Preserving fertility in patients with cervical cancer: radical trachelectomy

Dr Marcelo Nascimento is a gynaecological oncologist. His private practice is located at Mater Medical Centre.

Up to 18 per cent of patients diagnosed with cervical cancer in Australia are 40 years of age or younger. Traditionally, the recommended surgical treatment for early stage disease (IA2 - IB1) is a radical hysterectomy and removal of pelvic lymph nodes (pelvic lymphadenectomy). This operation is very effective at treating early disease but it means that all patients lose their fertility. Radical abdominal or vaginal trachelectomy are relatively new techniques in gynaecological cancer surgery being utilised in women with early cervical cancer who wish to preserve their fertility.

This surgery involves resection of the cervix, the upper 1–2 cm of the vagina and the parametrium, which is the soft tissue next to the cervix bilaterally. This is done in a similar manner to a radical abdominal hysterectomy, but with preservation of the uterine corpus. This technique is safe, feasible, provides equivalent disease free and overall survival when compared to a radical hysterectomy. It also means reduced physical and psychological morbidity, better quality of life and, of course, preserves fertility in acceptable rates.

Scenario

A 30 year-old asymptomatic patient with one previous successful pregnancy, who was very keen to preserve her fertility, was diagnosed with cervical cancer. She presented with an abnormal Pap smear demonstrating a high grade squamous intraepithelial lesion (HSIL). She had normal menstrual cycles with no intermenstrual or post-coital bleeding. No other relevant medical history was noted.

Abnormal colposcopy revealed widespread aceto-white epithelium with mosaicism extending onto the left side of cervix close to the vaginal fornix. Cervical biopsies also demonstrated HSIL. A local excision of the cervix and endocervical curettings were performed (large Fischer Cone Biopsy) to treat the patient’s high grade dysplasia (HSIL). The final histopathology demonstrated not only the known HSIL, but also an early cervical cancer (Stage IA2).

Further imaging work up demonstrated no evidence of metastatic disease. Treatment options including advantages and disadvantages of radical trachelectomy (with the aim to preserve fertility) versus radical hysterectomy were extensively discussed with the patient and her husband. The patient’s decision was to proceed with radical trachelectomy and, all going well, attempt a pregnancy 9–12 months after her operation.

Operation

This patient had an abdominal radical trachelectomy and bilateral pelvic lymphadenectomy. A Pfannenstiel (low transverse abdominal incision) and bilateral complete pelvic lymphadenectomy was performed in a similar manner to patients undergoing a radical abdominal hysterectomy.

The limits of nodal dissection are the deep circumflex iliac vein caudally and the proximal common iliac artery cephalad. This fertility-sparing operation would be abandoned if any evidence of extrauterine disease/lymph nodal disease was identified. The aim of the radical abdominal trachelectomy was to resect the cervix, the upper 1–2 cm of the vagina and the parametrium (which is a frequent site of cancer dissemination) (Figure 1), in a similar manner to a radical abdominal hysterectomy, but sparing the uterine fundus.

The procedure is begun by developing the paravesical and pararectal spaces and dissecting the bladder caudal to the midvagina. Careful uterine manipulation is taken not to disturb the top of uterus and the infundibulopelvic ligaments (the blood supply of the ovaries and uterus), which are kept intact. Care is also taken not to injure the fallopian tubes. The uterine vessels were ligated and divided at their origin from the internal iliac vessels. Bilateral parametrium with uterine vessels are mobilised medially with the specimen and a complete ureterolysis is performed similar to a radical abdominal hysterectomy. The recto-vaginal peritoneum is incised and the uterosacral ligaments divided. The parametria is divided.

A vaginal cylinder is inserted to better estimate the desired length of the vaginal cuff that will be removed. The vagina is incised and the specimen is completely separated from the vagina, placed in the mid-pelvis while still keeping its attachment to the uterus (Figure 2). The lower uterine segment is then estimated and clamps are placed at the level of the internal cervical orifice (Figure 3). Using a knife, the radical trachelectomy is completed by separating the fundus from the upper endocervix at approximately 5 mm below the level of the internal cervical orifice (Figure 4). The uterine fundus with preserved attachments to the utero-ovarian ligaments is placed in the superior part of the pelvis and the specimen, consisting of radical trachelectomy and parametria, is sent for histopathology assessment (Figure 5). Uterine curettings are also performed. Anastomosis between the corpus and distal upper vagina is performed using a parachute technique with 0 Vicryl suture (Figures 6 and 7).

Post-op

The patient had an uneventful post operative course with no complications. The final histopathology demonstrated a residual focus of cervical cancer. All margins of resection were well clear and all 23 pelvic lymph nodes were also clear of disease.

Outcome

This patient fell pregnant 14 months after her radical trachelectomy and had a caesarean section at 38 weeks. She had a healthy baby girl weighing 3520 grams. A completion total laparoscopic hysterectomy was performed as part of her cervical cancer treatment 12 months after her caesarean section with the histopathology demonstrating no evidence of residual disease. Patient’s follow-up has been clear.

Reference: Fertility-sparing radical abdominal trachelectomy for cervical carcinoma: Technique and review of the literature. Abu-Rustum N, Sonoda Y, Black D. Gynecologic Oncology 103 (2006) 807–813.