保留宫颈癌患者生育功能的腹式根治性宫颈切除术五例报告

为了探讨对欲保留器官、生育功能的早期宫颈癌患者实施腹式根治性宫颈切除术的可行性和安全性,对5例要求保留器官、生育功能的早期宫颈癌患者(ⅠA期3例,ⅠB期2例)计划实施腹式根治性宫颈切除术。5例患者均成功实施根治性宫颈切除术,其中1例因术中快速冰冻切片病理检查发现病灶上缘距宫颈断端2mm,而补行子宫体切除。平均手术时间202min(180～230min),术中平均出血325mL(150～650mL),术中、术后无并发症。随访3～13个月,无复发,4例患者术后月经均正常。2例欲妊娠的患者中,1例已成功妊娠,现孕33周,产科检查无异常。初步研究结果提示,严格掌握手术适应证,对欲保留器官、生育功能的早期宫颈癌患者,腹式根治性宫颈切除术是一种安全、可行的新术式。     

保留宫颈癌患者生育功能的腹式根治性宫颈切除术五例报告

为了探讨对欲保留器官、生育功能的早期宫颈癌患者实施腹式根治性宫颈切除术的可行性和安全性，对5例要求保留器官、生育功能的早期宫颈癌患者（ⅠA期3例，ⅠB期2例）计划实施腹式根治性宫颈切除术。5例患者均成功实施根治性宫颈切除术，其中1例因术中快速冰冻切片病理检查发现病灶上缘距宫颈断端2mm，而补行子宫体切除。平均手术时间202min（180～230min），术中平均出血325mL（150～650mL），术中、术后无并发症。随访3～13个月，无复发，4例患者术后月经均正常。2例欲妊娠的患者中，1例已成功妊娠，现孕33周，产科检查无异常。初步研究结果提示，严格掌握手术适应证，对欲保留器官、生育功能的早期宫颈癌患者，腹式根治性宫颈切除术是一种安全、可行的新术式。     

经腹筋膜外宫颈切除术32例临床分析

为了探讨经腹筋膜外宫颈切除术的临床意义及价值,回顾分析因宫颈上皮内瘤变(CIN)Ⅲ和Ⅰ A1期宫颈鳞癌行经腹筋膜外宫颈切除术的32例患者的临床资料.结果显示,32例患者的平均手术时间80.0 min(65～l10 min),平均出血量90.5 mL(50～180 mL),术后肠功能恢复时间28 h(22～36 h),住院时间7 d(5～10 d).切除宫颈病理显示,切缘均未查见CIN及癌灶.术中膀胱损伤1例(3.1％),因出血结扎一侧子宫动脉1例(3.1％),术后官颈残端粘连1例(3.1％).患者均成功保留子官体,随诊中未发现复发者.初步研究结果表明,经腹筋膜外宫颈切除术既可完整切除宫颈病变,又可保留子宫体,是已完成生育但要求保留子宫的年轻的CINⅢ和Ⅰ A1期宫颈癌的一种安全有效术式.     

根治性宫颈切除治疗早期宫颈癌临床价值的循证评价

目的系统评价根治性宫颈切除术治疗早期宫颈癌的安全性及保留生育功能的可行性。方法 我们系统检索PubMed、Embase、Cochrane Library以及中文全文数据库,对2000年1月至2009年12月国内外公开发表的所有有关根治性宫颈切除术治疗早期宫颈癌的文献进行回顾,对符合纳入标准的临床对照试验,采用Stata 9.2软件进行Meta分析,对无对照的临床研究则采用描述性分析,主要评价指标为生存率。结果 共纳入4篇根治性宫颈切除术和根治性全子宫切除术治疗早期宫颈癌生存率比较的临床对照试验和17篇无对照的临床研究,结果显示,根治性宫颈切除术和根治性全子宫切除术治疗早期宫颈癌的生存率差异无统计学意义,根治性宫颈切除术术后总妊娠率为47%。结论 宫颈根治切除术不会降低早期宫颈癌患者术后生存时间,不增加术后复发率,且能维持正常的妊娠及生育功能,提高患者生存质量,因而是安全可行的,但需要更多高质量的临床随机对照试验进一步验证。     

宫颈癌保留生育功能的腹式根治性宫颈切除术——一项潜在获益人群的研究

背景与目的:宫颈癌仍是全球妇科恶性肿瘤患者的主要死因,目前国内开展根治性宫颈切除术(radical trachelectomy,RT)手术的医院较少。本研究旨在探讨早期宫颈癌患者中,适合行保留生育功能的腹式根治性宫颈切除术(abdominal radical trachelectomy,ART)的患者比例。方法:回顾性地分析了2000年1月—2007年12月,腹式根治性宫颈切除术尚未在复旦大学附属肿瘤医院广泛开展前,因浸润性宫颈癌在本院行根治性子宫切除术的患者病历。根据行根治性宫颈切除术患者的指征,研究适合行ART的潜在患者人群。结果:经筛选,2000年1月—2007年12月期间共有3 220例患者因为浸润性宫颈癌行根治性子宫切除术。其中1 638例患者年龄≤45岁。根据复旦大学附属肿瘤医院行根治性宫颈切除术的标准,653例(39.87%)患者初步符合行ART的FIGO分期、肿瘤大小和病理类型的标准,但其中49例患者最终因肿瘤播散而放弃保留生育功能的手术。本研究最终确定604例(36.87%)患者可能适合接受ART手术。结论:在年龄≤45岁的宫颈癌患者中,有一定比例的人群符合ART的指征。对这部分患者,如能在术前充分告知患者手术的风险和获益,将有可能接受ART,在治疗肿瘤的同时保留生育功能。     

宫颈癌筛查方式该怎么选

????我们最近发表的一篇重要文献中，将我院在2004—2014年完成的100多例保留生育功能的经腹根治性宫颈切除术与同期开展的根治性子宫切除术不保留生育功能的患者比较，生存率和复发率都是相等的。而且保留生育功能的患者会更加注重随访，由于我们随访密切，术后更加注意辅助治疗，其预后甚至比不保留生育功能的患者还要好。因此，我们可以得出这样的结论：只要是适合的人群，接受合适的手术步骤（该术式对医生的手术技巧要求较高），在术前评估、术中冰冻切片淋巴结安全性评估，术后的随访及辅助治疗等方面都做到充分的考虑和实施，都能获得比较好的结果，这一点同样也已经被美国NCCN指南接受。     

次全子宫切除两种手术方式的临床研究

目的:比较腹式次全子宫切除术和腹腔镜次全子宫切除术两种手术方式的术式选择及临床效果。方法:回顾性分析九江市妇幼保健院2009年1月-2012年12月收治的100例子宫良性病变（子宫肌瘤35例、子宫腺肌症42例、子宫内膜复杂性增生17例、功能失调性子宫出血6例）行手术治疗患者的临床资料,其中36例行腹式次全子宫切除术,64例行腹腔镜下次全子宫切除术,比较两组手术时间、术中出血量、术后肛门排气时间,评价术后性生活满意程度。结果:两组术后肛门排气时间、术中出血量、术后性生活满意程度比较差异有统计学意义（P<0.05）,手术时间比较两组无明显差异（P>0.05）。结论:腹腔镜下次全子宫切除术能减少术中出血量、术后恢复快,适用于宫颈无恶性病变的患者。     

保留盆腔神经丛腹腔镜宫颈癌根治术的临床疗效观察

目的探讨腹腔镜下保留盆腔自主神经的根治性子宫切除术治疗宫颈癌的临床效果。方法选取重庆市万州区人民医院2015年1月至2017年10月收治的50例子宫颈癌患者,采用数字表法随机分为腹腔镜下保留盆腔神经丛的根治性子宫切除术治疗组（LNSRH组）和腹腔镜广泛子宫切除术治疗组（LRH组）,每组各25例,比较两组患者的手术效果。结果50例患者手术全部成功,两组患者术中及术后均未出现严重并发症,LNSRH组患者的术中出血量、留置尿管时间、术后排气时间以及术后排便时间均少于LRH组患者,差异均有统计学意义（均P＜0.05）。结论腹腔镜下保留盆腔自主神经根治性子宫切除术治疗早期宫颈癌安全可行,相对腹腔镜广泛子宫切除术能明显提高术后生活质量。     

经腹根治性宫颈切除术治疗早期宫颈癌5例暨妊娠分娩1例报告

目的探讨经腹根治性子宫颈切除术治疗有生育欲望的早期浸润性子宫颈癌患者的可行性与安全性。方法2004年4月～2005年3月，对3例Ⅰa期和2例Ⅰb期子宫颈癌患者行经腹根治性子宫颈切除术。结果5例患者均成功施术，其中1例因术中冷冻切片检查发现癌灶距宫颈切缘仅2mm，且已切除全部宫颈，遂补行子宫体切除术；1例术后病理检查发现脉管内癌栓而术后辅助行TP方案化疗2个周期。平均手术时间为202min（180～230min），术中平均出血量为325ml（150～650ml），术中、术后无并发症。随访12～22月，无肿瘤复发，4例患者月经正常，1例妊娠36^＋ 5周者经剖宫产术娩出一健康女婴，现母婴均健康。结论只要严格掌握适应证，经腹根治性子宫颈切除术治疗有生育欲望的早期浸润性子宫颈癌患者是安全、可行的。     

保留生育功能的宫颈根治术8例临床分析

目的:探讨保留生育功能的根治性宫颈切除术在早期宫颈癌治疗中的可行性及临床疗效。方法:对2006年4月至2011年12月,8例Ⅰa1-Ⅰb2期宫颈癌患者,施行根治性宫颈切除术,术后随访其生存及生育情况。结果:平均手术时间3.5小时(3-5小时),术中平均出血量420ml(300-550ml),术后1月内恢复正常月经,术后5例发生淋巴囊肿。术后平均随访44.87个月(23-67个月),Ⅰb2期1例术后2年死亡,7例Ⅰa1-Ⅰb1期患者生存至今,其中1例成功受孕并生育。结论:对Ⅰa1-Ⅰb1期年轻宫颈癌患者,行保留生育功能的手术是可行的。对Ⅰb2期及以上患者,应视为RVT的相对禁忌证,部分可经医疗矫正的生殖问题并非RT绝对禁忌证。     

早期宫颈癌广泛性宫颈切除术研究进展

目的:总结国内外关于年轻、早期宫颈癌患者的治疗现状,探讨广泛性宫颈切除术(RT)在早期宫颈癌患者保留生殖生理功能中的应用价值。方法:应用Medline及CNKI全文数据库检索系统,以"早期宫颈癌、广泛性宫颈切除、保留生殖生理功能"等为关键词,检索1994-01-2011-01的相关文献共100篇。纳入标准:1)RT在早期宫颈癌治疗中的应用;2)宫颈粘连狭窄的防治;3)盆底功能重建。根据纳入标准符合分析的文献16篇。结果:RT能达到与广泛性子宫切除术(RH)同样的治疗效果,两者术后并发症与复发率无明显差异,术中应重视宫颈机能不全及子宫脱垂的防治,提高术后生活质量。结论:合理掌握手术指证,对早期宫颈癌实施保留子宫体的治疗是安全的。     

Cytologic findings after fertility-sparing radical trachelectomy

BACKGROUND: Radical trachelectomy is a surgical procedure intended to preserve fertility in patients with early-stage cervical carcinoma in which the cervix is amputated in continuity with the parametrium and upper vagina, thereby sparing the uterus and adnexa. Follow-up is performed with periodic cytology specimens. The objective of the current study was to analyze the cytologic findings after this novel procedure. METHODS: Isthmic and vaginal Papanicolaou-stained ThinPrep cytology specimens taken from patients after radical vaginal and abdominal trachelectomy were reviewed. The specimens were also analyzed for the presence of benign endocervical cells, lower uterine segment glandular cells, endometrial stromal cells, and endometrial cells. The findings were correlated with the original diagnosis and follow-up, which included subsequent cytology specimens and biopsies. RESULTS: Cytology specimens (n = 223) from 44 patients were included in this study. An endometrial component was identified in 131 of the cases (59%). Twenty-eight cases were diagnosed as abnormal in the original cytology examination. Twenty of these cases and 5 additional cases that were diagnosed cytologically as benign had subsequent biopsies. The biopsies confirmed the presence of a lesion in only 4 of 25 biopsies (3 low-grade squamous intraepithelial lesions and 1 adenosquamous carcinoma). All cases diagnosed as atypical glandular cells represented tubal metaplasia, lower uterine segment glandular cells, or endometrial stromal cells. CONCLUSIONS: Cytology specimens after trachelectomy frequently contain glandular cells from the lower uterine segment epithelium or endometrial stromal cells, which can lead to a misdiagnosis of atypical glandular cells of undetermined significance. Tubal metaplasia is also a potential pitfall in these specimens. Pathologists and gynecologic oncologists should be aware of the potential pitfalls in the surveillance of smears after trachelectomy.     

Advances in fertility-sparing surgery for cervical cancer

This article reviews the literature on fertility-sparing surgery in early cervical cancer. The article evaluates selection criteria, preoperative management and the most frequent surgical procedures used for preservation of fertility in cervical cancer. The article also analyzes oncological, fertility and pregnancy results. Oncological outcomes are not statistically different among single groups (vaginal radical trachelectomy, abdominal radical trachelectomy, simple trachelectomy or cone with or without neoadjuvant chemotherapy). Oncological results after fertility-sparing procedures in women with tumors smaller than 2 cm are comparable with women with the same risk factors after radical hysterectomy. Pregnancy following fertility-sparing surgery is associated with a variety of adverse pregnancy outcomes, especially second-trimester loss and preterm delivery. Less radical procedures (simple trachelectomy or cone with or without neoadjuvant chemotherapy) show statistically significant better pregnancy results. The pregnancy rate after abdominal radical trachelectomy was dramatically lower than in women treated with other types of fertility-sparing surgery. In the future, it will be necessary to optimize the technique and management of fertility-sparing surgery in order to attain good oncological results. Pregnancy outcomes should be given high priority. Fertility-sparing surgery is valuable for women who want to preserve their reproductive capability.     

Conservative Treatment in Young Patients with CervicalCancer: A Review

For cervical cancer cases with a low risk of relapse who wish to maintain their fertility, radical trachelectomyis an alternative to radical hysterectomy. Pelvic magnetic resonance imaging is recommended before surgery,with laparoscopic assisted lymphatic dissection required for assessment of lymphatic metastasis. If there is avisible lesion in the cervix, the specimen taken during trachelectomy should be sent for frozen section. Thecomplications of radical trachelectomy are chronic vaginal discharge, irregular vaginal bleeding, dysmenorrhea,ulceration, amenorrhea and cervical stenosis. The probability of cervical cancer recurrence with a lesion ofsimilar size is comparable with radical trechelectomy and radical hysterectomy. Two thirds of pregnancies aftertrachelectomy lead to live births of which approximately 40% of them are healthy. However, the probability ofsecond trimester abortion and pre-term labor is greater than in the general population. Because of the possibilityof uterine arterial injury in short cervix, vaginal delivery should be avoided and a cesarean operation in 37-38thweek is recommended. Adjuvant treatment with chemotherapy followed by radical trachelectomy is a suitableoption for larger lesions. On the other hand, conization or simple trachelectomy are more proper approachesfor very small lesions.     

First case of vaginal radical trachelectomy in a pregnant Japanese woman

A diagnosis of cervical cancer during pregnancy poses difficult management and ethical problems. Survival of the patient is the foremost concern, but fetal viability and well-being must also be addressed. Radical trachelectomy (RT) has recently begun to be performed as a possible treatment modality for early stage invasive uterine cervical cancer in pregnant patients who would like to continue their pregnancy. A 32-year-old Japanese woman visited a local hospital for prenatal care, and was diagnosed with a FIGO I B1 adenocarcinoma of the uterine cervix. She had a strong desire to avoid pregnancy termination, so she was admitted to our hospital for fertility-preserving surgery. After extensive counseling, vaginal radical trachelectomy with abdominal pelvic lymphadenectomy was performed in the 16th gestational week. The excised uterine cervix and lymph nodes were pathologically negative for cancer. To maintain her pregnancy, daily vaginal disinfection with povidone iodine, bed rest, and administration of ritodrine and an ulinastatin vaginal suppository were continued until the delivery. At 34 weeks' gestation, an emergency cesarean section was performed because of sudden premature rupture of the membranes. A baby girl was born weighing 2112 g, with Apgar score of 8/9. The mother remains without evidence of recurrence at the time of this report. This is the first case of successful pregnancy and delivery in Japan after vaginal RT.     

Cytologic findings after fertility‐sparing radical trachelectomy

BACKGROUND.

Radical trachelectomy is a surgical procedure intended to preserve fertility in patients with early‐stage cervical carcinoma in which the cervix is amputated in continuity with the parametrium and upper vagina, thereby sparing the uterus and adnexa. Follow‐up is performed with periodic cytology specimens. The objective of the current study was to analyze the cytologic findings after this novel procedure.

METHODS.

Isthmic and vaginal Papanicolaou‐stained ThinPrep cytology specimens taken from patients after radical vaginal and abdominal trachelectomy were reviewed. The specimens were also analyzed for the presence of benign endocervical cells, lower uterine segment glandular cells, endometrial stromal cells, and endometrial cells. The findings were correlated with the original diagnosis and follow‐up, which included subsequent cytology specimens and biopsies.

RESULTS.

Cytology specimens (n = 223) from 44 patients were included in this study. An endometrial component was identified in 131 of the cases (59%). Twenty‐eight cases were diagnosed as abnormal in the original cytology examination. Twenty of these cases and 5 additional cases that were diagnosed cytologically as benign had subsequent biopsies. The biopsies confirmed the presence of a lesion in only 4 of 25 biopsies (3 low‐grade squamous intraepithelial lesions and 1 adenosquamous carcinoma). All cases diagnosed as atypical glandular cells represented tubal metaplasia, lower uterine segment glandular cells, or endometrial stromal cells.

CONCLUSIONS.

Cytology specimens after trachelectomy frequently contain glandular cells from the lower uterine segment epithelium or endometrial stromal cells, which can lead to a misdiagnosis of atypical glandular cells of undetermined significance. Tubal metaplasia is also a potential pitfall in these specimens. Pathologists and gynecologic oncologists should be aware of the potential pitfalls in the surveillance of smears after trachelectomy. Cancer (Cancer Cytopathol) 2008. © 2007 American Cancer Society.     

Incidence,risk factors and treatment of cervical stenosis after radical trachelectomy: A systematic review

PurposeCervical stenosis is a major and specific postoperative complication following radical trachelectomy. The current article presents a review of studies describing the incidence, risk factors and treatment methods of cervical stenosis after this fertility sparing procedure.MethodsWe searched PubMed, MEDLINE, Embase (January 1994 through November 2014) using the following terms: uterine cervix neoplasms, cervical cancer, radical trachelectomy, fertility sparing and fertility preservation. We included original articles and case series. Case reports, review articles, articles not in English and articles not mentioning cervical stenosis were all excluded.ResultsWe identified 1547 patients. The incidence rates of cervical stenosis ranged from 0% to 73.3% with an average rate of 10.5%. Among patients with abdominal, vaginal, laparoscopic and robotic radical trachelectomy, the incidences of cervical stenosis were 11.0%, 8.1%, 9.3% and 0%, respectively. In patients in whom whether cerclage was placed or not, the incidence rates of cervical stenosis were 8.6% and 3.0%, respectively (P = NS). Among those in whom whether anti-stenosis tools were placed or not, the incidences of cervical stenosis were 4.6% and 12.7%, respectively (P < 0.001). Cervical stenosis was a potential cause of infertility and increased the use of artificial reproductive technology. Surgical dilatation resolved stenosis in the majority of cases but had to be repeated.ConclusionsCervical stenosis is related to the surgical approach, cerclage and anti-stenosis tools utilised. It affects not only the quality of life but also obstetrical outcomes of patients following radical trachelectomy. Greater attention should be given to the prevention and treatment of this complication.     

Fertility-sparing surgery in early-stage cervical cancer: indications and applications

This article describes the surgical and pathologic findings of fertility-sparing radical trachelectomy using a standardized surgical technique, and reports the rate of posttrachelectomy outcomes. The authors analyzed a prospectively maintained database of all patients with FIGO stage IA1-IB1 cervical cancer admitted to the operating room for planned fertility-sparing radical abdominal trachelectomy. Sentinel node mapping was performed through cervical injection. Between November 2001 and May 2010, 98 consecutive patients with FIGO stage IA1-IB1 cervical cancer and a median age of 32 years (range, 6-45 years) underwent a fertility-sparing radical trachelectomy. The most common histology was adenocarcinoma in 54 patients (55%) and squamous carcinoma in 42 (43%). Lymph-vascular invasion was seen in 38 patients (39%). FIGO stages included IA1 (with lymph-vascular invasion) in 10 patients (10%), IA2 in 9 (9%), and IB1 in 79 (81%). Only 15 (15%) needed immediate completion radical hysterectomy because of intraoperative findings. Median number of nodes evaluated was 22 (range, 3-54), and 16 (16%) patients had positive pelvic nodes on final pathology. Final trachelectomy pathology showed no residual disease in 44 (45%) cases, dysplasia in 5 (5%), and adenocarcinoma in situ in 3 (3%). Overall, 27 (27%) patients needed hysterectomy or adjuvant pelvic radiation postoperatively. One (1%) documented recurrence was fatal at the time of this report. Cervical adenocarcinoma and lymph-vascular invasion are common features of patients selected for radical trachelectomy. Most patients can undergo the operation successfully with many having no residual invasive disease; however, nearly 27% of all selected cases will require hysterectomy or postoperative chemoradiation for oncologic reasons. Investigation into alternative fertility-sparing adjuvant therapy in patients with node-positive disease is needed.     

改良腹式广泛宫颈切除术(MART)在早期宫颈癌保留生育功能治疗中的应用分析

目的 探讨改良腹式宫颈广泛切除术治疗有生育要求的早期宫颈癌的疗效及安全性.方法 选择早期宫颈癌患者42例,按照不同手术方式分为改良腹式广泛宫颈切除术(改良组)31例和开腹广泛宫颈切除术(对照组)11例.记录2组患者手术时间、术中出血量、切除淋巴结数目、保留宫颈长度、切除宫旁组织长度,术后引流量、并发症、住院时间、膀胱功能恢复情况及术后病理情况.随访患者宫颈创面愈合情况,月经恢复情况、复发情况及受孕情况.结果 改良组患者手术时间、术中出血量、子宫动脉损伤率、子宫切除率明显小于对照组,差异有统计学意义(P＜0.05);2组患者切除淋巴结个数与切除宫旁组织长度差异无统计学意义(P＞0.05).改良组患者住院时间、膀胱功能障碍发生率和宫颈黏连发生率显著小于对照组,差异有统计学意义(P＜0.05).2组患者术后均未出现复发,改良组患者术后月经减少发生概率为12.9％,显著低于对照组的27.3％ (P ＜0.05).结论 改良腹式宫颈广泛切除术治疗有生育要求的早期宫颈癌患者疗效确切,安全性高,是一种值得临床推广的早期宫颈癌治疗术式.