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.     

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.     

Laparoscopic abdominal radical trachelectomy

BACKGROUND: Radical trachelectomy is a fertility preserving alternative for young women with early stages of cervical cancer. Currently, a technique of abdominal radical approach is used in a few centres. With growing availability of laparoscopy, a novel technique of laparoscopic radical trachelectomy might be an alternative. CASE: Presented is one case of laparoscopic pelvic lymphadenectomy with radical trachelectomy in young woman with IB cervical cancer. No intraoperative or postoperative complications occurred. Operation time reached 250 min, estimated blood loss was 250 ml. Limited follow-up of 9 months was uneventful and patient indicates normal menstrual pattern and satisfactory sexual intercourse. CONCLUSION: Laparoscopic abdominal radical trachelectomy with pelvic lymphadenectomy might be an alternative technique in the treatment of early stages cervical cancer in patients who desire future pregnancy. The procedure is in principle identical to the standard abdominal radical hysterectomy. Centres practising laparoscopic radical hysterectomy can adopt the technique without any special surgical training.     

Less radical fertility-sparing surgery than radical trachelectomy in early cervical cancer

The purpose of this pilot study was to determine feasibility and safety of a novel and less radical fertility-preserving surgery; laparoscopic lymphadenectomy with sentinel lymph node identification (SLNI) followed by large cone or simple trachelectomy. Obstetrical and oncologic outcomes were evaluated. Twenty-six patients (6-IA2, 20-IB1) selected on basis of favorable cervical tumor characteristics and the desire to maintain fertility underwent laparoscopic SLNI, frozen section (FS), and a complete pelvic lymphadenectomy as first step of treatment. All of nodes were submitted for microscopic evaluation (sentinel nodes for ultramicrostaging). After a 7-day interval, large cone or simple vaginal trachelectomy was performed in patients with negative nodes. The average of sentinel nodes per side was 1.50 and the average of total nodes was 28.0. Four FS were positive (15.4%). In these cases, Wertheim radical hysterectomy type III was immediately performed. We had no false-negative SLN neither on FS nor on final pathology assessment. Median follow-up was 49 months (18-84). One central recurrence (isthmic part of uterus) was observed 14 months after surgery. This patient was treated with radical chemoradiotherapy, and there was no evidence of the disease 36 months after treatment. Fifteen women planned pregnancy, 11 women became pregnant (15 pregnancies), and 7 women delivered eight children (one in 24 weeks, one in 34 weeks, one in 36 weeks, and five between 37 and 39 weeks). We conclude that lymphatic mapping and SLNI improves safety in this fertility sparing surgery. Large cone or simple trachelectomy combined with laparoscopic pelvic lymphadenectomy can be a feasible method with a high successful pregnancy rate.     

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.     

Fertility-sparing radical abdominal trachelectomy for cervical carcinoma: technique and review of the literature

OBJECTIVES: Radical trachelectomy has emerged as a reasonable fertility-sparing operation for selected patients with stage I cervical cancer. The purpose of this report is to describe our technique of radical abdominal trachelectomy, a fertility-sparing operation in women with cervical cancer, and review the current literature on this procedure. METHODS: A review of a prospectively maintained database of all fertility-sparing radical trachelectomy procedures performed at our institution. RESULTS: Between 11/01 and 3/06, we performed a total of 42 fertility-preserving radical trachelectomies with pelvic lymphadenectomy for women with invasive cervical cancer. We had previously reported on 2 pediatric abdominal trachelectomies, which are excluded from this report. Five of the remaining 40 cases had undergone a radical abdominal trachelectomy, and 35 cases were performed laparoscopically with a radical vaginal approach. The characteristics of the 5 adult patients who underwent abdominal radical trachelectomy included stage IB1 disease in all cases, a mean age of 36 years (range, 33-39), and a mean estimated blood loss of 280 ml (range, 50-400); 1 patient with squamous cell carcinoma needed completion radical hysterectomy at the time of trachelectomy due to disease extending into the endometrium, and 1 patient needed postoperative chemoradiation due to a positive parametrial lymph node. The remaining 3 patients resumed normal menstruation postoperatively. All patients remain disease-free at the time of this report. The only remaining uterine blood supply in these patients are the utero-ovarian vessels. There were no postoperative complications, and transurethral Foley catheters were removed in all cases within 2 weeks. CONCLUSIONS: Radical abdominal trachelectomy with pelvic lymphadenectomy is a feasible operation for selected women with stage I cervical cancer who desire to preserve reproductive function. Menstruation and reproductive function may be preserved after bilateral uterine vessel ligation. The procedure expands the inclusion criteria of radical vaginal trachelectomy to patients with distorted cervicovaginal anatomy in which the vaginal approach may not be feasible.     

Central pelvic recurrence 7 years after radical vaginal trachelectomy

BACKGROUND: We report a case of central pelvic recurrence 7 years after radical vaginal trachelectomy for adenocarcinoma of the cervix. CASE: A 30-year-old woman was treated by radical vaginal trachelectomy and bilateral pelvic lymph node dissection (a fertility sparing procedure) in 1996 for cervical cancer. Pathology demonstrated a well differentiated, stage 1B1 adenocarcinoma. She presented 7 years later with a central pelvic recurrence measuring 30 mm in width. She subsequently underwent radical hysterectomy for central clearance and did not require post-operative radiotherapy. CONCLUSIONS: Should selected patients who were initially treated by radical trachelectomy for early stage cervical cancer, in particular those with adenocarcinoma (as 50% of recurrences have been reported in this group of patients), be offered hysterectomy once child bearing is complete?     

Radical vaginal trachelectomy as a fertility-sparing procedure in women with early-stage cervical cancer-cumulative pregnancy rate in a series of 123 women

OBJECTIVE: To analyse the fertility rates, complications and recurrences in a group of women who have undergone radical vaginal trachelectomy and pelvic lymphadenectomy for early-stage cervical cancer. DESIGN: An observational series. SETTING: A Gynaecological Oncology Centre. POPULATION: One hundred and twenty-three consecutive women who underwent radical vaginal trachelectomy and pelvic lymphadenectomy for early-stage cervical cancer. METHODS: Data were collected prospectively. MAIN OUTCOME MEASURES Complications, recurrences, pregnancies and live births are presented as percentages of the total population. Fertility is presented as a 5-year cumulative rate, with women attempting to conceive as the denominator. RESULTS: A total of 123 women were followed up for an average of 45 months. Eleven (8.9%) had completion treatment (two radical hysterectomies and nine chemoradiotherapy) at the time of initial treatment. There were three recurrences (2.7%) among the women who did not have completion treatment and two (18.2%) in those who did. There were 6 perioperative and 26 postoperative complications. Sixty-three women attempted pregnancy. There were 55 pregnancies in 26 women and 28 live births in 19. Three women had continuing pregnancies. The 5-year cumulative pregnancy rate among women trying to conceive was 52.8%. All but two women were delivered by classical caesarean section and seven (25.0%) babies were born at 31+6 weeks or less. CONCLUSIONS: For selected women with early-stage cervical cancer, radical vaginal trachelectomy and pelvic lymphadenectomy are fertility-sparing options, with a low incidence of recurrence and acceptable cumulative conception rates. Complications are few, although there is a high premature labour and miscarriage rate among pregnant women.     

Conservative surgical methods for FIGO stage IA2 squamous cervical carcinoma and their role in preserving women's fertility

OBJECTIVE: Until recently, the treatment of choice for stage IA2 squamous cervical cancer has been radical hysterectomy with pelvic node dissection. However, many of these cases occur in younger women, for whom the preservation of fertility is desirable. More conservative methods have emerged as alternative treatment modalities for these women, as they may allow for future fertility, without having a considerable adverse effect on cure rates. The objective of this review is to present the published data on these methods (radical vaginal, abdominal or laparoscopic trachelectomy and laparoscopic pelvic lymphadenectomy, deep cold-knife excision and lymphadenectomy, ovarian transposition and radiotherapy) and comment on their clinical role. METHOD: A detailed literature search was done in MEDLINE (1966-2003), EMBASE (1974-2003) and CINAHL (1982-2003) for data on cure rates, survival and reproductive outcome of radical vaginal trachelectomy as well as other conservative treatment options. RESULTS: The recurrence rates after radical trachelectomy range from 0% to 8% and are comparable to reported results from series of patients treated with radical hysterectomy. There are over 35 reported live births out of approximately 210 women who had this operation. However, the rates of second trimester losses and preterm deliveries due to cervical weakness are high. Data from the other methods are limited. CONCLUSION: Vaginal radical trachelectomy is currently the fertility-sparing procedure with the most available data supporting its use. Although these results are encouraging, there is lack of level I evidence (i.e. randomized controlled trials) comparing safety and survival rates between conservative and radical methods. Therefore, these techniques should be used by fully trained operators, with the understanding that this is not the standard treatment at present.     

Management of low-risk early-stage cervical cancer: Should conization,simple trachelectomy,or simple hysterectomy replace radical surgery as the new standard of care?

The standard treatment for women with early-stage cervical cancer (IA2–IB1) remains radical hysterectomy with pelvic lymphadenectomy. In select patients interested in future fertility, the option of radical trachelectomy with pelvic lymphadenectomy is also considered a viable option. The possibility of less radical surgery may be appropriate not only for patients desiring to preserve fertility but also for all patients with low-risk early-stage cervical cancer.     

Robot-assisted abdominal laparoscopic radical trachelectomy

BACKGROUND: Radical trachelectomy in conjunction with pelvic lymphadenectomy is an established method to preserve fertility in early cases of cervical cancer. The radical trachelectomy is usually performed vaginally despite the initial use of laparoscopy for the lymphadenectomy. The complexity of a laparoscopic abdominal trachelectomy may explain this dual approach. Here we describe the surgical technique of a robot-assisted laparoscopic radical trachelectomy with lymphatic mapping using a radiotracer and without a vaginal approach. CASES AND SURGICAL TECHNIQUE: Two nulliparous women with early cervical cancer underwent a laparoscopic radical trachelectomy and pelvic lymphadenectomy with the assistance of the da Vinci robot (Intuitive Surgical Inc, Sunnyvale, CA). After the sentinel lymph nodes were found negative on frozen section, the parametria, paracolpia and sacrouterine ligaments were dissected sparing the main branches of the uterine arteries. Following ligation of the descending branches of the uterine arteries the cervix and the vagina were transsected using monopolar diathermia and the vagina was sutured to the remaining cervix. Finally, a permanent cerclage was placed. Time for surgery was 387 and 358 min respectively. No perioperative complications were noted and the postoperative period was uneventful in both cases. CONCLUSIONS: Robot-assisted laparoscopic abdominal trachelectomy is a feasible alternative to a combined laparoscopic and vaginal approach.     

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.     

Isolated recurrence at the residual uterine cervix after abdominal radical trachelectomy for early cervical cancer

BACKGROUND: We report an isolated recurrence at the residual cervix shortly after abdominal radical trachelectomy for cervical cancer. CASE: A 34-year-old woman underwent radical abdominal trachelectomy and pelvic lymphadenectomy for FIGO stage IB1 squamous cell cervical cancer. The tumor measured 10 mm in maximum diameter with 4 mm of invasion. Histology showed lymph vascular space involvement with no infiltration of adjacent structures and no pelvic lymph node metastases. Tumor-free resection margins exceeded 15 mm. At the 6-month follow-up examination, cervical cytology showed cells suspicious for recurrent cervical cancer. Abdominal hysterectomy was performed and histology showed an isolated 3-mm recurrence in the residual cervix. The patient is free of disease 8 months after hysterectomy. CONCLUSION: Recurrence at the residual cervix is a potential risk of abdominal trachelectomy for early cervical cancer. Patients should be counseled accordingly and followed closely.     

Pediatric radical abdominal trachelectomy for cervical clear cell carcinoma: a novel surgical approach

INTRODUCTION: Clear cell carcinoma of the cervix and vagina is rare in the pediatric population. Many of these tumors are associated with prior intrauterine diethylstilbestrol (DES) exposure. All DES-associated tumors are believed to contain microsatellite instability (MI). Historically, the recommended treatment is radical hysterectomy and pelvic lymphadenectomy, which result in infertility in all cases. Radical abdominal or vaginal trachelectomy and pelvic lymph node dissection is a new technique utilized in adult women with early cervical cancer who wish to retain fertility. This novel approach is also pertinent to the pediatric patient and is described in this report. A molecular analysis is also performed to determine if these are DES-associated tumors. METHODS: Due to the narrow vaginal anatomy in pediatric patients, a vaginal approach is not possible, and an abdominal approach is performed. The resection includes the cervix, upper vagina, parametrium, and paracolpos. Pelvic lymphadenectomy is performed in a similar manner to the adult patient. Matched pairs of normal and tumor DNA from both cases were examined for evidence of MI using a consensus panel of microsatellite markers. RESULTS: Two girls aged 6 and 8 years and without history of DES exposure presented with vaginal bleeding. Vaginoscopy revealed cervical polyp in both cases. Biopsies demonstrated clear cell cancer stage IB1 in both patients. They underwent radical abdominal trachelectomy and bilateral pelvic lymph node dissection along with anastomosis of uterine isthmus to upper vagina. Intraoperative frozen-section analysis confirmed negative uterine and vaginal margins. No adjuvant treatment was given and both girls remain disease free. Neither tumor showed evidence for MI, confirming that these are not DES-associated tumors. CONCLUSION: To our knowledge, this is the first report of radical abdominal trachelectomy in the pediatric age group and it is likely to include the youngest patient with clear cell carcinoma of the uterine cervix not associated with DES exposure. This novel approach is feasible and appears safe in the pediatric age group.     

早期宫颈癌保留生育功能手术5例临床分析

目的:为保留早期宫颈癌患者的生育功能,实施广泛宫颈切除及盆腔淋巴结清扫术。方法:对2003年4月至2004年4月收治的要求保留子宫的5例早期宫颈癌患者采用经腹腔镜辅助的广泛宫颈切除及盆腔淋巴结清扫术。结果:5例患者在术中及术后均无并发症发生,术后1个月恢复正常月经,随访未发现复发癌。结论:早期子宫颈癌实施腹腔镜辅助的广泛宫颈切除及盆腔淋巴结清扫术可以保留患者的生育功能。     

早期宫颈癌患者保留生育功能的治疗策略研究进展

广泛全子宫切除术和盆腔淋巴结切除术仍然是年轻早期宫颈癌患者治疗的常规术式,患者因此丧失生育能力。本文针对国内外最新研究进展,回顾性分析宫颈癌根治术后宫旁、阴道旁及淋巴结转移情况,发现早期宫颈癌患者中仅27%存在淋巴结转移,并对前哨淋巴结切除术的临床应用前景以及为保留生育功能而进行“最小而有效的”手术治疗方式的研究现状进行总结讨论。前哨淋巴结切除术可提高术中诊断淋巴结转移与否的准确度,减少不必要的过度治疗,目前有替代盆腔淋巴结切除术的趋势。目前保留生育功能的手术主要有6种术式,即扩大宫颈锥切术、单纯宫颈切除术、经阴道广泛性宫颈切除术、开腹广泛性宫颈切除术、腹腔镜下广泛性宫颈切除术和机器人辅助腹腔镜下广泛性宫颈切除术。对于病灶＞2 cm的患者,推荐先行新辅助化疗（NACT）3~4个疗程后,再结合妇科检查及影像学证据,选择宫颈切除范围和具体术式。     

Abdominal radical trachelectomy: a new surgical technique for the conservative management of cervical carcinoma

Traditionally radical hysterectomy has formed the mainstay of treatment for early stage cervical carcinoma. More recently radical trachelectomy and laparoscopic lymphadenectomy have been introduced to allow preservation of fertility. We present a new approach to fertility-sparing surgery, namely abdominal radical trachelectomy. The technique is similar to a standard radical hysterectomy and lymphadenectomy. In our technique the ovarian vessels are not ligated and, following lymphadenectomy and skeletonisation of the uterine arteries, the cervix, parametrium and vaginal cuff are excised. The residuum of the cervix is then sutured to the vagina and the uterine ateries re-anastomosed.     

Surgery for cervical cancer

The incidence of cervical cancer is falling. As a result of changes in the case-mix of cervical cancer the surgical options for treatment of this disease are changing. A younger patient load and the associated desire to preserve fertility have led to consideration of conservative procedures such as large loop excision of the transformation zone, cone biopsy and ‘radical’ trachelectomy. Radical procedures now include radical vaginal or radical laparoscopic hysterectomy as well as the classical Wertheim's hysterectomy. In this article we review the historical development of surgery in the management of cervical cancer and then discuss the prognostic characteristics of this disease as they influence surgical choice. We detail the surgical procedures currently used in this disease and describe the choices available with respect to stage of disease. The role of lymphadenectomy and oophorectomy are also considered and the influence of pregnancy on cervical cancer is reviewed.