Abdominal radical trachelectomy: a fertility-preserving option for women with early cervical cancer

Abdominal radical trachelectomy is a fertility-preserving alternative to radical hysterectomy or chemoradiation for young women with stage IA2 to IB cervical cancers. Thirty-three patients were offered this procedure. The mean age was 30.5 years (range 23-37). Three procedures were abandoned because of positive pelvic nodes (two patients) and involvement of the margin between the amputated cervix and uterine fundus (one patient). Of the remaining 30 patients, 10 had stage IA2 tumours, 15 had stage IB1 and 5 had stage IB2. During follow up of a median of 47 months (mean 32 months, range 14-75 months), no recurrences have been detected. A normal menstrual pattern resumed within eight weeks of surgery in all but two patients. Five patients attempted to conceive. Three women have fallen pregnant, resulting in one first trimester miscarriage and two caesarean section deliveries at term. Our experience suggests that abdominal radical trachelectomy provides a method of treating women with stage IA2 to IB cervical cancers with conservation of fertility without apparently compromising recurrence or survival rates. It appears to provide equivalent oncological safety to a standard Wertheim hysterectomy using a technique familiar to all practising gynaecologic oncologists.     

A comparison of laparascopic-assisted radical vaginal hysterectomy and radical abdominal hysterectomy in the treatment of cervical cancer

OBJECTIVES: The aim of this study was to compare peri-operative morbidity and recurrence-free survival of early-stage cervical cancer patients treated by laparoscopic-assisted radical vaginal hysterectomy (LARVH) with time-matched radical abdominal hysterectomy (RAH) controls at our center. METHODS: Since July 1984, all patients with FIGO stage IA/IB cervical cancer undergoing radical surgery by members of our division have been entered into a prospective database. Since November 1996, one surgeon at our center has performed LARVH on all surgically appropriate patients. Non-parametric tests were used. Differences between medians were compared using Wilcoxon Rank Sum test. Statistical analysis used the Kaplan-Meier method to calculate disease-free survival. Differences between survival curves were compared with the log rank test. Statistical significance was defined as P < 0.05. RESULTS: Between November 1996 and December 2003, 71 and 205 patients have undergone LARVH and RAH, respectively, for FIGO stage IA/IB carcinoma of the cervix. Both groups were similar with respect to age and Quetelet index. There were no differences in tumor size, histology, grade, depth of invasion, lymph node metastases, or surgical margins. All laparoscopic procedures were completed successfully with no conversions to laparotomy. Intra-operative morbidity characteristics analyzed (LARVH vs. RAH) were blood loss 300 ml vs. 500 ml (P < 0.001), operative time 3.5 h vs. 2.5 h (P < 0.001), and intra-operative complications 13% vs. 4% (P < 0.03). Intra-operative complications in the LARVH group included: cystotomy (7), ureteric injury (1), and bowel injury (1). There was no difference in transfusion rates. There was no difference between post-operative infectious and non-infectious complications (LARVH vs. RAH), 9% vs. 5% and 5% vs. 2%, respectively. The median time to normal urine residual was 10 days vs. 5 days (P < 0.001), and the median length of hospital stay was 1 day vs. 5 days (P < 0.001). Twenty-two percent of patients received post-operative radiotherapy for high-risk features in both groups. After a median follow-up of 17 and 21 months, there have been 4 recurrences in the LARVH group and 13 in the RAH (P = NS). The overall 2-year recurrence-free survival was 94% and 94% in the LARVH and RAH groups, respectively (P = NS). CONCLUSION: Our data demonstrate that early cervical cancer can be treated successfully with LARVH with similar efficacy and recurrence rates to RAH. The major benefits are less intra-operative blood loss and shorter hospital stay. It is a safe procedure with low overall morbidity and complication rates. However, at present, LARVH is associated with an increase in intra-operative complications, and patients may have an increased time to return to normal bladder function.     

Laparoscopic Nerve-Sparing Radical Trachelectomy: Surgical Technique and Outcome

Study ObjectiveTo assess the feasibility of the laparoscopic approach in fertility-preserving and radical surgery of cervical cancer in young patients.DesignRetrospective study (Canadian Task Force classification I).SettingHospital Son Llatzer, Palma de Mallorca, Spain.PatientsNine women with early cervical cancer.InterventionLaparoscopic nerve-sparring radical trachelectomy.Measurements and Main ResultsData for 9 consecutive women undergoing laparoscopic nerve-sparing radical trachelectomy because of FIGO IA2 (n = 2) or FIGO IB1 (n = 7) infiltrating cervical carcinoma of the squamous type (n = 6) or adenocarcinoma (n = 3) were analyzed. Resection of the pericervical ligaments was laparoscopically performed, preserving innervation of the bladder and the arterial supply of the uterus. The laparoscopic approach enabled completion of the operation via the vaginal route without difficulties. The mean duration of surgery was 270 minutes. No relevant perioperative complications occurred. Two women became pregnant: 1 underwent an elective cesarean section delivery at week 38, and hysterectomy was performed 6 months later; and the other woman was pregnant at the time of this writing. Mean duration of follow-up was 28 months. Six patients currently have regular menses without evidence of disease. One patient had a central recurrence at 14 months, which was treated using surgery and radiochemotherapy, and she was free of disease at the last follow-up.ConclusionsLaparoscopic nerve-sparring radical trachelectomy may be an alternative in fertility-preserving surgery for cervical cancer in centers in which specialization in radical vaginal surgery is lacking. The procedure enables preservation of autonomic innervation of the urinary bladder and the arterial supply of the uterus.     

Sexual Function after Modified Radical Hysterectomy (Piver II/Type B) vs. Classic Radical Hysterectomy (Piver III/Type C2) for Early Stage Cervical Cancer. A Prospective Study

IntroductionWhen cervical cancer is detected at an early stage (International Federation of Gynecology and Obstetrics [FIGO] IA2‐IB1), it can be successfully treated by radical surgery alone. Considering that most patients are young and sexually active at the moment of diagnosis and the long life expectancy of survivors after the treatment, quality of life (QoL) and sexual function are important issues for cancer survivors and caregivers. However, only a few studies have examined the QoL and sexual function in disease‐free cervical cancer survivors, and there are no studies in the literature comparing prospectively sexual function after different types of radical hysterectomy.AimTo compare sexual function in two groups of early stage cervical cancer survivors treated by radical surgery alone, undergoing two different types of radical hysterectomy.MethodsPatients treated by radical hysterectomy with systematic lymphadenectomy for early stage cervical cancer (FIGO IA2‐IB1) have been enrolled and divided in two groups with regard to type of radical hysterectomy performed; S1: modified radical hysterectomy (Piver II/Type B), S2: classic radical hysterectomy (Piver III/ Type C2).Main Outcome MeasureTwenty‐four months after surgery we assessed the sexual function using the European Organization for Research and Treatment of Cancer Cervix Cancer Module Questionnaire, which is a validated system for the assessment of disease‐ and treatment‐specific issues that affect the QoL and sexual functioning of women who are treated for cervical cancer.ResultsOf the 31 patients enrolled in the S1 group and 46 in the S2 group, 23 and 33 patients have been included, respectively. We observed significant differences between the two groups in terms of symptom experience, sexual/vaginal functioning, sexual activity, and sexual enjoyment. There was not any significant difference regarding lymphedema, peripheral neuropathy, and sexual worry.ConclusionSurvivors of early stage cervical cancer treated by modified radical hysterectomy (Piver II/ Type B) have a better sexual function than those operated by classic radical hysterectomy (Piver III/ Type C2). Plotti F, Nelaj E, Sansone M, Antonelli E, Altavilla T, Angioli R, and Benedetti Panici P. Sexual function after modified radical hysterectomy (Piver II/Type B) vs. classic radical hysterectomy (Piver III/Type C2) for early stage cervical cancer: A prospective study. J Sex Med 2012;9:909–917.     

Cystoscopic temporary ureteral catheterization during radical vaginal and abdominal trachelectomy

OBJECTIVES: To describe the role of temporary retrograde ureteral catheterization at the time of fertility-sparing radical vaginal or abdominal trachelectomy in women with early-stage cervical cancer. METHODS: We analyzed a prospectively maintained database of all patients with cervical cancer who were explored for radical vaginal or abdominal trachelectomy at our institution. Cystourethroscopy and ureteral catheterization were performed prior to the vaginal or abdominal operation in all patients, except two pediatric ones. Temporary bilateral retrograde ureteral catheters were planned for all patients as part of our routine procedure to facilitate identification of the distal ureters. 5Fr whistle-tip or open-ended catheters were used and usually advanced to approximately 20 cm. Catheters were removed at the end of the operation in all cases. All catheters were inserted by a gynecologic oncology fellow or attending. RESULTS: Between 11/01 and 12/05, 40 patients were taken to the operating room for planned fertility-sparing radical vaginal or abdominal trachelectomy. We previously reported on two pediatric patients; they are excluded from this report. The median age for adult patients was 32 years (mean, 31.6; range, 23-40). International Federation of Gynecology and Obstetrics (FIGO) stage included IB1 (26), IA2 (6), and IA1 with lymphovascular invasion (6). Thirty-four patients underwent radical vaginal trachelectomy and four underwent a radical abdominal trachelectomy. Two (5%) of 38 patients required immediate completion radical hysterectomy due to extensive endocervical disease (one in the vaginal group and one in the abdominal group). Bilateral ureteral catheters were inserted successfully in 37 (97%) of 38 patients and facilitated identification of the distal ureter during the dissection. In one case, the right ureteral orifice could not be successfully catheterized, and the case was completed with unilateral catheterization. The estimated time to perform this part of the operation was approximately 15-20 min. Twenty-eight patients (74%) had 5Fr whistle-tip ureteral catheters inserted, and 10 had open-ended catheters inserted. There were no intraoperative complications. Median hospital stay was 3 days (range, 3-7). Hematuria, evident in the drainage bag attached to the Foley catheter, usually resolved in 24-48 h. Two (20%) of 10 patients who had open-ended catheters inserted developed a transient rise in postoperative creatinine (1.7 and 3.5 mg/dl, respectively) compared to 0/28 patients who had whistle-tip catheters placed (P<0.001). Both were attributed to postoperative distal ureteral edema, and only one patient required reinsertion of temporary ureteral stents. No patient developed long-term urinary complications or fistulae. CONCLUSIONS: Cystourethroscopy and bilateral retrograde ureteral catheterization by gynecologic oncologists is a simple and quick procedure that may facilitate identifying the distal ureter during radical vaginal or abdominal trachelectomy. We favor using 5Fr whistle-tip catheters as they may be associated with less ureteral mucosal trauma and subsequent postoperative edema. The skills needed for this procedure should be available to fellows in gynecologic oncology training.     

Abordaje laparoscópico en la cirugía radical conservadora del cáncer invasivo de cérvix en pacientes jóvenes. Experiencia preliminar

ObjectiveThe purpose of this study was to evaluate, in a preliminary way, the role of a new surgical approach of fertility-preserving surgery in young patients with early invasive cervical cancer (radical trachelectomy)Patients And MethodsThe first three cases scheduled for laparoscopic vaginal radical trachelectomy corresponding to patients with 35, 36 and 39 years old and FIGO IB1 invasive cervical cancer. Patients were informed of the experimental character of the technique and a fully informed consent was obtained. Vaginal approach was facilitated by laparoscopic preparation of anatomical spaces (paravesical and pararectal) and radical division of cardinal and uterosacral ligaments. The arterial irrigation of uterine corpus was preservedResultsLaparoscopic approach was carried out in all the cases with a mean operative time of 3 h and 10 min. In the first two cases the results of frozen sections allowed to carry out the radical trachelectomy without incidences. Both surgical speciments presented safe negative margins and a mean of 18 pelvic nodes. In the third case a radical vaginal hysterectomy was performed due to find a metastasis in one pelvic node. Two postoperative complications were registered: an pelvic infection that required vaginal drainage and a laparoscopic incisional hernia that required surgical repair. Actually the two patients treated with a conservative surgical approach carry out oral birthcontrol treatment, presenting regular menstruations and negative control of vaginal cytologiesConclusionsLaparoscopic approach, including division of cardinal and uterosacral ligaments, allows to preserve the arterial irrigation of the uterus and to provide a better vaginal radical access     

Expression of p53, Ki-67, and CD31 in the vaginal margins of radical hysterectomy in patients with stage IB carcinoma of the cervix

OBJECTIVES: This study was undertaken to evaluate the expression of p53, Ki-67, and CD31 both in the tumor and in the vaginal margins of radical hysterectomy in patients with stage IB squamous cell carcinoma of the cervix, as an attempt to use these proteins as possible markers for residual tumor in cervical cancer. METHODS: Thirty patients with stage IB squamous cell carcinoma of the cervix were submitted to radical hysterectomy (study group), and thirty patients with uterine myoma were submitted to vaginal hysterectomy (control group) and were prospectively studied from November 2001 to September 2002. Tissue samples were taken from the tumor or cervix, anterior vaginal margin (AVM), and posterior vaginal margin (PVM) and were immunohistochemically evaluated by monoclonal antibodies for p53, Ki-67, and CD31. Vaginal samples in which the histological examination showed tumor involvement were excluded from the study. RESULTS: Patient's mean age was 48.7 +/- 10.4 years (27-73 years). The clinical stage was IB1 in 22 patients (73.3%) and IB2 in eight patients (26.7%). The expressions of p53, Ki-67, and CD31 were significantly higher in the tumor than in the benign cervix (P < 0.001). Higher expressions of these markers were noted in the vaginal margins of radical hysterectomy in patients with cervical carcinoma compared to the vaginal margins of control patients. This association was demonstrated for p53 in the AVM proximal (P = 0.045), for Ki-67 in AVM proximal (P < 0.001), AVM distal (P < 0.001), PVM proximal (P = 0.009), and PVM distal (P < 0.001), and for CD31 in AVM proximal (P = 0.003) and AVM distal (P = 0.018). There was no difference in p53, Ki-67, and CD31 expression between the proximal and distal regions of the vaginal margins in patients with carcinoma of the cervix. CONCLUSION: The expressions of p53, Ki-67, and CD31 were significantly higher in both the histologically positive (cervical tumor) and negative (vaginal margins) tissues of patients who had undergone radical hysterectomy for cervical cancer compared to the benign control tissues.     

Outcomes of Minimally Invasive versus Open Radical Hysterectomy for Early Stage Cervical Cancer Incorporating 2018 FIGO Staging

Study ObjectiveTo compare outcomes after minimally invasive surgery (MIS) vs open radical hysterectomy for early stage cervical cancer incorporating 2018 Federation of Gynecology and Obstetrics (FIGO) staging.DesignA retrospective analysis.SettingA single teaching hospital.PatientsPatients after radical hysterectomy for stage IA1 with lymphovascular invasion, IA2, or IB1 squamous, adenosquamous, or adenocarcinoma of the cervix between 2007 and 2018, mirroring the Laparoscopic Approach to Cervical Cancer trial criteria.InterventionsThe use of MIS surgery for performing radical hysterectomy.Measurements and Main ResultsThe outcomes were compared between patients undergoing MIS vs open approaches. A total of 126 patients met the inclusion criteria. The approach was open in 44 patients (35%) and MIS in 82 patients (65%); 49% were laparoscopic and 51% were robotic. Distribution based on the 2009 FIGO staging showed 1 stage IA1 with lymphovascular invasion, 15 stage IA2, and 110 stage IB1 patients. Although not statistically significant, the 3-year disease-free survival (DFS) was higher in the open compared to the MIS group (95% vs 87%; p = .17), and the overall survival was higher in the open compared to the MIS group (97% vs 92%; p = .25).Fourteen patients whose disease recurred were Stage IB1 by FIGO 2009 staging; 11/14 were reclassified to a higher stage by 2018 FIGO staging (5/5 open, 6/9 MIS). Adjuvant therapy was recommended for all these patients based on the Sedlis criteria (10/14) or other risk factors (4/14). Despite this, only 1/9 of MIS patients whose disease recurred received adjuvant therapy compared with 3/5 patients whose disease recurred in the open group (p = .05).ConclusionIn a cohort of patients similar to that of the Laparoscopic Approach to Cervical Cancer trial, 2018 FIGO staging may be useful to refine indications for MIS radical hysterectomy in early stage cervical cancer. However, disparate outcomes between MIS and open approaches may be explained by differences in compliance with National Comprehensive Cancer Network guidelines for adjuvant therapy.     

Surgical and pathologic outcomes of fertility-sparing radical abdominal trachelectomy for FIGO stage IB1 cervical cancer

ObjectivesTo describe the surgical and pathologic findings of fertility-sparing radical abdominal trachelectomy using a standardized surgical technique, and report the rate of post-trachelectomy adjuvant therapy that results in permanent sterility.MethodsA prospectively maintained database of all patients with FIGO stage IB1 cervical cancer admitted to the operating room for planned fertility-sparing radical abdominal trachelectomy was analyzed. Sentinel node mapping was performed via cervical injection of Technetium and blue dye.ResultsBetween 6/2005 and 5/2008, 22 consecutive patients with FIGO stage IB1 cervical cancer underwent laparotomy for planned fertility-sparing radical abdominal trachelectomy. Median age was 33 years (range, 23–43). Histology included 13 (59%) with adenocarcinoma and 9 (41%) with squamous carcinoma. Lymph-vascular invasion was seen in 9 (41%) cases. Only 3 (14%) needed immediate completion radical hysterectomy due to intraoperative findings (2 for positive nodes, 1 for positive endocervical margin). Median number of nodes evaluated was 23 (range, 11–44); and 6 (27%) patients had positive pelvic nodes on final pathology — all received postoperative chemoradiation. Sixteen (73%) patients agreed to participate in sentinel node mapping which yielded a detection rate of 100%, sensitivity of 83%, specificity of 100% and false-negative rate of 17%. Eighteen of 19 (95%) patients who completed trachelectomy had a cerclage placed, and 9/22 (41%) patients had no residual cervical carcinoma on final pathology. Median time in the operating room was 298 min (range, 180–425). Median estimated blood loss was 250 ml (range, 50–700), and median hospital stay was 4 days (range, 3–6). No recurrences were noted at the time of this report.ConclusionsCervical adenocarcinoma and lymph-vascular invasion are common features of patients selected for radical abdominal trachelectomy. The majority of patients can undergo the operation successfully; however, nearly 32% of all selected cases will require hysterectomy or postoperative chemoradiation for oncologic reasons. Sentinel node mapping is useful but until lower false-negative rates are achieved total lymphadenectomy remains the gold standard. Investigating alternative fertility-sparing adjuvant therapy in node positive patients is needed.     

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.     

Oncologic outcome of fertility-sparing radical trachelectomy versus radical hysterectomy for stage IB1 cervical carcinoma

ObjectiveTo compare the oncologic outcomes of women who underwent a fertility-sparing radical trachelectomy (RT) to those who underwent a radical hysterectomy (RH) for stage IB1 cervical carcinoma.MethodsWe performed a case–control study of all patients with stage IB1 cervical carcinoma who underwent a vaginal or abdominal RT between 11/01 and 6/07. The control group consisted of patients with stage IB1 disease who underwent an RH between 11/91 and 6/07 and who would be considered candidates for fertility-sparing surgery. Information was extracted from a prospectively acquired database. Recurrence-free and disease-specific survival (RFS and DSS) were estimated using Kaplan–Meier estimates and compared with the log-rank test where indicated. Multivariate analysis was performed using the Cox regression method.ResultsForty stage IB1 patients underwent an RT and 110 patients underwent an RH. There were no statistical differences between the two groups for the following prognostic variables: histology, median number of lymph nodes removed, node positive rate, lymph-vascular space involvement (LVSI), or deep stromal invasion (DSI). The median follow-up for the entire group was 44 months. The 5-year RFS rate was 96% (for the RT group compared to 86% for the RH group (P = NS). On multivariate analysis in this group of stage IB1 lesions, tumor size < 2 cm was not an independent predictor of outcome, but both LVSI and DSI retained independent predictive value (P = 0.033 and 0.005, respectively).ConclusionFor selected patients with stage IB1 cervical cancer, fertility-sparing radical trachelectomy appears to have a similar oncologic outcome to radical hysterectomy. LVSI and DSI appear to be more valuable predictors of outcome than tumor diameter in this subgroup of patients.     

Fertility-Sparing Surgery for Early-Stage Cervical Cancer: A Systematic Review of the Literature

ObjectiveThis systematic review aimed to evaluate oncologic and reproductive outcomes after fertility-sparing surgery (FSS) for early-stage cervical cancer (early CC).Data SourcesOvid MEDLINE, Ovid EMBASE, and Cochrane CENTRAL were searched from 1980 to the present using Medical Subject Headings terms; other controlled vocabulary terms; and keywords related to fertility, cervical cancer, and surgical techniques.Methods of Study SelectionA total of 2415 studies were screened, with 53 studies included. Studies reporting recurrences with a median follow-up of 12 months in early CC (International Federation of Gynecology and Obstetrics 2009 stages IA with lymphovascular space invasion, IB, or IIA) of traditional histologic type undergoing FSS were included.Tabulation, Integration, and ResultsThe studies were grouped by intervention, including vaginal radical trachelectomy (VRT), abdominal radical trachelectomy (ART), minimally invasive radical trachelectomy (MIS-RT), and conization or simple trachelectomy (ST), and studies involving neoadjuvant chemotherapy (NACT). Combined rates of recurrence (RR), cancer death (CDR), pregnancy (PR), and live birth (LBR) were calculated per procedure on the basis of all included studies that reported outcomes on that procedure.The results were as follows:VRT: RR 4%, CDR 1.7%, PR 49.4%, and LBR 65.0%ART: RR 3.9%, CDR 1.4%, PR 43.2%, and LBR 44.0%MIS-RT: RR 4.2%, CDR 0.7%, PR 36.2%, and LBR 57.1%Cone or ST: RR 4.2%, CDR 0.8%, PR 55.1%, and LBR 71.9%NACT: RR 7.5% and CDR 2.0%ConclusionFSS of early CC with VRT, ART, or MIS-RT have comparable oncologic outcomes in carefully selected patients, with reproductive outcomes favoring VRT. Data on nonradical FSS with cone or ST are less robust but support similar oncologic outcomes to radical trachelectomy with fewer reproductive complications. NACT in this setting requires more investigation before routine implementation into practice.     

Laparoscopically assisted radical vaginal hysterectomy (Coelio-Schauta): a comparison with open Wertheim/Meigs hysterectomy

The objective of this study was to compare the safety, efficacy, and short-term benefits of the Coelio-Schauta procedure with open Wertheim/Meigs radical abdominal hysterectomy. We retrospectively analyzed records of our first 35 consecutive patients undergoing laparoscopically assisted radical vaginal hysterectomy (LARVH) for early cervical cancer and 32 consecutive patients of open radical hysterectomy (ORH) performed between 1999 and 2005 in our institution. We analyzed patient age, bodyweight, previous abdominal surgery, operating time, blood loss, perioperative complications, postoperative bladder dysfunction, other postoperative complications, and histologic type. The FIGO stage, excision margins, node count and node status, follow-up, and recurrence rates were also taken into account. We excluded stage IA and stage II disease patients to reduce the impact of tumor size on the outcome of the surgery. This left 27 patients with stage IIB disease who had LARVH and 28 patients with stage IB disease who had ORH. These patients formed the study group. The cohorts were similar in age, bodyweight, previous abdominal surgery, histologic subtype, FIGO stage, resection margins, node count and node status, length of follow-up, and recurrence. There were statistically significant differences between LARVH and ORH for duration of surgery (mean 160 vs 132 min), intraoperative blood loss (479 vs 715 mL), hospital stay (mean 5 vs 9.3 days), postoperative complications (6 vs 20 patients), and duration of bladder catheterization (mean 4.4 vs 8.8 days). Four LARVH patients and no ORH patients had urinary tract injury that was repaired. None had long-term sequelae. Our data confirm that LARVH is a suitable alternative to ORH hysterectomy for small-volume stage IB1 cervical cancer with similar clinical efficacy and a superior postoperative recovery and postoperative morbidity profile. Urinary tract trauma is a clear risk in the early stages of the learning curve.     

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.     

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.     

Ovarian metastases in early-stage cervical cancer (IA2–IIA): a multicenter retrospective study of 1965 patients (a Cooperative Task Force study)

This is a retrospective study of patients treated for early-stage cervical cancer to identify pathologic risk factors associated with ovarian metastases and, therefore, to establish when ovarian preservation can be performed without increasing the risk of relapse in order to improve the quality of life in premenopausal patients. Between 1982 and 2004, 1965 patients with FIGO stage IA2-IB-IIA cervical squamous cell carcinoma and nonsquamous histology types were surgically treated; 1695 (86%) patients underwent primary radical hysterectomy, bilateral salpingo-oophorectomy, and pelvic node dissection, the remaining 270 patients (14%) had their ovaries preserved. The clinical records were reviewed for all patients and clinical features at presentation, the histopathology and follow-up data were recorded. Overall, ovarian metastases were diagnosed in 16 of 1695 patients, for an incidence rate of 0.9%. Univariate analysis shows age (45 years: P = 0.0079), FIGO stage (IB1-IIA 4 cm: P = 0.0133), histology (squamous vs nonsquamous, P = 0.0014), noninvolved peripheral stromal thickness (<3 vs >3 mm: P = 0.0001), lymphvascular space involvement (present vs absent, P = 0.0007), lymph node status (positive vs negative, P = 0.00009) to be statistically associated with the presence of ovarian metastases. Multivariate analysis shows only age (P = 0.0119), FIGO stage (P = 0.011), histology (P = 0.001), and unaffected peripheral stromal thickness (<3 mm: P = 0.037) to be independent risk factors for ovarian metastases. Based on the present data and on the data available in the literature, ovarian preservation could be safely performed in young patients with early-stage squamous cell carcinoma (histology as the most significant risk factor), with macroscopically normal ovaries, and with preserved peripheral unaffected cervical stroma.     

Management of early-stage cervical carcinoma by modified (Type II) radical hysterectomy

OBJECTIVE:. Surgical management of cervical carcinoma by radical hysterectomy has been proven a highly effective method in treating early-stage disease. The purpose of this study was to evaluate the efficacy and safety of modified (Type II) radical hysterectomy for the treatment of early-stage (I-IIA) cervical carcinoma. METHODS: A retrospective analysis of data on 435 patients with cervical carcinoma who were managed by modified radical hysterectomy was performed. In 145 cases a multimodal approach was used due to the presence of one or more risk factors such as lymph node metastasis, CLS involvement, bulky tumor, and exocervical extension of disease. Preoperative irradiation was offered to 62 patients, whereas adjuvant irradiation was offered to 101 patients. RESULTS: The mean age of the patients was 42.5 years. The majority of the patients had squamous cell cancer (81.6%). The patients were clinically staged as IA (3.2%), IB (86.7%), and IIA (10.1%). Positive pelvic lymph nodes were noted in 65 patients (14.9%). Operative morbidity was minimal, whereas adjuvant radiation treatment had no impact on the disease but caused genitourinary morbidity in terms of ureteral stricture and postoperative bladder dysfunction (P < 0.001). The overall 5-year survival was 88.7%. The most significant predictors related to 5-year survival were nodal metastasis (P < 0.001), adenomatous histology (P < 0.001), lesion size (P < 0.001), and CLS involvement (P = 0.004). Adjuvant radiation resulted in better local pelvic control of the disease. CONCLUSION: The results of our study support the concept that less radical procedures could be effectively applied to early-stage cervical carcinoma 4 cm or smaller with optimal surgical margins.     

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 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.     

Pregnancies after radical vaginal trachelectomy for early-stage cervical cancer

Objective: The purpose of this study was to evaluate the role of fertility-preserving surgery in the treatment of early-stage cervical cancer. Study Design: We retrospectively reviewed our first 30 patients treated by laparoscopic pelvic lymphadenectomy, followed by radical vaginal trachelectomy, from October 1991 to April 1998. Results: The median age of the patients was 32 years (range 22-42 years); 15 were nulligravid and 19 nulliparous. Twenty cancers were at stage IB, 1 was at stage IA₁ , 7 were at stage IA₂ , and 2 were at stage IIA. The majority (18/30) were squamous. Two lesions were >2 cm in size, and only 4 had vascular space invasion. The median operative time was 285 minutes (range 155-455 minutes), median blood loss 200 mL (range 50-1200 mL), and median hospital stay 4 days (range 2-9 days). There were 4 intraoperative complications—2 attributed to the trachelectomy and 2 resulting from the lymphadenectomy. The current median follow-up time is 25 months (range 1-79 months). One patient had a recurrence in the left parametrium 18 months after vaginal radical trachelectomy and died of metastatic disease. The only 6 patients attempting pregnancy so far have succeeded: 4 have had healthy babies delivered by cesarean section at 39, 38, 34, and 25 weeks of gestation. Two are currently 33 and 8 weeks pregnant. Conclusion: Radical vaginal trachelectomy appears to be a valuable procedure in well-selected patients with early-stage cervical cancer. Successful pregnancies are definitely possible after this procedure. This new surgical technique warrants further careful evaluation to determine precise indications. (Am J Obstet Gynecol 1998;179:1491-6.)