Keywords

Introduction

The standard recommendation for the treatment of patients with early-stage cervical cancer (stages IA2–IB1) interested in fertility preservation is radical trachelectomy [1]. In 1994, Dargent et al. [2] reported on the safety and feasibility of vaginal radical trachelectomy (VRT) with laparoscopic lymph node dissection for the treatment of early-stage cervical cancer. However, one of the major concerns with regard to the vaginal approach when considering radical trachelectomy is the fact that it requires surgeon expertise in radical vaginal surgery and also in advanced laparoscopic procedures. In 1997, Smith et al. published the first report of abdominal radical trachelectomy (ART) [3]. The advantages of ART include the reproducibility of the technique, the fact that the procedure can be performed without training in radical vaginal surgery, that it requires no laparoscopic equipment, and a wider parametrial resection can be achieved with this approach.

Radical trachelectomy has also been reported through a minimally invasive approach. The laparoscopic approach offers the benefits of minimally invasive surgery; however, it is also associated with the fact that it is a challenging technique requiring the expertise of a well-trained surgeon in radical laparoscopic pelvic surgery [4, 5]. Others have published on the robotic-assisted approach [6, 7]. However, the number of published data on these minimally invasive approaches is limited and the follow-up times are short thus limiting the information on long-term oncologic outcomes.

This chapter will describe the surgical technique, and the oncological and obstetric outcomes after radical trachelectomy. We will also provide details on the most common complications associated with this procedure.

Surgical Technique

The initial entry into the abdominal and pelvic cavity is performed through either a low transverse (Pfannenstiel, Cherney, Maylard) or median incision. The main advantage of the median incision is the broader space that it provides. Careful inspection of the pelvic and peritoneal surfaces is performed in order to rule out any metastatic disease. To gain access into the retroperitoneum one may begin by transecting the round ligament and making an incision along the lateral aspect of the infundibulo-pelvic ligament. The round ligaments may also be preserved depending on the surgeon preference. However, as an alternative, one may also begin by opening the pouch of Douglas by making an incision between both uterosacral ligaments (Fig. 102.1). The paravesical (limited laterally by the iliac vessels, medially by the obliterated umbilical artery, caudally by the deep uterine vein, posteriorly by internal iliac artery and anteriorly by the pubic bone) and pararectal spaces (limited laterally by internal iliac artery, medially by the hypogastric nerve, anteriorly by the uterine artery and posteriorly by the sacral fascia) are developed (Figs. 102.2 and 102.3). Upon inspection of the retroperitoneum, if there is any evidence of obvious nodal disease, surgeons should consider sending the lymph node for frozen section evaluation to determine the status of the lymph node. If there is evidence of disease in the lymph node, the ART should be aborted and definitive chemotherapy and radiation recommended.

Fig. 102.1
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Opening the pouch of Douglas

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Fig. 102.2
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Right pelvic lateral spaces

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Fig. 102.3
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Left pelvic lateral spaces

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A complete pelvic lymphadenectomy is performed from the level of the bifurcation of the common iliac vessels proximally to the circumflex iliac vein distally. This dissection includes the external iliac nodes, internal iliac nodes, and obturator nodes (Fig. 102.4). There is no utility of sending normal appearing nodes to frozen section. As an alternative, sentinel node mapping can be performed, with good performance regarding, detection rate , sensitivity and specificity [8].

Fig. 102.4
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Right lymph node dissection

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The uterus is gently grasped with a Somer uterine elevating forceps (Aesculap Surgical Instruments, Tuttlingen, Germany) (Fig. 102.5). After exposing the paravesical and pararectal spaces bilaterally, the ureters must be identified bilaterally before proceeding with any pelvic dissection. Care must be taken to assure that the infundibulopelvic ligaments with the ovarian vessels are intact. In addition, special attention must be paid to assure that there is no injury to the fallopian tubes or the utero-ovarian ligament. Therefore, surgeons must place special emphasis to assure that fallopian tubes are not grasped during the surgery. The dissection continues by placing upward traction on the uterus and developing of peritoneal bladder fold. The bladder must be mobilized inferiorly to assure that at least a 1–2 cm margin of upper vagina is secured. The ureters are separated from the peritoneum medially starting the pelvic brim and continuing distally until the point where they course under the uterine vessels. .(Figs. 102.6, 102.7 and 102.8) Often one can also visualize the ureters entering the bladder in the Yabuki’s space. (Figs. 102.9 and 102.10) The uterine arteries are then ligated at their origin.

Fig. 102.5
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Posterior view, uterine clamp

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Fig. 102.6
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Left ureteral tunnel

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Fig. 102.7
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Anterior parametrium

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Fig. 102.8
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Left uretero-vesical junction

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Fig. 102.9
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Bladder fold dissection

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Fig. 102.10
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Bladder pilars dissection

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There is some debate regarding preservation of the uterine vessels. According to Tang et al. [9] among 16 patients who had preserved uterine arteries, only two (12.5 %) showed identifiable bilateral uterine arteries, seven (43.6 %) showed unilateral uterine artery occlusion and seven (43.6 %) exhibited bilateral occlusion. The authors concluded that the uterine arteries, when dissected and preserved, have an 87.4 % chance of obstruction in the postoperative period, thus the authors do not recommend uterine artery preservation when performing an abdominal radical trachelectomy.

Once the ureters have been properly mobilized bilaterally to the level of insertion into the bladder, surgeons must proceed with medial mobilization of the parametrial tissue bilaterally. This is done by assuring to mobilize the ureters inferiorly and laterally. In addition, surgeons must be certain to transect the vesico uterine ligament to further mobilize the bladder inferiorly. The uterosacral ligaments are then identified and transected bilaterally in medial-most third (Fig. 102.11). The parametrial tissue should be dissected so that there is a lateral margin of resection of approximately 3–5 cm (Fig. 102.12). A colpotomy is then performed circumferentially (Figs. 102.13 and 102.14). At this time, the cervix, parametrial tissue, and upper vagina are amputated from the uterus (Fig. 102.15). The landmark used to help guide with the amputation of the cervix is located approximately 0.5 or 1 cm below the internal uterine os, and the cut is preferably done with cold knife, in order to assure that there is no cauterized tissue that would potentially hinder the pathologic interpretation. The specimen is then sent for frozen section evaluation to assure that at least a 5-mm margin free of tumor (Figs. 102.16 and 102.17).

Fig. 102.11
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Posterior view

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Fig. 102.12
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Anterior margins

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Fig. 102.13
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Trachelectomy specimen pre-resection 1

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Fig. 102.14
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Trachelectomy specimen pre-resection 2

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Fig. 102.15
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Resection of the specimen

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Fig. 102.16
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Trachelectomy specimen 1

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Fig. 102.17
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Trachelectomy specimen 2

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At this point, surgeons must determine whether they will place a cerclage at the same time of the procedure or do so when the patient becomes pregnant at a later time. In our institution, we prefer to place a cerclage at the time of the radical trachelectomy. The documented advantages of a cerclage are that it is important to reduce undesired obstetric complications such cervical incompetence, second trimester losses, premature rupture of membranes or preterm labor. The potential disadvantages are that it may cause cervical stenosis, chronic vaginal discharge, or it may potentially erode through the vagina. In a recent literature review, the investigators showed that the average rate of stenosis rate after radical trachelectomy was 10.5 % (0–73.3 %). The rates of cervical stenosis was 8.6 % when a cerclage was placed and 3.0 % when none was placed. In our institution, we do routinely place a cerclage at the time of radical trachelectomy.

When placing a cerclage, several suture may be used. We prefer to use 0-Ethibond suture(Johnsons & Johnsons, New Jersey, USA). The cerclage is placed approximately 2 cm superior to the lower edge of the uterus in order to decrease the likelihood of cerclage erosion into the vagina as a consequence of placing the cerclage too close to the uterine vaginal anastomosis. The suture of the cerclage should also be placed posteriorly to avoid erosion of the cerclage into the bladder. The abdominal wall is then closed in a routine fashion.

Another area of controversy is whether to place a uterine cannula to prevent the occurrence of future amenorrea after radical trachelectomy. A number of tools have been used such as pediatric Foley catheter or a Smitt sleeve (Elekta AB, Stockholm, Sweden) When placing the Smitt sleeve, it is important to suture the Smitt sleeve to the uterus using 4–0 Chromic suture. Among those in whom a cannula was placed the rate of stenosis was 4.6 % compared to 12.7 % when none was used (P < 0.001) [12]. In a recent study by Vieira el at. [10], the investigators used a pediatric Foley in 57 (62 %) of 92 patients versus a Smitt sleeve (Elekta AB, Stockholm, Sweden) in 23 (25 %) of 92 patients or none in 12 patients (13 %). In the Foley catheter group, six (10.5 %) developed cervical stenosis, compared with one (4.3 %) patient who developed stenosis in the Smitt sleeve group and one (8.3 %) patient with no catheter placement. Additionally, Nick et al. showed that the rate of cervical stenosis after radical trachelectomy prior to use of the Smitt sleeve was 14 % and 0 % after implementating its use in every case [11]. When a Smitt sleeve is secured to the uterus, it is then removed 3–4 weeks after the radical trachelectomy.

At this point, the uterus draws its blood supply from the utero-ovarian ligaments that in turn derive their blood supply from the ovarian vessels bilaterally (Fig. 102.18). The uterus is then anastomosed to the vagina using interrupted 2–0 Vicryl sutures. Sutures may be placed continuously or interrupted (Fig. 102.19). Alternatively, one may use a barbed suture, such as a V-loc suture (Covidien, London, UK).

Fig. 102.18
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Uterine corpus and adnexae pos-resection

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Fig. 102.19
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Utero-vaginal anastomosis

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Results

As of August 2015, there were a total of 663 intended ART’s published in the literature [13–29]. The procedure was performed as planned in 608 patients, whereas in the remaining 55 patients a conversion to a radical hysterectomy was required. Conversions to radical hysterectomies were done for close margins or nodal involvement. The most common histology was squamous cell carcinoma (76 %), and the most frequent stage was IB1 (75 %). Lymphovascular space involvement was present in 21.5 % of cases (Table 102.1). The surgical time ranged from 100 to 611 minutes and the blood loss ranged from 50 to 4300 ml. The transfusion rate among those who reported this information was 42 % (102/238) (Table 102.2).

Table 102.1 Demographic and tumor information for patients who underwent abdominal radical trachelectomy
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Table 102.2 Intraoperative and postoperative outcomes for patients who underwent abdominal radical trachelectomy
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Intraoperative complications other than bleeding necessiting transfusion are rare, or not reported in most studies. The most common postoperative complication described is cervical stenosis occurring in 9.5 % of patients, followed by infection or abscess in 38 8.6 %, and lymphocyst in 5.9 % of patients [9] (Table 102.3). The global pregnancy rate after ART was 17.9 % which is very similar to 16.2 % described in a recent literature review [9]. Pregnancy rate was calculated as follows: total pregnancies/patients with fertility preservation. It is important to highlight that not all authors report the number of patients seeking to get pregnant, but among those reporting this information, the percentages fluctuate between 16.9 % [11] and 60 % [25]. Obtetrical outcomes show that there were 109 pregnancies out of a total 658 patients who maintained their fertility, with 25 miscarriages (14 first trimester and 9 s trimester). A total of 14 patients had an ongoing pregnancy at the time of report. There were 71 deliveries, 24 of them at term, 28 preterm, and 19 without information on delivery time. Table 102.4 summarizes the obstetrical results.

Table 102.3 Intraoperative and postoperative complications for patients who underwent abdominal radical trachelectomy
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Table 102.4 Pregnancy rates and obstetrical outcomes for patients who underwent abdominal radical trachelectomy
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Given the current data on abdominal radical trachelectomy, it seems that this procedure is safe and feasible and offers patients with early-stage cervical cancer a very reasonable option for fertility preservation with excellent oncologic outcomes. In the future, perhaps less radical approaches, such as simple conization or simple hysterectomy, will be feasible for select patients with low-risk criteria.