossibleto apply an adequate source of radium to thegrowth and, while these growths can be treated bysupervoltage X-radiation, there is insufficientpublished material to provide comparable five-year cure rates against the standard Stockholmtechnique.

4. Carcinoma of the cervix complicated bypelvic inflammatory disease or fibroids has usuallyprovided an indication for surgical treatmentrather than radiation. If radiation is employed inthe presence of pelvic inflammatory disease, Kott-meier has advised that a laparotomy and bilateralsalpingo-oophorectomy should first be performedand the patient then treated by irradiation. Alogical development of such an operation would beto extend the operation to include pelvic lymph-adenectomy. If lymphadenectomy is thoroughlyperformed, it is a small additional step to completethe classical Wertheim operation.

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November 1956 HOWKINS: Treatment of Carcinoma of the Cervix S23

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Total exenteration specimen showing infiltration of bladder on left and infiltration andulceration of rectum on right. The patient survived for fourteen months.

5. In the past adenocarcinoma of the endocervixhas been considered unfavourable for radiation bymost authorities but Kottmeier and his Stockholmcolleagues deny this. He gives a five-year curerate for adenocarcinoma treated by radiation of44- 45 per cent. against 43 per cent. treated bysurgery. In spite of this, until the superiority ofradium or surgery is established beyond doubt,most surgeons would prefer to use surgery foradenocarcinoma of the cervix.

6. In the later stages of cervical cancer when, forinstance, the 'bladder is involved but there is agrowth-free space between the parametrial exten-

sion and the pelvic wall, the use of radium involvesthe risk of a vesico-vaginal fistula, and the sameargument applies to the rarer involvement of therectum. In such patients, and especially where thebladder only is involved, some form of exentera-tion operation should be considered. The anteriorexenteration which involves removal of the bladderand implantation of the ureters into some part of thebowel is a reasonable procedure, though the longterm cure rate cannot be great even if the growthis confined entirely to the pelvis and is eradicatedso that no recurrence endangers the patient.Progressive renal degeneration from anastomotic

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524 PQSTGRADUATE MEDICAL: JOURNAL ..: November 956

back pressure and retrograde infection will ulti-mately cost the patient her life. A death fromhydronephrosis is certainly more pleasant than onefrom advanced pelvic cancer with all the misery ofurinary and faecal fistula and the malignantcachexia of an infected and advancing growth.

Total exenteration which involves the removalof the rectum in addition to the bladder, uterusand vagina, is an operation which most thinkingsurgeons still find difficult to justify. AlthoughBrunschwig in New York has claimed a number offive-year survivals after this operation, there can-not be many patients in whom the operation ismorally or humanely indicated. It is only fair toexplain to the patient, before embarking on such amutilating procedure, the full implications of herprimary disease and the complications and penal-ties of the operation if successful. It takes acourageous and intelligent patient to master thewater-proofing and management of a Rutzen bag.Therefore, only those who have the moral staminato tolerate a wet colostomy should be subjected tothe operation. It need not be stressed that phy-sical fitness above the average is needed to face thestrain of the operation itself and this procedure isunjustifiable in a poor surgical risk. There will,however, be a few patients who are willing andready to undergo the operation and for them it isa last slender hope of cure.

Before a surgeon starts to treat cancer of thecervix in all its stages by surgery, there are certainessentials which must be fulfilled :

a. These operations should never be performedin small hospitals (Howkins6); so much dependsfor their success on the team-work that is onlyavailable in a big unit that it is safest for the patientfor all cases to be segregated in centres whereevery anaesthetic, radiation, biochemical and otherfacility is available.

b. A long apprenticeship is necessary in whichto learn the intricate anatomy of those regions ofthe pelvis not ordinarily explored by the usualgynaecological operations. For instance, theidentification and ligation of the superior andinferior gluteal and pudendal branches of thehypogastric venous system is an essential step ina properly performed radical hysterectomy forcarcinoma of the cervix. Failure to ligate thesevessels safely and adequately can endanger thepatient's life and will prove an insuperableobstacle to a proper dissection. Furthermore, thistype of surgery demands quite a considerableknowledge of urological techniques and any sur-geon undertaking it must be prepared to implantureters and make an artificial bladder himself.

c. The author cannot pay too great a tribute toDr. Frankis Evans and Dr. C. J. Massey Dawkins,the anaesthetists who have simplified the technical

difficulties of an extended pelvic dissection bysuperb relaxation and a minimum of unnecessarybleeding. The author's strong preference is forepidural anaesthesia in all these cases and the oneoccasion when this was not available has onlyconvinced him of the superiority of the epiduralblock.

d. Pre-operative and post-operative treatment:It is inexcusable to submit any patient to anoperation for carcinoma of the cervix who hasnot first been stabilized at the optimum level.Similarly, the post-operative control of fluid andelectrolyte balance must be understood by thoseclinicians in charge of the case and full laboratoryfacilities available for the quick estimation ofsodium and potassium.When the surgeon has marshalled all the neces-

sary facilities, he must make sure that his surgicaltreatment carries no greater risk to his patient thanthe alternative of radiation. In the best hands,such as those of Meigs and Currie7, the operativemortality is in the region of i to 2 per cent. Thedefinition of operative mortality is death from anycause within twenty-eight days of operation andthis should be the standard accepted by all surgeonswhen reporting their results. Any surgeon whosedeath rate is higher than this should examine histechnical approach under the headings consideredabove.

His next consideration must be the extent of hisoperation. This primarily demands a thoroughdissection of those glands which may be involved.These, briefly, are the glands below the bifurcationof the aorta and below the level of the brim of thetrue pelvis. Ideally, all these glands should bemeticulously removed and it is only by this dissec-tion that surgery will be able to provide a betterfive-year cure rate than radiation. The next mostimportant consideration is the removal as widelyas possible of all the potentially involved parame-trium and paracolpos and it is here that the author'smethod of synchronous combined abdomino-vaginal hysterectomy is submitted as beingsuperior to the classical Wertheim's operation6.In this method two teams, one working from thevaginal route and one from the abdomen, employ atechnique similar to that of Lloyd-Davies in hisoperation of synchronous combined excision of therectum and colon. All the parametrium andparacolpos is removed as far laterally as the pelvicwall and as far downwards as the levator animuscles which can then be removed if necessary.At the end of the operation, the pelvis is emptyexcept for the following structures: The commonand external iliac artery and vein, the ureters andbladder, the obturator nerve (though this may besacrificed with relative impunity), the levator animuscles and the lumbo-sacral plexus and rectum

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November I956 HOWKINS: Treatment of Carcinoma of the Cervix 525

posteriorly. In extending the excision of theparametrium backwards along the utero-sactalligaments, care must be taken not to damage theterminal branches of the superior haemorrhoida!artery since such an accident jeopardizes the bloodsupply to the bowel whereby a fistula may result.If anterior exenteration is to be performed, it issufficient to transplant the ureters into the sigmoidat the most convenient spot. The amount ofhyperchloraemic acidosis resulting from this pro-cedure can be easily controlled by simple alkalistaken by the patient when she feels off-colour,nauseated, thirsty, or has an unpleasant taste in themouth. An intelligent patient will soon know thewarning symptoms. Control of the anal sphincterand moderation of fluid intake should give thepatient an uninterrupted six to eight hours sleepand enable her to perform most social activities.

Total exenteration presents certain problemswhich must be solved if this operation is to surviveas a reasonable surgical procedure:

a. It is universally acknowledged that a wetcolostomy is unpleasant and often unmanageable.

b. The implantation of the ureters in the largebowel, as already pointed out, is fraught withgrave risk to the kidney from infection and obstruc-tion.

c. The electrolyte disturbance from the selectiveabsorption of chloride from the bowel urine isupsetting and unpleasant to the patient and mayprove a danger. It is, therefore, suggested that aseparate artificial bladder made from an isolatedloop of terminal ileum, one end of which is closedand the other brought out in the right lower quad-rant as a permanent ileostomy, should be imployed.Clean urine can thus be collected, uncontaminatedwith faeces, in a separate bag while an ordinary

colostomy in the left side of the abdomen can betrained to operate regularly once every morning,thus causing the patient little or no disability. Thepresence of the ureter in an isolated loop of ileumuncontaminated by bowel contents should diminishthe risks cf infection to the kidney.There is one further danger of total exenteration

to the patient, namely, the raw area left by theextirpation of the pelvic viscera. Infection in thisraw area is unavoidable and the adhesion of coils ofsmall bowel to it provide a real danger of intestinalobstruction. It is suggested, therefore, by theauthor that a two-stage operation should be per-formed for total pelvic exenteration. In the firststage, the permanent colostomy is formed and theartificial bladder is established with implantationof both ureters into it. Some form of peritonealshelf should be constructed between these twoartificial stomata so that the small bowel is unableto prolapse into the pelvis. After a reasonable inter-val, the total exenteration can be completed as amore or less extra-peritoneal procedure, if neces-sary by a transverse sub-umbilical incision. Bythis method, it is hoped to eliminate the risks ofintestinal obstruction. This complication has toooften proved a real and, in some cases, lethaldanger to those cases in which total exenterationhas been performed.

REFERENCES1. KOTTMEIER, H. L. (I955), J. Obstet. and Gyn., Brit. Emp.,

62, 741.2. DOBBIE, B. M. W. (I955), J. Obstet. and Gyn., Brit. Emp.,

62, 765.3. SCHLINK, H. H. (1950), J. Obstet. and Gyn., Brit. Emp.,

57, 714.4. CURRIE, D. W. (1952), Proc. Roy. Soc. Med., 45, 327.5. GLUCKSMANN, A., and WAY, S. (1948), J. Obst. and Gyn.,

Brit. Emp., 55, 573.6. HOWKINS, J. (195I), Lancet, April 21, p. 872.7. CURRIE, D, W., Personal communication.

Continued from page 52I-7. A. Stallworthv, M.A., F.R.C.S., F.R.C.O.G., F.A.C.S.(Hon.)ultimate aim, however, should be to preventpelvic infection from occurring by the bettercontrol of pulmonary tuberculosis and theimmunization of infants exposed to infection.

BIBLIOGRAPHYASPLUND, J., and RYDEN, A. B. V. (1952), Acta. Obstet. Gynec.

Scand., 31, i86.BARNES, T. (I955), J. Obstet. Gynaec. Brit. Emp., 62, I62.EKENGREN, K. (1955), Acta. Radiol. Stockh. Suppl., 123.GREENHILL, J. P. (I94I), 'Year Book of Obstetrics and

Gynecology,' The Year Book Publishers, Chicago.GREENHILL, J. P. (1942), Ibid.HALBRECHT, I. (1947), Lancet ii, 947.JEDBERG, H. (1950), Acta. Obstet. Gynec. Scand., 31, Suppl. I.O'BRIEN, J. R., and LAWLOR, M. K. (I947), J. Obstet. Gynaec.

Brit. Emp., 54, 639.MAGNUSSON, W. (1945), Acta. Radiol. Stockh., 26, 264.

MORGAGNI, J. B. (I744). 'De Sedibus et Causis MorborumEpistola 38, No. 34. E. D. Radius.'

RABAU, E. et al. (1943), J. Amer. Med. Ass., 122, 8oi.RABAU, E. (1952), J. Obstet. Gynaec. Brit. Emp., 59, 743.SCHOCKAERT, J. A., and FERIN, J. (1939), Bull. Soc. Belg.

Gynec. Obstet., 15, 407.SHARMAN, A. (I947), Brit. med. J., ii, 83.STALLWORTHY, J. A. (1952), J. Obstet. Gynaec. Brit. Emp.,

59, 729.STALLWORTHY, J. A. (1954), Med. World, Vol. 80, 3, 258.STALLWORTHY, J. A. (I955), in Bourne, A. (Ed.), British

Gynaec. Practice, Heinemann, London, 530.

SUN, K. (1948), Amer. J. Obst. Gyn., 55, 953.SUTHERLAND, A. M. (1943), J. Obstet. Gynaec. Brit. Emp.,

50, i6i.SUTHERLAND, A. M. (1950), Lanc3t, ii, 742.SUTHERLAND, A. M. (1954), J. Obstet. Gynaec. Brit. Emp.,

61, 614.WILLIAMS, E. 0. (I955), Ibid., 62, 823.

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