Radical and Simple Trachelectomy Periprocedural Care

Updated: Dec 23, 2015
  • Author: Christine Rojas, MD; Chief Editor: Warner K Huh, MD  more...
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Periprocedural Care

Patient Education & Consent

The management of early cervical cancer with fertility-sparing surgery requires thorough counseling and informed consent. Medical providers should discuss advantages, disadvantages, and alternative options with the patient.

The intraoperative complications that may occur during radical trachelectomy include vascular trauma requiring possible laparotomy, ureteral injury, cystotomy, and injury to other intra-abdominal structures.

Plante et al evaluated the complications after vaginal radical trachelectomy in 126 patients and found that some of the complications included bladder hypotonia (16%), urinary tract infection (8%), lymphocele(8%), vulvar edema (8%), vulvar hematoma (7%), suprapubic hematoma (3%), lymphedema (2%), pelvic abscess (2%), lombalgia (2%), the need for blood transfusions (1.6%), femoral cutaneous palsy (1%), and prolonged ileus (1%). [9]

It is crucial to discuss with the patient that, despite efforts to preserve fertility with radical trachelectomy, there may be short- or long-term obstetrical, gynecological, and fertility complications.

As part of the informed consent, it is important that the patient is aware that radical trachelectomy may be abandoned intraoperatively for multiple reasons, such as endometrial extension, close or positive resection margins, or lymph node metastasis. In the analysis by Plante et al, of 140 planned vaginal radical trachelectomies, only 125 were performed. Eleven percent of cases resulted in an abandoned trachelectomy, with the main reason being lymph node metastasis (60%). [9] In addition, patients should be advised that final pathology may demonstrate a higher risk for recurrence, requiring adjuvant treatment.

Patient Instructions

The patient is usually admitted on the day of surgery. Clear written instructions should be given to the patient for the 24 hours before surgery.

The patient should not have anything to eat or drink at least 6 hours prior to surgery.

Based on the patient’s home medication list, the provider may instruct the patient to withhold certain medications on the day of surgery.

Elements of Informed Consent

Discuss alternate treatment modalities (eg, conization, radical hysterectomy, chemoradiation, chemotherapy, combination therapies). Inform the patient of risks/benefits of each treatment modality.

Review the importance and purpose of pelvic lymphadenectomy. Discuss in detail that the findings on frozen section may lead to cancellation of a fertility-sparing procedure.

Review obstetrical complications in the short and long term, including the potential for being unable to conceive in the future.

Review gynecological complications in the short and long term.

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Pre-Procedure Planning

Patient selection is essential in the preoperative evaluation process.

Initially, a thorough history and physical examination, routine blood work, and imaging studies, such as CT scanning, MRI, and chest radiography should be performed. A complete blood cell (CBC) count, type and screen, and comprehensive metabolic panel (CMP) are recommended prior to surgery. Other possible laboratory studies that may be helpful based on patient’s medical history include PT/PTT/INR.

Prior to fertility-sparing surgery, it is critical to determine the tumor size and lymph node status. Identification of lymph node status still remains an important prognostic factor for survival. Lymph node involvement excludes fertility-sparing surgery. As part of tumor staging, it is not unusual for a patient to undergo CT scanning, MRI, and/or positron emission tomography (PET) to evaluate for lymph node metastasis.

MRI is considered helpful in selecting patients for radical trachelectomy because it provides an assessment of the tumor size and location, amount of cervical stroma infiltration, length of the endocervical canal, and the distance between the upper margin of the lesion and the isthmus. [12] Unfortunately, these imaging techniques have limitations in detecting nodal metastasis. CT and MRI have a low sensitivity compared to surgical staging in detecting metastasis. Camilien et al found that CT scanning has a sensitivity of 67% for detection of para-aortic nodes and 25% of pelvic nodes. [15]

Owing to these limitations, surgical staging has evolved into a method for assessing lymph node involvement.

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Equipment

Fertility-sparing surgery can be performed vaginally, abdominally, or through a minimally invasive approach (ie, straight stick laparoscopy or robotic-assisted laparoscopy).

The equipment for the abdominal approach consists of the standard laparotomy gynecology set. It is important to have pedicle clamps, tissue forceps, dissecting scissors, and needle holders that are long enough to operate deep in the pelvis. The vascular pedicles are suture ligated with 0 Vicryl. Most providers use either 0 Prolene or 0 Ethibond suture for the prophylactic cerclage placement at the end of the procedure. The same is true for the vaginal approach to a trachelectomy procedure.

The basic instruments required for laparoscopic surgery include the electronic cart, laparoscopic instrument table, and vaginal instrument table. [16] The electronic cart contains the monitor, camera unit, light source, and image-recording system.

The laparoscopic instrument table contains the laparoscope, fiberoptic cord, trocars and sleeves of varying diameter, and surgical instruments based on surgeon’s preference, such as graspers, dissectors, scissors, blunt probes, suction irrigator, needle drivers, knot pushers, uterine manipulators, and electrocautery devices. The vaginal instrument table contains a Foley catheter, weighted speculum, multiple retractors, single-toothed tenaculum, lidocaine with vasoconstrictor (ie, epinephrine) injection, scalpel, Mayo and Metzenbaum scissors, forceps, multiple clamps, surgeons preference of electrocautery device, nonabsorbable suture for cerclage placement, and absorbable suture. [16]

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Patient Preparation

Prior to surgery, broad spectrum antibiotics are recommended for prophylaxis.

The patient is prepared and draped in a sterile fashion in the lithotomy position. Bowel preparation is unnecessary.

Anesthesia

General or regional anesthesia is used.

Positioning

Patients are placed in a Trendelenburg position for laparoscopic pelvic lymphadenectomy. The lithotomy position is the standard position for vaginal surgery. The patient’s buttocks should be over the table’s edge to allow access to the perineum. In order to avoid stretch injury to the femoral, sciatic, or obturator nerves, the thighs should not be flexed greater than 90°, and the hips should be abducted no greater than 45°. [17]

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Monitoring & Follow-up

For the postoperative course, patients should have adequate pain control.

There are no clear guidelines regarding patient office follow-up after trachelectomy. However, a cytologic and colposcopic examination is recommended every 3-4 months for the first 3 years, every 6 months for the subsequent 2 years, and yearly thereafter. [12]

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