title: Resection of the embryologically defined uterovaginal (Müllerian) compartment and pelvic control in patients with cervical cancer: a prospective analysis.
abstract: BACKGROUND
  Radical hysterectomy based on empirical surgical anatomy to achieve a wide tumour resection is currently applied to treat early cervical cancer. Total mesometrial resection (TMMR) removes the embryologically defined uterovaginal (Müllerian) compartment except its distal part. Non-Müllerian paracervical and paravaginal tissues may remain in situ despite their possible close proximity to the tumour. We propose that in patients with early cervical cancer, the resection of the Müllerian compartment will lead to maximum local tumour control with low morbidity. We also propose that the relatively high rate of pelvic failure after conventional radical hysterectomy, despite adjuvant radiation, might be a consequence of the incomplete removal of the Müllerian compartment. The aim of our study was to test these hypotheses.
  
  
  METHODS
  We did a prospective trial to assess the effectiveness of TMMR without adjuvant radiation in patients with International Federation of Gynecology and Obstetrics (FIGO) stage IB, IIA, and selected IIB cervical cancer. We also generated MRI-based pelvic relapse landscapes from patients who had experienced pelvic failure after conventional radical hysterectomy.
  
  
  RESULTS
  212 consecutive patients underwent TMMR without adjuvant radiation. 134 patients (63%) had high-risk histopathological factors. At a median follow-up of 41 months (5-110), three patients developed pelvic recurrences, two patients developed pelvic and distant recurrences, and five patients developed distant recurrences. Recurrence-free and overall 5-year survival probabilities were 94% (95% CI 91-98) and 96% (93-99), respectively. Treatment-related grade 2 morbidity was detected in 20 (9%) patients, the most common being vascular complications. Resection of the Müllerian compartment resulted in local tumour control irrespective of the metric extension of the resection margins. The pelvic topography of the peak relapse probability after conventional radical hysterectomy indicates an incomplete resection of the posterior subperitoneal and retroperitoneal extension of the Müllerian compartment.
  
  
  CONCLUSIONS
  Resection of the embryologically defined uterovaginal compartment seems to be pivotal for pelvic control in patients with cervical cancer. TMMR without adjuvant radiation has great potential to improve the effectiveness of surgical treatment of early-stage cervical cancer.
  
  
  BACKGROUND
  University of Leipzig, Leipzig, Germany.
authors.affiliation: Department of Obstetrics and Gynecology, University of Leipzig, Leipzig, Germany. michael.hoeckel@uniklinik-leipzig.de
authors.forename: Michael
authors.initials: M
authors.lastname: Höckel
authors.forename: Lars-Christian
authors.initials: LC
authors.lastname: Horn
authors.forename: Norma
authors.initials: N
authors.lastname: Manthey
authors.forename: Ulf-Dietrich
authors.initials: UD
authors.lastname: Braumann
authors.forename: Ulrich
authors.initials: U
authors.lastname: Wolf
authors.forename: Gero
authors.initials: G
authors.lastname: Teichmann
authors.forename: Katrin
authors.initials: K
authors.lastname: Frauenschläger
authors.forename: Nadja
authors.initials: N
authors.lastname: Dornhöfer
authors.forename: Jens
authors.initials: J
authors.lastname: Einenkel
mesh_terms: D000328:Adult; D000368:Aged; D018572:Disease-Free Survival; D005260:Female; D006801:Humans; D007044:Hysterectomy / Q000379:methods*; D008197:Lymph Node Excision / Q000379:methods; D008875:Middle Aged; D009095:Mullerian Ducts; D009364:Neoplasm Recurrence, Local / Q000517:prevention & control*; D011446:Prospective Studies; D002583:Uterine Cervical Neoplasms / Q000473:pathology / Q000601:surgery*; D014599:Uterus / Q000196:embryology; D014621:Vagina / Q000196:embryology