Radical trachelectomy – fertility sparing surgery for cervical cancer

Tagged cervical cancer, trachelectomy, fertility; Posted 10 years ago by Andreas Obermair

Cervical cancer is predominantly an issue for women in under-resourced countries. The incidence is massive and treatments are simply not available. Returning from a trip to South Africa, I had to accept that a large number of women diagnosed with cervical cancer receive a few sessions of palliative radiotherapy (to stop bleeding) but get sent away to die.

For women in highly developed countries cervical cancer is still an issue. Adverse effects from radical treatment including loss of fertility create massive problems for a life after cancer. Radical trachelectomy is a treatment concept that we've followed since 2005 at our institution to preserve fertility for women with cervical cancers confined to the cervix.

Technique: Here is a 7-minute video that I recorded because I was unable to find good footage of the procedure for my own education. The procedure itself is technically similar to a radical hysterectomy (with a couple of extra challenges).

Important issues to start a successful radical trachelectomy program

 1. Select the right patients: We offer radical trachelectomy to patients with invasive SCC and adenocarcinoma of the cervix, limited to the cervix (stage 1). Typically, patients wish to retain fertility or at least the option of fertility.

We do not offer radical trachelectomy to patients with tumours that are FIGO stage 2+, to patients in who fertility is not an issue, to patients who have positive lymph nodes (on PET-CT) or patients with involvement of the corpus.

2. Provide information to patients:

• We inform patients that no surgeon worldwide will have a vast experience with radical trachelectomy and therefore the procedure should be regarded as an “experimental” procedure in most surgeons’ hands.
• Patients need to understand the risks and possible complications of the procedure as well as its alternatives.
• We inform patients that the procedure will be abandoned if we find positive nodes intraoperatively. In that case, we will recommend primary chemoradiation.  
• If histology confirms a positive uterine resection margin (which we have not experienced as yet), we will recommend a subsequent hysterectomy. We do not rely on intraoperative frozen section due to the risk of false positive errors.
• Postoperative PAP smears will be difficult to interpret. The cells come from the endometrium and the pathologist would be concerned if you would not disclose that the patient does not have a cervix left.
• Patients need to understand the obstetrics outcomes are encouraging but not guaranteed. Almost every second woman who will have the procedure and who wishes to fall pregnant will eventually take home a healthy newborn.
• In regards to the mode of delivery, I am aware of only caesarean sections following radical trachelectomy. I am unaware of vaginal deliveries subsequent to the procedure.
• I am also unaware of high quality results on the use of cervical cerclage. I never put a cerclage band in. All my patients went to 37+ weeks without problems. A cerclage band potentially creates a foreign body and I am concerned about the effect of a foreign body on preterm labour.

Since offering radical trachelectomy to our patients 10 years ago, we developed the procedure at our institution and these are the phases we went through.

1. Initially we offered the procedure only vaginally. However, we were not happy with the extent of parametrial resection. Everybody would agree that the amount of parametria and uterosacral ligament is less through a vaginal surgical approach. As a consequence we switched to an abdominal approach. While we were happy with the surgical outcome, we realised that the procedure is rather invasive and recuperation from open, abdominal surgery is cumbersome. Now we offer laparoscopic radical trachelectomy. We are happy with the surgical outcomes and with the recovery of our patients.
2. Initially we offered radical trachelectomy to patients with cervical cancers not larger than 2 cm or 3 cm. However, tumour size has become less important over time. Recently, I saw a patient with a 5 cm cervical adenocarcinoma, confined to the cervix (stage 1b2). I gave her neoadjuvant chemotherapy, which resulted in a great response. She had a laparoscopic radical trachelectomy and will have the potential to have children in the future.

While radical trachelectomy does not solve the issue of cervical cancer world-wide, it may provide hope to a small group of cervical cancer patients who are keen to retain fertility and have established cancer treatment at the same time.

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