Clinical Review

Cervical Cancer Patients: Need Not Forgo Fertility

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Radical vaginal trachelectomy offers a select group of cervical cancer patients an alternative to traditional radical hysterectomy. The author examines studies that have shown positive oncologic and childbearing outcomes for reproductive-age patients desiring future fertility.


 

References

Key Points
  • Lesions should be smaller than 2 cm to achieve the most favorable outcomes. Masses up to 3 cm can be resected, but the recurrence rate is higher, especially if the tumor has invaded the lymph-vascular space.
  • Resect the cervix 0.5 to 1 cm distal to the isthmus. If the proximal incision margin has cleared the cancer, close the peritoneum and suture the vaginal mucosa to the cervical stump.
  • The rate of second-trimester loss is elevated as a result of subclinical chorioamnionitis due to exposure of the membranes to vaginal flora. The Saling procedure has been shown to prevent ascending infections.
  • The majority of women who have undergone radical vaginal trachelectomy successfully conceive, and most pregnancies result in a live birth.

While the mean age at which cervical cancer is diagnosed is 51, approximately 10% to 15% of women will develop cervical cancer in their reproductive years.1 Traditionally, early-stage cervical cancers in young women have been treated by radical hysterectomy, resulting in permanent sterility. Now, these patients have an alternative: radical vaginal trachelectomy. This entails the excision of the majority of the cervix and parametria, with preservation of the uppermost portion of the cervix and uterus, allowing the possibility of future childbearing (Figure 1).

The rate of second trimester loss is elevated in radical vaginal trachelectomy patients.

A conservative approach for the treatment of early-stage cervical cancer was first proposed approximately 20 years ago by Aburel, a Romanian gynecologist.2 He reported his experience with the abdominal “subfundic radical hysterectomy.” However, subsequent successful pregnancies did not occur, and the procedure was abandoned. In 1987, the French gynecologist Dargent began performing radical vaginal trachelectomy in concert with laparoscopic pelvic lymphadenectomy. He published his initial results in 1994.3 Thereafter, researchers in Quebec,4 Toronto,5 and London6 have reported their experiences with this procedure. Currently, almost 200 cases are reported in the literature. After describing patient selection and the technique, I will review the data regarding complications and oncologic and reproductive outcomes.

Figure 1


The shaded area indicates the portion of the cervix and upper vagina that will be resected during the procedure.

Patient selection

Although the potential benefit—preservation of fertility—is profound, the percentage of patients with cervical cancer who are candidates for radical vaginal trachelectomy is relatively small. The indications are the presence of an invasive cervical cancer (stage Ia2, Ib1, or IIa), the desire for future childbearing, no involvement of the upper endocervical canal, and no evidence of metastases on preoperative chest radiography and physical exam. Lesions 2 cm or smaller are ideal. While masses up to 3 cm can be resected, the recurrence rate is higher (similar to that after radical hysterectomy). Further, the absence of lymph-vascular space involvement (LVSI) is preferred, but its presence is not an absolute contraindication to the surgery.

Technique

Prior to the radical vaginal trachelectomy, perform a pelvic lymphadenectomy either transperitoneally or retroperitoneally, depending on the surgeon’s preference. If immediate histopathologic analysis of the lymph nodes is negative for metastases, proceed with the trachelectomy.

With the patient in the dorsal lithotomy position, grasp the vagina approximately 3 cm from the cervix and inject it with lidocaine. Then, using a scalpel, incise the vagina at the 12 o’clock position. After developing the vaginal cuff, suture it over the tumor using an absorbable suture in a figure-of-eight stitch, which provides traction to help identify proper surgical planes. Using the technique for a vaginal hysterectomy, create the vesicovaginal space. Then grasp the vagina at the 9 o’clock and 11 o’clock positions and sharply develop the paravesical space. Access to this space is located at approximately the 10 o’clock position. Repeat the same procedure on the contralateral side. (In this case, grasp the vagina at the 3 o’clock and 1 o’clock positions; access to this space is located at the 2 o’clock position.)

In the hands of an experienced surgeon, the complication rate is comparable to that of radical hysterectomy.

Place retractors in the paravesical spaces and retract the bladder anteriorly. The bladder pillars, which contain the ureters and are located in between the vesicovaginal and paravesical spaces, are now fully exposed (Figure 2). Palpate the ureter in each bladder pillar, then sharply divide each pillar, using cautery for hemostasis as needed. The ureters are now visible, as are the descending branches of the uterine artery.

At this point, the posterior cul-de-sac and the pararectal spaces can be accessed. Divide the uterosacral and cardinal ligaments 2 cm from the cervix (Figure 3). Retract the ureters and clamp the descending branch of the uterine artery. Finally, resect the cervix 0.5 to 1 cm distal to the isthmus and send the specimen to pathology (Figure 4). If the proximal (deep) incision margin has cleared the cancer, close the peritoneum and place a cerclage using a strong nonabsorbable suture (Figure 5). I prefer a double cerclage of No. 1 polyester or polypropylene. Then suture the vaginal mucosa to the cervical stump, not to the mucosa, to help prevent postoperative stenosis (Figure 6).

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