Introduction/Background Occult discovery of invasive cervical cancer discovered after hysterectomy for non-malignant tumors is not uncommon. For patients presenting an incidental diagnosis of early stage invasive cervical cancer (FIGO Stages IA1-IB2), two possible strategies can be proposed: Adjuvant radiation Therapy with no tumor target or Radical Parametrectomy (RP) associated with upper vaginectomy and pelvic lymph node dissection.

Methodology The procedure starts by incising the peritoneum on the lateral pelvic sidewall. Dissection is proceeded from the round ligament stump towards the ligated infundibulo-pelvic pedicle stump, followed by the development of the retroperitoneal space with the identification of the umbilical artery, the iliac vessels and laterally the psoas muscle with the genito-femoral nerve. Paravesical and pararectal spaces are developed down to the pelvic floor. A radical pelvic lymphadenectomy is performed bilaterally. Once lymph node involvement is excluded, we proceed to parametrectomy.

Radical parametrectomy is started with the dissection from the posterior leaf of the broad ligament. The anterior division of the internal iliac artery (IIA) is identified and the uterine artery and vein are transected proximally at their origin using a vascular sealing system or Hem-O-Lok clips. The ureters are then mobilized from their attachments and separated from the medial leaf of the peritoneum down to the ureteral tunnel below the uterine artery and to their entrance into the bladder. Aided by the vaginal probe, the bladder peritoneum is incised, and the bladder is dissected and mobilized inferiorly down to the middle third of the vagina. After dissection of the bladder pillar, the vesico-vaginal space is joined to the paravesical space, completely separating the bladder from the anterior vaginal wall. In cases of anatomical distortion or bladder adhesions, instillation of 300cc of saline solution associated with Methylene blue dye in the bladder might be required to guide the dissection. Posteriorly, the peritoneum is incised at the level of the cul-de-sac of Douglas and the rectovaginal space is developed isolating the uterosacral ligaments. The proximal parametrium and para-vaginal tissues are finally dissected as in a Type B1 Querleu Morrow radical hysterectomy.

The same procedure is performed on both sides. A circular incision is made about 3 cm below the vaginal cuff aided by upward vaginal traction.

Results When compared to Radiation therapy RP presents a lower rate of late complications, making it the preferred approach to treat younger patients. Traditionally performed via laparotomy, minimally invasive approach is now proven feasible and effective.

Conclusion This article presents a focused anatomic review and describes the surgical technique of the five-port robotic assisted radical parametrectomy.

Disclosures Eric Lambaudie and Gilles Houvenaeghle report grants and personal fees from Intuitive Surgical, outside the submitted work.

The other authors have no other conflicts of interest to declare.