Abdominal radical trachelectomy: a fertility-preserving option for women with early cervical cancer
Dr L. Ungár, Department of Gynaecologic Oncology, St Stephen Hospital, Nagyvárad tér 1, Budapest 1096, Hungary.
Abdominal radical trachelectomy is a fertility-preserving alternative to radical hysterectomy or chemoradiation for young women with stage IA2 to IB cervical cancers. Thirty-three patients were offered this procedure. The mean age was 30.5 years (range 23–37). Three procedures were abandoned because of positive pelvic nodes (two patients) and involvement of the margin between the amputated cervix and uterine fundus (one patient). Of the remaining 30 patients, 10 had stage IA2 tumours, 15 had stage IB1 and 5 had stage IB2. During follow up of a median of 47 months (mean 32 months, range 14–75 months), no recurrences have been detected. A normal menstrual pattern resumed within eight weeks of surgery in all but two patients. Five patients attempted to conceive. Three women have fallen pregnant, resulting in one first trimester miscarriage and two caesarean section deliveries at term. Our experience suggests that abdominal radical trachelectomy provides a method of treating women with stage IA2 to IB cervical cancers with conservation of fertility without apparently compromising recurrence or survival rates. It appears to provide equivalent oncological safety to a standard Wertheim hysterectomy using a technique familiar to all practising gynaecologic oncologists.
Despite the availability of screening programs in developed countries, early cervical cancer remains a challenging disease to treat in young women. Surgical management of stage IA2 to IB cancers generally involves radical abdominal hysterectomy, with good results in terms of survival and quality of life, but loss of future childbearing potential. The incidence of cervical cancer is increasing in young women at a time when they are delaying their childbearing.1,2 These two phenomena have led to an increased recognition that fertility preservation is a significant and meaningful quality of life outcome for many cancer patients.3
The idea of preserving the uterine corpus and the adnexae during radical hysterectomy was first published by Aburel in 1932 and cited by Chiricuta.4 No follow up data or successful pregnancies were reported.
Radical vaginal trachelectomy was developed for treatment of stages IA2 to IIA cancers in 1987, allowing preservation of the uterine fundus but removal of the cervix, part of the parametrium and the upper one-third of the vagina.5,6 The procedure is combined with laparoscopic pelvic lymphadenectomy. Concerns regarding the oncological safety of the method include the incomplete removal of the lateral parametrium where random metastases have been demonstrated histologically.7,8 In larger tumours (>2 cm), recurrence rates of up to 29% have been reported.5 In addition, learning the vaginal radical procedure can be difficult due to the limited operative field for teaching and the low number of suitable candidates in each centre.
Abdominal radical trachelectomy has the potential to overcome some of these problems as the radicality of the procedure can be identical to that of a traditional type III Wertheim hysterectomy. The similarity of abdominal radical trachelectomy to a traditional radical hysterectomy lends itself to use in any gynaecologic cancer centre. Women who have given informed consent are potential candidates if retention of fertility is desired. Pregnancies following the abdominal radical trachelectomy procedure have been reported.9–11 We present the follow up data on abdominal radical trachelectomy, which we have used as fertility-preserving surgery in women with FIGO stage IA2 to IB cervical cancers since 1997.
After our initial IRB approved pilot study,12 all patients presenting from July 1997 to August 2002 with cervical cancer stage IA2 to IB2 and a desire to preserve fertility, were offered the option of either abdominal radical trachelectomy or radical hysterectomy. Each was counselled as to the experimental nature of the procedure. The 33 cervical cancer patients who expressed a desire for fertility-preserving surgery during this time and underwent the procedure make up this prospective cohort, with follow up of all patients until October 2003.
The surgical technique has been described previously.13 Briefly, the round ligaments are divided and the retroperitoneum entered. A thorough pelvic lymphadenectomy to the level of the bifurcation of the aorta is performed, with removal of all pelvic lymphatic groups. The extent of the pelvic lymphadenectomy is identical to that in a traditional radical hysterectomy, including the common iliac, superior gluteal, subaortic, presacral, external iliac and obturator nodes. The nodal tissue is analysed by frozen pathological section. If tumour is detected within the lymph nodes, the abdominal radical trachelectomy procedure is abandoned and the operation is converted to a laterally extended radical hysterectomy14,15 and pelvic/para-aortic lymphadenectomy.
The uterine vessels are ligated at their origins and the uterine corpus transected at the level of the internal os. A cross section of the superior portion of the separated cervix is sent for frozen section to ensure a tumour-free margin. The infundibulo-pelvic vessels, which provide uterine perfusion, are mobilised and the uterine corpus retracted on them for the remainder of the parametrectomy. The cervix is removed together with the parametria and the upper one-third of the vagina, as in a conventional radical hysterectomy. Following a thorough dissection and removal of the cervix, parametrium and upper vagina, the proximal vaginal margin is resutured to the seromuscular margin of the retained uterine body with a single layer running suture to re-establish continuity.
Alternatively, a conventional type III–IV radical hysterectomy is carried out with the infundibulo-pelvic vessels left intact. After transecting the vagina, the uterus is transected at the level of the internal os, the abovementioned frozen section is carried out and the uterine corpus is anastomosed to the vagina. Uterine cerclage had not been used in our series of operations.
Thirty-three women chose radical abdominal trachelectomy as primary management of cervical carcinoma. Three procedures were abandoned after positive pelvic nodes (two patients) and involvement of the margin between the amputated cervix and the uterine fundus with tumour (one patient) were detected. The mean age of the remaining 30 patients was 30.5 years (range 23–37), mean weight 64.3 kg (range 50–85 kg); mean length of operating time 3 hours 46 minutes (range 2 hours 50 minutes to 5 hours) and mean number of lymph nodes removed from the pelvis 32.2 (range 17–44). Ten patients had FIGO stage IA2 tumours (9 squamous and 1 adenosquamous carcinoma), 15 had stage IB1 (14 squamous and 1 adenocarcinomas), while 5 women had stage IB2 tumours (3 squamous and 2 glassy cell carcinoma). Four of the stage IB1 tumours were over 2 cm in diameter. The largest tumour was 6 cm in diameter. One clinical stage IB1 tumour exhibited microscopic spread of tumour to the upper vagina. Lymphovascular space invasion was noted in 1 of 10 stage IA2, 3 of 15 stage IB1 and 4 of 5 stage IB2 tumours. Two of the tumours with lymphovascular space invasion also demonstrated perineural spread. Tumour-free margins of more than 5 mm were present in all cases. Patients with non-squamous tumours were advised of the risk of ovarian and distant metastases and all insisted on fertility-retaining surgery.
A median of two units of packed red blood cells were transfused to 66.6% of patients while antibiotics were used in 44% of patients post-operatively. Hospital stay ranged between 12 and 22 days (mean 14 days). Intra-operative complications were rare. In one patient, a unilateral ureteral injury occurred during dissection that had to be repaired with suturing and stenting with no sequelae. In another patient, routine follow up Pap smear demonstrated atypical glandular cells. Because of the limited experience with follow up of abdominal trachelectomy patients at that time and at the request of the patient, a hysterectomy was performed. No tumour was detected in the specimen. No recurrences have been detected to date, with a median follow up of 47 months (mean 32 months, range 14–75 months). A normal menstrual pattern resumed within eight weeks of surgery in all but two patients. In these two women, ultrasound examination was suggestive of obliteration of the endometrial cavity.
Five of the 30 patients have tried to conceive resulting in two spontaneous and one IVF pregnancies. One pregnancy ended in miscarriage at five weeks estimated gestational age. Two patients delivered healthy babies at term by caesarean section with no complications. The babies weights were 3200 and 3350 g despite the reliance on the ovarian vessels for uterine perfusion.
The traditional treatment options for young women with early cervical cancer include radical abdominal hysterectomy and chemoradiation. A growing demand for preservation of fertility in young early-stage cervical cancer patients initiated the introduction of the radical trachelectomy procedures. Radical vaginal trachelectomy was introduced 16 years ago5 and has gained popularity. The possibility of a successful pregnancy with an excellent quality of life and a recurrence rate comparable to historic data has supported the use of the method. Published follow up data from centres performing radical vaginal trachelectomy with laparoscopic lymph node dissection include a total of 236 women, with tumours ranging from pathological stage IA2 to stage IIB.5,6,16–20 Tumour has recurred in eight patients (3.4%) during follow up of 1–123 months. Two patients had distant recurrence, two had lateropelvic recurrence with four patients having parametrial or centropelvic recurrence.21 Prior to publication of these data, concerns regarding the possible oncological risk of limited parametrial resection and the limited opportunities for gynaecologic oncologists to learn radical vaginal trachelectomy prompted us to develop the abdominal radical trachelectomy technique.
To date, there have been no recurrences of tumour in our patients treated with abdominal radical trachelectomy. We acknowledge that our patient numbers are relatively small, but believe that the radicality of the parametrial, sacrouterine, vesico-cervical and pelvic lymphatic tissue resection in our procedure may contribute to high levels of disease-free survival. The procedure differs from a traditional Wertheim radical hysterectomy only in the preservation of the uterine corpus. In contrast, the vaginal approach limits the parametrial resection to tissue in the medial half of the broad ligament.
Restriction of radical vaginal trachelectomy to those women with tumours less than 2 cm in diameter and with invasion of less than 10 mm has been suggested by Dargent et al.5 following analysis of their data, which showed tumour recurrence in two of seven women with tumours over these dimensions. Because the abdominal radical trachelectomy procedure appears to be equivalent to the traditional Wertheim procedure, this limitation may not be applicable to abdominal trachelectomies. Indeed, the techniques may be complimentary in large centres where radical vaginal trachelectomy could be reserved for tumours less than 2 cm in diameter with abdominal radical trachelectomy being employed for larger cancers or those with unfavourable histology.
Complication rates for radical abdominal trachelectomy appear to be similar to those of radical hysterectomy. Ureteric injury was the only intra-operative injury in our series. Voiding difficulties were common but resolved within two to three weeks, consistent with our experience with radical hysterectomy. Operative complications described with radical vaginal hysterectomy include cystotomy, enterotomy and pelvic haematoma.5,17,18 We believe that the overall incidence of intra-operative and post-operative complications is likely to be lower with abdominal radical trachelectomy than with radical vaginal trachelectomy when performed in average sized gynaecologic oncology centres. The technique for abdominal radical trachelectomy varies only slightly from that of the routine radical hysterectomy, is readily taught to training surgeons and is reproducible in any gynaecologic oncology unit. In contrast, radical vaginal trachelectomy may be a more difficult technique to master in most centres with limited patient numbers. For larger tumours, the extent of parametrial resection with radical vaginal trachelectomy may be inadequate. Radical vaginal trachelectomy does, however, offer the advantage of a shorter hospital stay, shorter post-operative recovery and possibly less bladder and bowel dysfunction due to the limited parametrial resection.
Subsequent fertility of women who have undergone abdominal radical trachelectomy is probably similar to that of radical vaginal trachelectomy. Of a total of 236 women reported to have undergone radical vaginal trachelectomy,5,6,11,16–20 63 liveborn children have been reported. Only five of our cohort have attempted to conceive, in part due to our recommendation that each patient waits for two years following the procedure while undergoing close surveillance. In two patients, ultrasound examination did not demonstrate an endometrial cavity, consistent with Asherman's syndrome. One woman required dilatation of the new cervical os due to stenosis. Larger numbers of patients will be needed to determine whether the 25% rate of late miscarriages noted in one study5 and the 28% incidence of preterm premature rupture of the membranes in another study of radical vaginal trachelectomy patients22 will occur in patients treated with abdominal radical trachelectomy. We do not place a cerclage suture at the time of surgery but to date have not seen evidence of subsequent cervical incompetence with second trimester miscarriages. It is probably that some reduction in fertility occurs with both the abdominal radical trachelectomy and radical vaginal trachelectomy procedures, due to the loss of the mechanical protection provided by the cervix and the cervical mucous plug.
We believe that abdominal radical trachelectomy provides a safe option for young women with early cervical cancer, which should be able to be offered in any recognised gynaecologic cancer centre.
RH received an educational grant from Tyco Healthcare Australia.