根治性子宫颈切除术和腹腔镜下淋巴结切除术在早期子宫颈癌治疗中的应用

目的 探讨根治性子宫颈切除术和腹腔镜下淋巴结切除术,在早期子宫颈癌治疗中的可行性和效果。方法2001年8月至2003年5月,对12例Ⅰ a期至Ⅰ b2期的子宫颈癌患者,施行腹腔镜下盆腔淋巴结切除术,切除的盆腔淋巴结经病理学检查证实无淋巴结转移者,随即行根治性子宫颈切除术,保留子宫体。结果 12例患者均在腹腔镜下完成盆腔淋巴结切除术,淋巴结检查均为阴性;根治性子宫颈切除术均经阴道完成,平均手术时间142 min(115—178 min),术中出血量约180 ml(120—230 ml)。术后无感染及出血,平均住院时间6.7 d。经随访3—28个月,1例患者妊娠,无一例肿瘤复发。结论 对于未生育且强烈要求保留生育功能的早期子宫颈癌患者,行腹腔镜下盆腔淋巴结切除术和根治性子宫颈切除术是可行的;手术创伤小,术后患者恢复快。     

A fertility-preserving option in early cervical carcinoma: laparoscopy-assisted vaginal radical trachelectomy and pelvic lymphadenectomy

OBJECTIVE: Laparoscopic vaginal radical trachelectomy is a fertility-preserving alternative to radical hysterectomy or chemoradiation in young women with stage IA2 to IB cervical cancers. The aim of this study is to describe the feasibility and outcome of laparoscopic radical vaginal trachelectomy and pelvic lymphadenectomy in women treated with early cervical cancers who wish to maintain fertility. STUDY DESIGN: From August 2000 through December 2004, 16 patients were offered this procedure. Patients were selected for this treatment on the basis of favorable cervical tumors and a desire to maintain fertility. Laparoscopic pelvic lymphadenectomies were performed in all patients. Vaginal radical trachelectomy was performed immediately if removed lymph nodes were negative. Obstetrical and oncological outcomes were evaluated. RESULTS: Sixteen women underwent this procedure. The mean operative time was 142 min (115-178 min), with a mean blood loss of 180 ml (120-230 ml), and the average hospital stay was 6.7 days. No intraoperative or postoperative complications occurred. With an average follow-up of 28.2 months, there have been no recurrences. Five pregnancies have subsequently occurred, with two third-trimester deliveries, two miscarriages at 24 and 26 weeks' gestation, and one patient is currently 18 weeks' pregnant. CONCLUSIONS: Laparoscopy-assisted radical vaginal trachelectomy is an adequate treatment, with its minimally invasive procedure and shorter recovery time, for early-stage cervical cancer in women who wish to preserve fertility. However, fertility issues remain the largest unanswered problem with this technique.     

Radical trachelectomy and pelvic lymphadenectomy with uterine preservation in the treatment of cervical cancer

OBJECTIVE: The purpose of this study was to determine whether radical trachelectomy, combined with pelvic lymphadenectomy, can be a feasible method for the treatment of early-stage cervical carcinoma in women who want to preserve their fertility. STUDY DESIGN: From January 1, 1995, through December 31, 1999, 12 women with stage I carcinoma of the cervix were scheduled to undergo radical trachelectomy and pelvic lymphadenectomy of the intact uterus as treatment. The procedure was abandoned in 2 women because of endometrial extension of the cancer. Surgical margins were clear in all other women. No lymph node metastases were encountered. The proximal cervical remnant was reinforced in 10 women. RESULTS: Hospitalization ranged from 2 to 8 days (mean, 3.2 days). Estimated blood loss averaged 203 mL (range, 50-600 mL). Complications included 2 intraoperative cystotomies and 1 pelvic hematoma. Four pregnancies have occurred, with 2 third-trimester deliveries and 2 preterm losses at 24 and 26 weeks of gestation, respectively. The follow-up period has ranged from 28 to 84 months (mean, 47.6 months). CONCLUSION: Radical trachelectomy, combined with pelvic lymphadenectomy, can be a feasible method of treatment for early-stage cervical carcinoma in women who want to preserve their fertility.     

保留生育功能的宫颈癌手术选择注意事项及术后生育问题

随着早期宫颈浸润癌的发病逐渐年轻化,保留生育功能的宫颈癌根治术日益受到关注。目前根治性宫颈切除术可以选择经阴道、腹式、经腹腔镜和机器人等手术途径。文章对各种不同手术方式的特点、手术指征、一些关键技术和术后生育问题进行阐述。     

Radical vaginal trachelectomy for invasive cervical cancer

The use of operative laparoscopy in gynecologic oncology has paved the way to a more conservative approach in radical treatments of some cancers, particularly cervical cancer. After the vaginal approach which shortens the hospital stay and the morbidity of a radical hysterectomy, a new fertility-preserving radical treatment has been proposed : the Radical Vaginal Trachelectomy (RVT). This technique has been used since 1991 in our institution. Until July 1999, 37 patients with early-stage cervical cancer desiring to retain their fertility were treated by a laparoscopic pelvic lymphadenectomy (LPL) and RVT. The median age was 32 (22-42), and 25 were nulliparous. Twelve were FIGO stage Ia2, 22 Ib1, 2 IIa and one Ia1 (VSI+). Most of the tumors were squamous (23), grade I (21), and the lesion was 2cms or less in 35 patients. Median operating time was 275 minutes ( 200 for the last 10 cases), and blood loss 200cc. Complications were mainly due to the LPL (3 arterial injuries) rather than the RVT (one iatrogenic cystotomy and one parametrial bleeding). The mean follow-up is 42 months. Two patients recurred including one who had a small-cell neuroendocrine tumor. Ten patients had a total of 13 pregnancies with 7 live births. One newborn died of E.coli-septicemia. Two patients had early miscarriages and 2 second trimester abortions (17 and 20 weeks). Two patients are still pregnant. LPL-RVT seems to be a good treatment modality for early-stage cervical cancer. It preserves fertility without lowering the chances of survival.     

Radical vaginal trachelectomy (RVT) combined with laparoscopic pelvic lymphadenectomy: prospective multicenter study of 100 patients with early cervical cancer

OBJECTIVE: The aim of this prospective clinical multicenter study "Uterus 6" of the German Association of Gynecologic Oncologists (AGO) was to prove the recurrence rate of patients treated with pelvic lymphadenectomy and radical vaginal trachelectomy (RVT). We also wanted to prove the surgical safety of RVT. METHODS: Between March 1995 and November 2005, we intend to treat 108 patients with cervical cancer (TNM stage 1A1, L1 n = 18, 1A2 n = 21, 1B1 n = 69) by RVT. Eight patients were excluded since the study criteria were not met after RVT (tumor size >2 cm, neuroendocrine tumor type, tumor-involved resection margins, or positive pelvic lymph nodes). Thus, 100 patients were treated by RVT according to protocol. With 4 recurrences in a sample size of 100 patients, an upper limit of the 95% confidence interval (including continuity correction) of 10.5% was calculated. Recruitment had to be stopped if five or more recurrences occurred. RESULTS: The median follow-up time was 29 (1-128) months. Three (3%) recurrences occurred in 100 patients treated with RVT according to protocol. Thus, the upper confidence limit was 9.2%. The projected 5-year recurrence-free and overall survival rates were 97% and 98%. The average duration of surgery was 253 (115-402) min. Perioperative complications were: postoperative bleeding, embolism of the external iliac artery, retroperitoneal lymphocele, or paralytic ileus in one patient, respectively. CONCLUSIONS: RVT combined with laparoscopic pelvic and parametric lymphadenectomy for treatment of patients with early stage cervical cancer < or =2 cm results in a recurrence-free survival of more than 90.8%.     

Radical vaginal hysterectomy with extraperitoneal pelvic lymphadenectomy in cervical cancer

OBJECTIVE: The aim of this work was to examine three types of radical vaginal hysterectomy with different degrees of radicality, performed in order to reduce surgical complications and sequelae in different indications, and to test the feasibility of a new simple and quick technique for extraperitoneal pelvic lymphadenectomy to be used in combination with radical vaginal hysterectomy for treatment of cervical cancer. In this way the advantages of vaginal surgery (e.g.: unnecessary general anaesthesia, reduced surgical trauma, applicability to obese and poor surgical risk patients, fast time-saving procedure) can be preserved. METHODS: We compared retrospectively the long-term results of radical vaginal and radical abdominal operations in a large series of stage IB-IIA cervical cancer patients treated at our institution in Florence from 1968 to 1983. Furthermore, we analysed the results of our experience from 1995 to 1998, when we performed extraperitoneal pelvic lymphadenectomy, followed by radical vaginal hysterectomy, on 48 patients affected by cervical cancer. Extraperitoneal pelvic lymphadenectomy was performed through two small abdominal incisions (6-7 cm). Twenty-two patients (45%) were obese (BMI>30 kg/m2) and 20 were poor surgical risks. FIGO stage was: IB1 in 18 cases, IB2 in eight, IIA in six, IIB in 12, IIIB in four. Neoadjuvant chemotherapy was given in 12 cases and preoperative irradiation was given in ten. General and regional anaesthesia were used in 30 (62.5%) and in 18 (37.5%) cases, respectively. RESULTS: As for past experience, in stage IB the five-year survival of 356 patients who underwent radical vaginal hysterectomy and that of 288 who had radical abdominal hysterectomy with pelvic lymphadenectomy were 81% and 75%, respectively (p<0.05). Surgical complications were fewer with no mortality in the first group. In stage IIA, survival rates were 68% for radical vaginal hysterectomy and 64% for radical abdominal hysterectomy, in 76 and 64 cases, respectively (p=n.s.). As for the more recent experience, median operative time for extraperitoneal pelvic lymphadenectomy was 20 minutes for each side (range 15-36). In each patient a median of 26 lymph nodes were removed (range 16-48). Positive nodes were found in 12 cases (25%). Median operative time for radical vaginal hysterectomy was 40 minutes (range 30-65). Extraperitoneal pelvic lymphadenectomy complications included: lymphocyst, five cases (10%) and retroperitoneal hematoma, one (2%); all occurred at the beginning of the experience. Radical vaginal hysterectomy complications included: ureteral stenosis, one (2%) and uretero-vaginal fistula, one (2%). All complications occurred in patients who received radiotherapy or chemotherapy preoperatively. Median hospital stay was ten days (range 6-20). CONCLUSIONS: The results of our work demonstrate that our technique for extraperitoneal pelvic lymphadenectomy shows a good applicability to cervical cancer patients submitted to radical vaginal hysterectomy, which has a high rate of cure for stage IB and IIA as shown by our past experience. The procedure of extraperitoneal pelvic lymphadenectomy was quick, easy, and safe, and its realization was not detrimental to the advantages of radical vaginal hysterectomy. Our experience supports the continued use of this combined extraperitoneal and vaginal approach in the treatment of cervical cancer. Moreover, the three classes of radical vaginal hysterectomy allow tailoring the type of the operation to the clinical and physical characteristics of the patients.     

Simple extrafascial trachelectomy and pelvic bilateral lymphadenectomy in early stage cervical cancer

Objective

To determine the feasibility and safety of simple extra-fascial trachelectomy plus pelvic lymphadenectomy in young patients affected by early stage cervical cancer.

Methods

We have prospectively identified all patients with early-stage cervical cancer (stages IA2-IB1) referred to our department. Inclusion criteria were: age ≤ 38 years, strong desire to maintain fertility, FIGO stage ≤ IB1, tumor size < 2 cm, no LVSI, no evidence of nodal metastasis. Surgical technique included two steps: laparoscopic pelvic lymphadenectomy and vaginal simple extrafascial trachelectomy. Patients were followed up for oncological and obstetrical outcomes.

Results

Fourteen patients were enrolled in the study. Median age was 32 years (range 28-37); histotype was squamous in 11/14 (79%) cases and adenocarcinoma in 3/14 cases (21%); FIGO stage was IA2 in 5/14 (36%) patients, IB1 in 9/14 (64%) patients; median tumor size was 17 mm (range 14-19); median operative time was 120 min (range 95-210). No severe intraoperative complications were recorded. Postoperative complications were observed in two patients. No recurrences were detected. One patient died for other disease. Eight patients became pregnant and 3 of them had a term delivery.

Conclusion

Low risk early-cervical cancer patients could be safely treated by simple extrafascial trachelectomy in order to maintain fertility. More studies are needed to better define the role of conservative and ultraconservative surgical approaches (i.e. conization) in this setting, either for fertility purposes or to minimize surgical complications.     

Radical trachelectomy in the treatment of early cervical carcinoma

In recent years a new less radical methods in the treatment of early cervical carcinoma has been introduced. The radical trachelectomy with laparoscopic pelvic lymphadenectomy represents one of these options. This procedure is special in that it not only treats the cervical cancer in acceptable oncological fashion but at the same time preserves the fertility potential of the patients. Thus, this surgery represents a midway point in between conisation and radical hysterectomy. Based on our initial experience in this study the technique of radical trachelectomy is analysed in detail and at the same time the current literature on the subject is reviewed. We conclude that after careful selection of the patients this more conservative approach leads to the same results comparable to classical radical surgery.     

各种根治性宫颈切除术手术关键点及特点比较

根治性宫颈切除术(RT)是一种较新的手术方法,在治疗早期宫颈癌的同时允许患者保留生育功能.RT主要有阴式和腹式两种术式.文章就不同术式的手术适应证、手术关键步骤、肿瘤学安全性和术后生育结果等热点问题进行探讨.     

Radical abdominal trachelectomy and pelvic lymphadenectomy with uterine conservation and subsequent pregnancy in the treatment of early invasive cervical cancer

BACKGROUND: Recently, pregnancies in patients after radical vaginal trachelectomy and laparoscopic pelvic lymphadenectomy have been reported. Radical abdominal trachelectomy and pelvic lymphadenectomy with uterine conservation has been previously described; however, subsequent outcome and pregnancy has not. METHODS: Three patients with cervical carcinoma, 1 with stage IA1 with lymph-vascular space invasion and 2 with stage IA2, were treated with radical abdominal trachelectomy and pelvic lymphadenectomy with uterine conservation. RESULTS: All patients underwent the planned procedure with no significant intraoperative or postoperative complications. All patients had return to normal menstrual function. One patient had a successful pregnancy delivered at 39 weeks by cesarean section and is now subsequently pregnant with a second pregnancy. CONCLUSION: Radical abdominal trachelectomy is a technically feasible operation that uses operative techniques familiar to the American-trained gynecologic oncologist and results in wider parametrial resection than radical vaginal trachelectomy. In young patients desiring to retain fertility, successful pregnancies after radical abdominal trachelectomy are possible. Intraoperative and postoperative complications are likely to be lower with an abdominal versus a vaginal approach. Long-term survival of patients treated with radical trachelectomy for early invasive cervical cancer are yet to be determined.     

Laparoscopic radical trachelectomy or parametrectomy and pelvic and para-aortic lymphadenectomy for cervical or vaginal stump carcinoma: report of six cases

The aim of this study was to investigate the feasibility and safety of laparoscopic radical parametrectomy and pelvic and para-aortic lymphadenectomy after previous supracervical or extrafascial hysterectomy. This is a prospective study of six patients with vaginal or cervical stump carcinoma after previous supracervical or extrafascial hysterectomy. The technique of radical parametrectomy with pelvic and para-aortic lymphadenectomy as used for open surgical cases for years was performed laparoscopically. The average operating time was 180 min, the estimated average blood loss was 220 mL, and the duration of hospitalization was 11.8 days. There was no intraoperative or postoperative complication. Laparoscopic radical parametrectomy with pelvic and para-aortic lymphadenectomy for cervical or vaginal stump carcinoma can be successfully and safely accomplished.     

Fertility-sparing robotic-assisted radical trachelectomy and bilateral pelvic lymphadenectomy in early-stage cervical cancer

A combined pelvic lymphadenectomy with radical vaginal trachelectomy is an alternative to radical hysterectomy in the treatment of young women with cervical cancer desiring fertility preservation. This technique requires advanced vaginal surgery skills not commonly acquired. In an attempt to simplify the procedure we preformed what we believe to be the first case of robotic-assisted radical trachelectomy. A 30-year-old woman, gravida 1, para 1, desiring fertility preservation was given the diagnosis of invasive adenocarcinoma on cervical cone excision. The patient was treated with robotic-assisted pelvic lymphadenectomy and radical trachelectomy. We hope robotic-assisted radical trachelectomy will become an option for select women with early-stage cervical cancer who desire fertility preservation.     

Radical trachelectomy: a way to preserve fertility in the treatment of early cervical cancer

In the Centenary year of Wertheim's hysterectomy for the treatment of invasive cervical cancer, it is appropriate to look at less radical methods of managing early stage disease. Radical trachelectomy with pelvic lymphadenectomy is a conservative but locally radical procedure, preserving the corpus uteri and therefore fertility potential. The first 10 cases in a pilot study are presented. One patient has required post-operative radiotherapy and another a completion radical hysterectomy. Three live births by caesarean section and three other pregnancies have resulted. Careful selection within strict criteria may allow this more conservative approach without compromising cure. These procedures should be carried out in referral centres with continuing follow up and review.     

Radical hysterectomy and pelvic lymphadenectomy for stage IB2 cervical cancer

OBJECTIVE: We wished to evaluate survival and adverse outcomes of patients with stage IB2 cervical cancer treated primarily with radical hysterectomy and lymphadenectomy. METHODS: A review was performed of all patients undergoing primary radical hysterectomy for stage IB2 cervical cancer at two institutions from 1987 to 2002. Patients were stratified into low, intermediate (Gynecologic Oncology Group protocol 92 criteria), and high-risk (positive nodes, margins, or parametria) groups. Survival and progression-free interval were analyzed using the Kaplan-Meier method and multivariate analysis. RESULTS: Seventy-two patients underwent primary type III radical hysterectomy and lymphadenectomy (72 pelvic, 58 pelvic and paraaortic). Patients were classified as low (n = 6), intermediate (n = 49), or high (n = 17) risk for recurrence. Adjuvant therapy was administered to 94%, 12%, and 0% of the high-, intermediate-, and low-risk groups, respectively. Five-year survival was 72%, while 5-year progression-free survival was 63%. Five-year overall and progression-free survival by risk group were 47% and 40% (high-risk), 80% and 66% (intermediate-risk), 100% and 100% (low-risk). Predictors of survival in multivariate analysis were Caucasian race (P = 0.001), older age (P = 0.017), inner 2/3 cervical wall invasion (P = 0.045), and absence of lymph-vascular invasion (P < 0.001). Major complications were experienced by 10/72 (13.9%) patients. Among 34 patients who received radiation therapy, two (5.9%) experienced complications attributable to radiation. CONCLUSIONS: Radical hysterectomy and lymphadenectomy followed by tailored adjuvant therapy is a reasonable alternative to primary radiotherapy for stage IB2 cervical cancer. Patients with low- and intermediate-risk factors have satisfactory results after primary surgical management. A prospective randomized trial will clarify the optimal mode of initial therapy for patients with stage IB2 disease.