Total mesometrial resection of the uterus

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The shot Mesometriale resection of the uterus (TMMR) is a 1998 by the German gynecologist Michael Höckel ( University of Leipzig developed) new surgical procedure for the surgical treatment of cervical cancer .

Problems of the previous standard therapy

The current standard therapy in the form of abdominal radical hysterectomy ( Wertheim-Meigs operation ), which was carried out for the first time in 1898 , is of course based on historical ideas about the anatomy of the female pelvis and the local tumor spread. Despite the radical nature of the operation, many patients with histopathologically proven risk factors require additional radiation therapy or chemoradiotherapy after the operation . Nevertheless, a locoregional recurrence rate of 10 to 15 percent can be expected. The rate of treatment- related moderate and severe morbidity is high at 30 percent, since in surgical anatomy the autonomic pelvic nerves are ignored and the boundaries to the rectum and urinary bladder compartments are not clearly defined.

concept

Total mesometrial resection (TMMR) is based on a new oncological radicality principle on a developmental basis: the resection of a malignant tumor within the limits of the morphogenetic unit of its origin. The uterovaginal morphogenetic unit relevant for the local spread of the cervical carcinoma can be derived from the embryonic development . Anatomical structures that do not belong to this unit can be preserved despite the spatial proximity to the tumor . In combination with a nerve-sparing lymphadenectomy , the TMMR can achieve a very high freedom from locoregional recurrences with comparatively low treatment-related morbidity without additional radiation therapy. Therefore, the TMMR could replace the previous standard therapy in the near future. The possibility of doing without radiation therapy, which is otherwise necessary for up to 73 percent of patients, also offers women in developing countries a chance of recovery.

The total mesometrial resection consists of the

  • en bloc resection of the uterus, the upper part of the vagina and mesometrium as an evolutionarily defined unit
  • Removal of the rectouterine subperitoneal connective tissue up to the inferior hypogastric plexus
  • extensive pelvic / para-aortic lymph node removal under protection of the superior hypogastric plexus

In 2012 it was published that the surgical method can also be performed using a laparoscopy .

Results

The first results of a smaller study were that the local tumor control with 95 percent is above that of the standard treatment of 80 to 85 percent with a moderate and severe morbidity of only 9 percent (standard 25 to 30 percent). The latter is made possible by maintaining the urinary bladder mesos , the mesorectum and the autonomic nerve supply of the urinary bladder , residual sheath and rectum . A current prospective study on the effectiveness of TMMR without radiation after surgery in 212 patients with cervical cancer of the stages FIGO IB, IIA and selected IIB from 1998 to 2008 showed the following results: 134 of the patients (63 percent) had histopathological high-risk factors. With a median follow-up time of 41 months (5 to 110 months), three patients developed a pelvic recurrence , two a pelvic recurrence and distant metastases , and five women developed distant metastases. The recurrence-free interval and 5-year survival rate were 94 percent (95 percent CI 91 to 98) and 96 percent (93 to 99), respectively. The 5-year survival rate for patients with lymph node involvement was 91 percent, compared to 68 to 78 percent for conventional surgery.

Criticisms

Total mesometrial resection is a promising option, but it has not yet been investigated in prospective randomized or multicenter studies for morbidity and mortality. However, a prospective multicenter registry study on morbidity and locoregional control is in preparation.

See also

Web links

Individual evidence

  1. ↑ M. Höckel, N. Dornhöfer: The Hydra phenomenon of cancer: Why tumors recur locally after microscopically complete resection. Cancer Res, 65: pp. 2997-3002, 2005 PMID 15833823
  2. ↑ M. Höckel: Total Mesometrial Resection: A New Radicality Principle in the Surgical Therapy of Cervical Carcinoma. Oncologist 12: pp. 901-907, 2006, doi : 10.1007 / s00761-006-1110-y
  3. ↑ M. Höckel: Total Mesometrial Resection (TMMR): Surgical therapy of cervical cancer on the basis of a surgical anatomy derived from embryonic and fetal development. GebFra 62, pp. 1146-1152, 2003 doi : 10.1055 / s-2003-43458
  4. ↑ M. Höckel, L.-C. Horn, B. Hentschel, S. Höckel, G. Naumann: Total mesometrial resection: High resolution nerve-sparing radical hysterectomy based on developmentally defined surgical anatomy. Int J Gynecol Cancer 13: pp. 791-803, 2003 PMID 14675316
  5. ^ C. Böing, R. Kimmig: Stage-adapted treatment of cervical carcinoma. MMW Fortschr Med 12, pp. 32-34, 2007 PMID 17674888
  6. ↑ M. Candelaria et al .: Radiation-sparing managements for cervical cancer: a developing countries perspective. In: World Journal of Surgery 4: p. 77, 2006 PMID 17101048
  7. ^ A b Rainer Kimmig: "Robotic surgery" for cervical carcinoma. Endoscopic total mesometrial resection and therapeutic lymphadenectomy. Gynecologist 45 (2012), 707-713, doi : 10.1007 / s00129-012-3045-2
  8. ↑ M. Höckel: Total Mesometrial Resection (TMMR). Gynecologist 41 (5) 2008: 361-368 doi : 10.1007 / s00129-008-2133-9
  9. ↑ M. Höckel, L.-C. Horn, H. Fritsch: Association between the mesenchymal compartment of uterovaginal organogenesis and local tumor spread in stage IB-IIB cervical carcinoma: a prospective study. Lancet Oncol, 6: 751-56, 2005 PMID 16198980
  10. ↑ M. Höckel, LC Horn, N. Manthey, UD Braumann, U. Wolf, G. Teichmann, K. Frauenschläger, N. Dornhöfer, J. Einenkel: Resection of the embryologically defined uterovaginal (Müllerian) compartment and pelvic control in patients with cervical cancer: a prospective analysis. Lancet Oncology, Early Online Publication, June 1, 2009, doi : 10.1016 / S1470-2045 (09) 70100-7
  11. ↑ a b BBC Health News: Cervical cancer 'surgery boost'. June 1, 2009 online
  12. ^ MW Beckmann, S. Ackermann: Closing words (discussion). Deutsches Ärzteblatt 102, A3351, 2005 pdf