Radical and Simple Trachelectomy 

Updated: Dec 14, 2020
Author: Christine Rojas, MD; Chief Editor: Leslie M Randall, MD, MAS, FACS 

Overview

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.

Outcomes

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]

 

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.

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.

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]

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]

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]

 

Technique

Approach Considerations

Pelvic lymphadenectomy should be performed first to evaluate lymph node involvement. On frozen section, all surgical margins should be free of disease prior to proceeding further with a fertility-sparing procedure.

Pelvic lymphadenectomy consists of removing lymphatic tissue along the external and internal iliac vessels, up to the lower common iliac vessels, and around the obturator nerve.[13]

Vaginal Radical Trachelectomy

Vaginal radical trachelectomy consists of 5 steps: (1) vaginal cuff preparation, (2) posterior phase, (3) anterior phase, (4) lateral phase, and (5) excision of the specimen and closure.[3]

The procedure is begun by defining approximately 2 cm of the vaginal mucosa and grasping the vaginal margin with 5-8 straight clamps. A local anesthetic containing a vasoconstrictor is then injected followed by a circumferential incision along the vaginal mucosa.

Figure 1 (Figure 5): Vaginal Cuff Preparation Figure 1 (Figure 5): Vaginal Cuff Preparation

The anterior and posterior vaginal mucosa edges are grasped with clamps.

Figure 2(Figure 6): Completion of the Preparation Figure 2(Figure 6): Completion of the Preparation phase; placing the clamps

Then, the posterior phase is developed by opening the posterior cul-de-sac. The paracolpos are excised, and the pararectal space is opened. The uterosacral ligaments are isolated and divided. By releasing the posterior attachments, there is greater uterine descent to help with the anterior phase.[1]

The anterior phase is developed by opening the vesicouterine space followed by the paravesical spaces.

Figure 3 (Figure 7): Entering the vesicouterine sp Figure 3 (Figure 7): Entering the vesicouterine space
Figure 4 (Figure 8): Defining the paravesical spac Figure 4 (Figure 8): Defining the paravesical space

The ureter is localized and mobilized by dissecting the bladder pillar off the cardinal ligament.

Figure 5 (Figure 9): Defining both the vesicouteri Figure 5 (Figure 9): Defining both the vesicouterine and paravesical space; ureter exposed
Figure 6 (Figure 11): Excision of bladder pillars Figure 6 (Figure 11): Excision of bladder pillars

After the ureter has been dissected and identified, the uterine vessels will be visible over the ureter. Subsequently, the lateral phase is performed by excising the parametrium.

Figure 7 (Figure 12): Excision of parametrium Figure 7 (Figure 12): Excision of parametrium

Unlike in vaginal hysterectomy, only the descending branch of the uterine artery is excised. It is important to leave optimal vascularization of the uterus, since the procedure is being performed to preserve fertility.

The cervicovaginal artery is clamped, ligated, and cut.

Figure 8 (Figure 13): Identification of the descen Figure 8 (Figure 13): Identification of the descending branch of the uterine artery

Lastly, the cervix is transected approximately 1 cm below the internal cervical os.

Figure 9 (Figure 14): Transection of the cervix Figure 9 (Figure 14): Transection of the cervix

The specimen should be 1-2 cm wide, with a 1-cm vaginal mucosa and 1-2 cm of parametrium.[3]

The final step is the reconstruction phase. A prophylactic cerclage is placed at the level of the isthmus using a nonresorbable suture such as Prolene.

Figure 10 (Figure 15): Placing the cervical cercla Figure 10 (Figure 15): Placing the cervical cerclage

In order to avoid cervical stenosis, a rubber catheter is inserted into the remaining cervical canal.

The final step involves approximating the edge of vaginal mucosa to the new exocervix.

Figure 11(Figure 16): Completed vaginal closure Figure 11(Figure 16): Completed vaginal closure

Abdominal Radical Trachelectomy

Abdominal radical trachelectomy can be approached multiple ways. The surgery can be performed with a low transverse (with either a Cherney or Maylard) or a vertical incision.

Upon entry into the abdominal cavity, an intraabdominal survey is performed by paying close attention to the abdominal viscera and parietal peritoneum for possible evidence of metastasis. A self-retaining or Bookwalter retractor is used to provide better exposure into the abdominal cavity. The liver, diaphragm, spleen, small and large bowel and omentum are evaluated for evidence of metastasis.

A bilateral complete pelvic lymphadenectomy is performed. Any suspicious lymph nodes are sent for frozen-section evaluation. Upon evidence of metastasis, the radical trachelectomy procedure is abandoned. If there is no evidence of metastasis, the procedure is started by developing the paravesical and pararectal spaces.

The retroperitoneal space is opened through the round ligament.

Clamps are placed on the medial round ligaments to assist with uterine manipulation.

Care is taken to avoid injury to the infundibulopelvic and tuboovarian ligaments.

Once the ureter and bladder are dissected, the uterine arteries at transected at their origin bilaterally.

After mobilizing the ureter off the broad ligament, the parametria and paracolpos are dissected in a fashion similar to a radical hysterectomy.

At this point, the posterior cul-de-sac is incised and the uterosacral ligaments are divided.

Finally, clamps are placed on the lower uterine segment at the level of the internal os followed by transection of the specimen.

The vaginal mucosa is sutured to the remaining cervical stump, followed by a prophylactic cerclage.[4]

Figure 16 (Figures 47.34 page 1265 from TeLinde's Figure 16 (Figures 47.34 page 1265 from TeLinde's textbook) : Cerclage placement
Figure 17 (Figure 47.35 page 1265 from TeLinde's t Figure 17 (Figure 47.35 page 1265 from TeLinde's textbook): Reconstruction of uterine corpus to vaginal mucosa

Many centers perform the procedure by completing the entire dissection, including colpotomy, prior to amputation of the trachelectomy specimen.

Simple Trachelectomy

A tenaculum is placed on the cervix, followed by cervical injection of lidocaine solution containing a vasoconstrictor.

The vaginal wall is incised circumferentially just above the cervix, paying close attention to carry the incision through the full thickness of the wall.

Similar to a radical trachelectomy, the peritoneum is entered posteriorly and anteriorly. The uterosacral ligaments are clamped, cut, and ligated. Unlike a radical trachelectomy, the parametrium is not excised. The cervix is amputated just distal to the internal os.

The specimen is removed, and the cervical stump is sutured to the vaginal mucosa.