Background

Cervical cancer is the second most common malignancy in women worldwide.^[1]According to Surveillance Epidemiology and End Results (SEER) data from 2013-2017, the age-adjusted incidence of cervical cancer was 7.4 per 100,000 women per year.^[2]The standard treatment of cervical cancer worldwide includes surgery, chemoradiotherapy, or neoadjuvant chemotherapy followed by surgery. However, in young women with early cervical cancer who want to preserve fertility, alternative surgical options such as radical trachelectomy (RT) or simple trachelectomy are available in select cases.

Appropriate patient selection is crucial for successful fertility-sparing surgery. Radical trachelectomy can be approached vaginally, abdominally, laparoscopically, or robotically. Radical trachelectomy is a curative conservative procedure in which the cervix, upper 1-2 cm of the vagina, parametria (tissue adjacent to the cervix), and paracolpos are resected while preserving the uterine corpus and fundus.^[3]

In 1994, Dargent et al reported the first laparoscopic pelvic lymphadenectomy followed by radical vaginal trachelectomy. Since this initial report, over 1000 women have undergone this procedure, with over 250 successful pregnancies afterward.^[4]

The morbidity is considered low, with a tumor recurrence rate between 4.2% and 5.3% and a mortality rate between 2.5% and 3.2%.^[4]

Parametrial resection in early cervical cancer has been controversial. Schmeler et al performed an extensive literature search of conservative surgery in women with low-risk early cervical cancer (stage 1A2-1B1, < 2 cm, no lymph-vascular space invasion) from 1970-2010 and found that several studies reported parametrial involvement in less than 1% of patients.^[5]

More recent studies have explored a more conservative approach with less-radical surgery, including pelvic lymphadenectomy with cone biopsy, simple trachelectomy, or simple hysterectomy.^[5]Unlike radical hysterectomy (RH) or radical trachelectomy, simple trachelectomy involves the removal of the cervix and not the parametria.

Rob et al evaluated 26 patients with stage 1A2-1B1 cervical cancer who underwent lymph node evaluation through laparoscopic sentinel lymph node identification, frozen section, and complete pelvic lymphadenectomy. Four patients had positive lymph nodes and underwent a type 3 radical hysterectomy, whereas 22 patients had negative lymph nodes and underwent either a cone excision or simple trachelectomy. Only 1 of 26 patients developed central recurrence 14 months after the procedure, and the patient was successfully treated with chemoradiation.

Of the 15 women who wanted to conceive, 11 became pregnant, with 1 delivery at 24 weeks, 1 at 34 weeks, 1 at 36 weeks, 5 at term, and the remaining resulting in elective abortion, miscarriage, or ectopic pregnancy.^[6]Further studies are warranted to evaluate the safety of less-radical surgery in a larger group of patients.

Indications

The eligibility criteria for fertility-sparing surgery were initially proposed by Roy and Plante in 1998.^[3]These criteria include the following:

Desire to preserve fertility
Lesion size of 2 cm or smaller
FIGO stage 1A1 with presence of vascular space invasion or FIGO stage 1A2 and 1B1
No involvement of the upper endocervical canal as determined with MRI
No lymph node metastasis

Contraindications

Fertility-sparing surgery is not recommended in women who do not meet the criteria listed in Indications.

A tumor larger than 2 cm can be accompanied by lymph vascular space invasion, with extension to the upper endocervix or parametrium. The recurrence rate and probability of lymph node metastasis is greater with larger tumors.

In addition, patients with certain histologic subtypes, including neuroendocrine tumors, papillary serous, and sarcomas, are not candidates for radical trachelectomy.

Technical Considerations

Prior to performing a radical or simple trachelectomy, it is crucial to rule out lymph node involvement. A laparoscopic lymphadenectomy can be performed via either a transperitoneal or retroperitoneal approach. For surgeons who are less adept with laparoscopy, an extraperitoneal dissection is acceptable.^[7]If lymph node involvement is discovered, trachelectomy is abandoned.

Limited studies have been published on the intraoperative margin assessment of a radical trachelectomy specimen. Ismill et al described their frozen section protocol for 132 trachelectomy cases between 1994 and 2007. They found that the final margin assessment was consistent with the frozen section diagnosis in 98.5% of cases.^[8]

Their frozen section protocol consisted of examining the entire circumference of the lower uterine segment/upper endocervix (LUS/EC) through perpendicular sections. The peripheral soft tissue, including the parametria, was inked green, while the LUS/EC was inked blue. The proximal 1-cm segment was then transected from the rest of the specimen and opened to show the mucosa. A gross inspection was performed to identify any residual tumor. Subsequently, the 1-cm proximal specimen would be serially sliced into 10-12 sections, each measuring 3- to 5-mm thick. Upon evidence of tumor less than 5 mm from the margin on frozen section, the margin is revised by resecting another 5- to 10-mm portion of the lower uterine segment.^[8]

Best Practices

During the dissection portion of the radical trachelectomy, the ureter should be mobilized and identified along its path in order to avoid ureteral injury. After thorough ureteral dissection and mobilization has been completed, the vaginal branch of the uterine artery is ligated.

Fertility outcomes

Approximately 15% of women who undergo trachelectomy may be infertile and may require some form of assisted reproductive technology.^[9]Most cases of fertility problems are attributed to cervical stenosis. It is recommended that women wait 6-12 months following trachelectomy before attempting to conceive.^[10]

Obstetrical outcomes

A major concern of obstetrical care in women following simple or radical trachelectomy is the higher rate of preterm delivery. Preterm labor and delivery after a trachelectomy are thought to result from cervical insufficiency due to a shorter cervical length or subchronic chorioamnionitis that leads to premature rupture of membranes.^[11]

A study of 125 vaginal radical trachelectomies performed between 1991 and 2010 assessed the oncologic, fertility, and obstetrical outcomes. The investigators found that 4% of women delivered before 32 weeks’ gestation, 14% delivered between 28 and 36 weeks’ gestation, and 55% delivered at term (>37 weeks).^[9]The risk of miscarriage following vaginal radical trachelectomy is similar to that in the general population (16%-20%).^[12]

Gynecological outcomes

Alexander-Sefre et al performed a retrospective review analyzing the surgical morbidity associated with radical trachelectomy in 29 patients. The investigators reported dysmenorrhea in 24%, irregular menstruation in 17%, recurrent candidiasis in 14%, cervical suture problems in 14%, isthmic stenosis in 10%, and prolonged amenorrhea in 7%.^[13]

Oncologic outcomes

Diaz et al performed a case control study comparing the oncologic outcomes of women who underwent radical trachelectomy versus radical hysterectomy. They concluded that, of the 40 patients who underwent radical trachelectomy and 110 patients who underwent radical hysterectomy, a similar oncologic outcome was noted between the two groups.^[14]

It is important to note that a small percentage of patients require further treatment after fertility-sparing surgery.

In a study of 125 vaginal radical trachelectomies, 4%-5% of patients required adjuvant therapy after high-risk histology was found on final pathology.^[9]

Although the fertility-sparing surgery is designed to be a curative procedure, there is the risk of recurrence. Approximately 40% of recurrences occur in the parametrium or pelvic side wall, which may be attributable to insufficient parametrial excision. Nearly 25% of recurrences were noted in the pelvic, paraaortic, and/or supraclavicular lymph nodes.^[7]

Patient selection is critical to decrease the risk of recurrence. Risk factors for recurrence include lesions greater than 2 cm, presence of lymph-vascular space invasion, unfavorable histology, and close (defined as < 5 mm) surgical margins.^[12]

Periprocedure

Hacker NF, Friedlander ML. Cervical cancer. Berek JS, Hacker NF, eds. Berek and Hacker's Gynecologic Oncology. 5th ed. Philadelphia: Lippincott Williams and Wilkins; 2010. 341-95.
Cancer Stat Facts: Cervical Cancer. National Cancer Institute Surveillance, Epidemiology, and End Results Program. Available at https://seer.cancer.gov/statfacts/html/cervix.html. Accessed: December 14, 2020.
Chi DS, Abu-Rustum NR, Plante M, Roy M. Cancer of the cervix. Rock JA, Jones HW III, eds. TeLinde’s Operative Gynecology. 10th ed. Philadelphia: Lippincott Williams and Wilkins; 2003. 1247-73.
Martinez A, Poilblanc M, Ferron G, De Cuypere M, Jouve E, Querleu D. Fertility-preserving surgical procedures, techniques. Best Pract Res Clin Obstet Gynaecol. 2012 Jun. 26(3):407-24. [QxMD MEDLINE Link].
Schmeler KM, Frumovitz M, Ramirez PT. Conservative management of early stage cervical cancer: is there a role for less radical surgery?. Gynecol Oncol. 2011 Mar. 120(3):321-5. [QxMD MEDLINE Link].
Rob L, Charvat M, Robova H, et al. Less radical fertility-sparing surgery than radical trachelectomy in early cervical cancer. Int J Gynecol Cancer. 2007 Jan-Feb. 17(1):304-10. [QxMD MEDLINE Link].
Beiner ME, Covens A. Surgery insight: radical vaginal trachelectomy as a method of fertility preservation for cervical cancer. Nat Clin Pract Oncol. 2007 Jun. 4(6):353-61. [QxMD MEDLINE Link].
Ismiil N, Ghorab Z, Covens A, et al. Intraoperative margin assessment of the radical trachelectomy specimen. Gynecol Oncol. 2009 Apr. 113(1):42-6. [QxMD MEDLINE Link].
Plante M, Gregoire J, Renaud MC, Roy M. The vaginal radical trachelectomy: an update of a series of 125 cases and 106 pregnancies. Gynecol Oncol. 2011 May 1. 121(2):290-7. [QxMD MEDLINE Link].
Plante M, Renaud MC, Roy M. Radical vaginal trachelectomy: a fertility-preserving option for young women with early stage cervical cancer. Gynecol Oncol. 2005 Dec. 99(3 Suppl 1):S143-6. [QxMD MEDLINE Link].
Plante M, Smith EB, Cox S, Silverberg K, Reich S. The case of a viable pregnancy post vaginal radical trachelectomy followed by combined chemo-radiation therapy. Gynecol Oncol. 2011 Nov. 123(2):421-3. [QxMD MEDLINE Link].
Plante M. Vaginal radical trachelectomy: an update. Gynecol Oncol. 2008 Nov. 111(2 Suppl):S105-10. [QxMD MEDLINE Link].
Alexander-Sefre F, Chee N, Spencer C, Menon U, Shepherd JH. Surgical morbidity associated with radical trachelectomy and radical hysterectomy. Gynecol Oncol. 2006 Jun. 101(3):450-4. [QxMD MEDLINE Link].
Diaz JP, Sonoda Y, Leitao MM, et al. Oncologic outcome of fertility-sparing radical trachelectomy versus radical hysterectomy for stage IB1 cervical carcinoma. Gynecol Oncol. 2008 Nov. 111(2):255-60. [QxMD MEDLINE Link].
Camilien L, Gordon D, Fruchter RG, Maiman M, Boyce JG. Predictive value of computerized tomography in the presurgical evaluation of primary carcinoma of the cervix. Gynecol Oncol. 1988 Jun. 30(2):209-15. [QxMD MEDLINE Link].
Falcone T, Walters MD. The operating room suite and instrumentation. Baggish MS, Karram MM, eds. Atlas of Pelvic Anatomy and Gynecologic Surgery. 2nd ed. Philadelphia: Elsevier; 2006. 1035-6.
Sharp HT, Francis SL, Murphy AA. Diagnostic and operative laparoscopy. Rock JA, Jones HW, eds. TeLinde’s Operative Gynecology. 10th ed. Philadelphia: Lippincott Williams and Wilkins; 2003. 325.
Plante M, Roy M. Radical vaginal trachelectomy. Smith JR, Del Priore G, Curtin JP, Monaghan JM, eds. An Atlas of Gynecologic Oncology: Investigation and Surgery. 2nd ed. London: Taylor & Francis; 2005. 122-8.
Ungar L, Palfalvi L, Boyle DCM, Del Priore G, Smith JR. Radical abdominal trachelectomy. Smith JR, Del Priore G, Curtin JP, Monaghan JM, eds. An Atlas of Gynecologic Oncology: Investigation and Surgery. 2nd ed. London: Taylor & Francis; 2005. 134-9.
Li X, Li J, Wu X. Incidence, risk factors and treatment of cervical stenosis after radical trachelectomy: A systematic review. Eur J Cancer. 2015 Sep. 51(13):1751-9. [QxMD MEDLINE Link].
Robova H, Rob L, Halaska MJ, Pluta M, Skapa P. Review of neoadjuvant chemotherapy and trachelectomy: which cervical cancer patients would be suitable for neoadjuvant chemotherapy followed by fertility-sparing surgery?. Curr Oncol Rep. 2015. 17(5):446. [QxMD MEDLINE Link].

Media Gallery

Figure 1 (Figure 5): Vaginal Cuff Preparation
Figure 2(Figure 6): Completion of the Preparation phase; placing the clamps
Figure 3 (Figure 7): Entering the vesicouterine space
Figure 4 (Figure 8): Defining the paravesical space
Figure 5 (Figure 9): Defining both the vesicouterine and paravesical space; ureter exposed
Figure 6 (Figure 11): Excision of bladder pillars
Figure 7 (Figure 12): Excision of parametrium
Figure 8 (Figure 13): Identification of the descending branch of the uterine artery
Figure 9 (Figure 14): Transection of the cervix
Figure 10 (Figure 15): Placing the cervical cerclage
Figure 11(Figure 16): Completed vaginal closure
Figure 16 (Figures 47.34 page 1265 from TeLinde's textbook) : Cerclage placement
Figure 17 (Figure 47.35 page 1265 from TeLinde's textbook): Reconstruction of uterine corpus to vaginal mucosa