Surgical Procedures
- After general anesthesia with tracheal intubation, the patient was placed in the lithotomy position, and bilateral pelvic lymph node dissection was performed first.
- Dissect the vesicocervical and vesicovaginal spaces, and push the bladder downward.
- Dissect and free the uterine artery, ligate and cut it near the internal iliac artery; dissect and free the deep uterine vein followed by transection.
- Dissect the pararectal space, free the lower segment of the ureter, separate the anterior and posterior lobes of the vesicocervical ligament, and fully mobilize the ureter.
- Dissect the pararectal space and cut the uterosacral ligaments.
- Resect the cardinal ligaments, parametrial and paravaginal tissues.
- Ligatethe lower cervix with gauze strip following the no-tumor principle, and transect the vagina approximately 2 cm below the cervix.
Suture the vaginal stump.
Key Surgical Points
- Ensure sufficient width and depth when dissecting each anatomical space, and avoid injury to the bladder and rectum during dissection.
- When dissecting the vesicocervical ligament ("tunneling"), ligate or occlude small blood vessels supplying the ureter to prevent hemorrhage and ureteral injury.
Adopt a uterine manipulator-free technique; occlude the vagina below the cervix before vaginal resection and strictly adhere to the no-tumor principle.
Medical History Overview
Basic Information
Patient, 51 years old.
Chief Complaint
Postcoital bleeding once, cervical lesion detected for 2 days.
Past History & Marital and Childbearing History
History of hypertension for more than 5 years with long-term oral antihypertensive medication; current general condition is stable.Gravida 4, Para 2: 2 full-term vaginal deliveries and 2 induced abortions. Spouse and children are in good health.
Special Gynecological Examination
Normal vulvar development, unobstructed vagina; cervical hypertrophy with erosive lesion on the anterior lip, measuring about 4cm×3.5cm, hard in texture and prone to contact bleeding. No abnormal mass palpable in the parametrium; uterus anteverted, enlarged equivalent to 40+ days of gestation without tenderness; no obvious abnormality palpated in bilateral adnexal areas.Rectovaginal examination: smooth rectal mucosa, soft parametrium without thickening or stenosis.
Auxiliary Examinations
Outpatient vaginal discharge test, HPV and TCT showed no abnormalities.Further examinations completed after admission. Pelvic ultrasound on April 15, 2025: abnormal hypoechoic mass in the uterine wall suggestive of uterine leiomyoma (49mm×38mm, FIGO type 4, 5, 6); abnormal hypoechoic mass on the anterior cervical lip (23mm×15mm), suspected uterine leiomyoma.HPV test: 2 high-risk types 153.61, 12 high-risk types 1.28; LCT examination showed a large number of atypical cells, squamous cell carcinoma could not be excluded.Colposcopy-guided biopsy was performed, and postoperative pathological examination confirmed malignant tumor of cervical tissue.
Enhanced spiral CT plain scan + three-dimensional reconstruction of upper abdomen, lower abdomen and pelvis, plus plain spiral CT scan of chest:
- Abnormal enhanced lesion of the cervix, MRI examination recommended; multiple uterine leiomyomas.
- Mild fatty liver; scattered hepatic islands in the liver.
- Multiple small pulmonary nodules in both lungs; right pleural thickening.
- Lesion changes in the left lobe of the thyroid gland on scanning, correlation with ultrasound is recommended.
- Thoracolumbar hyperosteogeny.
Arteriovenous ultrasound of both lower extremities and cardiac ultrasound: left atrial enlargement, interventricular septal thickening, suggestive of hypertensive changes; mild mitral insufficiency, mild tricuspid insufficiency, mild pulmonary hypertension; decreased left ventricular diastolic function; arteriosclerosis of both lower extremities; unobstructed venous blood flow of both lower extremities.
Pelvic MRI: Multiple round abnormal signal shadows of varying sizes seen in the myometrium of the uterus, some protruding outside the uterine contour; the largest located at the uterine fundus, about 46mm×44mm×43mm with non-enhanced area. The junctional zone was relatively continuous, the endometrium was smooth without abnormal signal shadows; several small cystic slightly long T1 and long T2 signal shadows in the cervical area, the largest diameter about 13mm with clear boundary and no enhancement on contrast scan. Mass-like iso-T1 and long T2 signal shadows on the anterior and posterior lips of the external cervical os extending down to the upper 1/3 of the vagina, with a scope of about 23mm×20mm×21mm, high signal on DWI and low signal on ADC, obvious enhancement on contrast scan with relatively clear edge. Bilateral ovaries showed normal morphology and signal. A small amount of fluid signal in the rectouterine pouch; no definite enlarged lymph nodes in the pelvic cavity.Squamous cell carcinoma-associated antigen: 1.7ng/ml; other auxiliary examinations showed no significant abnormalities.
Admission Diagnosis
- Stage IB2 cervical cancer
- Multiple uterine leiomyomas
- Cervical human papillomavirus infection
- Grade 3 hypertension
- Fatty liver
Surgical Method
On April 30, 2025, under general tracheal intubation anesthesia, the patient underwent laparoscopic radical total hysterectomy + bilateral pelvic lymph node dissection + bilateral adnexectomy.
Postoperative Pathology
- Total uterus and uterine leiomyoma specimens:① Moderately differentiated HPV-related ulcerative cervical squamous cell carcinoma, tumor size about 2.5cm×2.5cm×1cm, invading the middle cervical stroma (1/3~2/3 layer). Vascular tumor thrombus was visible; no definite nerve bundle invasion was found. The lesion did not involve the lower uterine segment and vaginal fornix. No tumor involvement was observed in the vaginal wall resection margin and bilateral parametrial soft tissues.
Immunohistochemistry (Specimen No.72#): CK5/6(+), P63(+), P40(+), P53 (wild-type expression), Ki67 (approximately 60% positive in hot spot area), P16(+), EGFR(+), Syn(-), CK7 (partial positive), PAX-8(-), CD34 (vascular positive), D2-40 (lymphatic vessel positive), S-100 (nerve bundle positive).
② Multiple uterine leiomyomas with partial hyaline degeneration.③ Endometrium in proliferative phase.
- No metastasis detected in all resected lymph nodes:Left common iliac lymph node 0/5, left external iliac lymph node 0/5, left internal iliac lymph node 0/4, left obturator lymph node 0/6, left deep inguinal lymph node 0/16; right common iliac lymph node 0/5, right external iliac lymph node 0/2, right internal iliac lymph node 0/3, right obturator lymph node 0/6, right deep inguinal lymph node 0/4.
- Bilateral adnexal specimens: Chronic inflammatory changes in bilateral fallopian tubes; no obvious abnormality in bilateral ovaries.
- Pathological stage of this case: pT1b2N0Mx.
Surgeon Profile
Chen Yuanhong
Director & Chief Physician, Department of Gynecology, Dongguan Eastern Central Hospital (The Sixth Affiliated Hospital of Jinan University)Professional Master’s Supervisor in Gynecology, Jinan UniversitySelected into the first batch of 2024 "Dongguan Famous Doctor" Talent Introduction and Training ProgramExcellent Medical Educator of Jinan UniversityKey Medical Discipline Backbone of Dongguan Public Hospitals
Vice President, 1st Committee of Intelligent Eugenics and Eugenic Branch, Guangdong Health Information Network AssociationStanding Committee Member, 1st & 2nd Reproductive Gynecology Committee, Guangdong Primary Medicine AssociationStanding Committee Member, 1st Gynecology Committee, Guangdong Primary Medicine AssociationStanding Committee Member, Osteoporosis Management Branch, Guangdong Medical Industry Association (1st & 2nd Session)Standing Committee Member, Obstetrics and Gynecology Branch of Medical Community Branch, Guangdong Health Economics AssociationStanding Committee Member, Obstetrics and Gynecology Branch, Guangdong Health Economics AssociationStanding Committee Member, 1st Reproductive Health Branch, Guangdong Health Care AssociationStanding Committee Member, 1st Robotic Gynecologic Oncology Committee, Guangdong Geriatric Health AssociationStanding Committee Member, 1st Obstetrics and Gynecology Electrophysiology Committee, Dongguan Medical AssociationMember, 1st Gynecologic Oncology Branch, Guangdong Urology and Reproductive AssociationMember, 1st Gynecologic Oncologist Branch, Guangdong Medical Doctor AssociationMember, Reproductive Medicine Committee, Dongguan Medical AssociationMember, 2nd Female Reproductive Plastic Surgery Branch, Guangdong Association of Plastic SurgeryMember, 3rd & 4th Obstetrics and Gynecology Committee, Dongguan Medical Association
Young and Middle-aged Editorial Board Member, Journal of Practical Gynecologic EndocrinologyReview Expert, China Contemporary Medicine
Graduated from Shantou University Medical College, engaged in clinical practice, scientific research and teaching of obstetrics and gynecology for over 20 years. Presided over multiple provincial and municipal scientific research projects; published 3 SCI papers and more than 10 core journal papers.Received advanced training in gynecologic oncology and endocrinology at the Second Affiliated Hospital of Sun Yat-sen University, and gynecological laparoscopy at the First Affiliated Hospital of Sun Yat-sen University.Proficient in diagnosis and treatment of various obstetric and gynecological diseases; rich clinical experience in gynecologic oncology, pelvic floor disorders, endocrine diseases, infertility and recurrent miscarriage; specialized in laparoscopic, hysteroscopic and transvaginal gynecological surgeries.
Editor-in-Charge:
QinghuanReviewer: Ma Ye
