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Keywords:

  • Cervical cancer;
  • fertility preservation;
  • laparoscopic radical trachelectomy

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgement
  13. References
  14. Supporting Information

Please cite this paper as: Kim J-H, Park J-Y, Kim D-Y, Kim Y-M, Kim Y-T, Nam J-H. Fertility-sparing laparoscopic radical trachelectomy for young women with early stage cervical cancer. BJOG 2010;117:340–347.

Objective  To report the results of laparoscopic radical trachelectomy (LRT) with respect to surgical, oncological and reproductive outcomes.

Design  Retrospective analysis.

Setting  University of Ulsan College of Medicine, Asan Medical Centre, Seoul, Korea.

Sample  Thirty-two consecutive patients who wish to preserve fertility with early stage cervical cancer.

Methods  Demographic, clinicopathologic, surgical, and follow-up data were obtained from patients’ medical records. All patients agreed to telephone interviews to assess their menstrual and obstetrical outcomes.

Main outcome measures  Surgical parameters, perioperative complication, disease-free survival, overall survival, return and pattern of menstruation and pregnancy rate.

Results  Thirty-two consecutive patients who wish to preserve fertility with early stage cervical cancer were offered LRT. In five patients, the planned LRT procedures were abandoned during the operations because of lymph node metastasis or parametrial involvement on frozen section. The mean age was 29 years (range, 22–37 years). The mean tumour size was 1.7 cm in diameter (range, 0.4–3.5 cm). The mean operating time was 290 min (range, 120–520 min) and the mean estimated blood loss was 332 ml (range, 50–1000 ml). Perioperative transfusion was required in six patients. There were no perioperative complications requiring further management. After a median follow-up time of 31 months (range, 1–58 months), there was one recurrence and death from disease. Regular menstruation returned in 24 patients. Six patients attempted to conceive, and three succeeded.

Conclusions  Laparoscopic radical trachelectomy may be a safe and useful alternative to radical hysterectomy for women with early cervical cancer who want to preserve their fertility.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgement
  13. References
  14. Supporting Information

Nearly 15% of all cervical cancers are diagnosed in women under the age of 40 years.1 Recently, the number of women wishing to have their first child when they are 35–39 years of age has increased.2 Cervical cancer cases diagnosed during childbearing years, in women who have not yet conceived, are therefore rising in number. Because of the introduction of organised screening programs for cervical cancer in developed countries, many cervical cancers are diagnosed at an early stage when the cancers are amenable to radical hysterectomy, which is the standard treatment.3–5 For young women with early stage cervical cancer who wish to preserve their fertility, radical hysterectomy is not acceptable. Radical trachelectomy was therefore introduced for these patients as an alternative to radical hysterectomy.

Vaginal radical trachelectomy (VRT) with laparoscopic pelvic lymphadenectomy was introduced for the first time in 1986, and was reported on in 1994 by Dargent et al.6 To date, over 790 instances of the use of these techniques have been reported in the literature, with over 302 pregnancies and 190 live births reported following these procedures.7 The morbidity associated with these techniques is low, with a tumour recurrence rate of 5% and a mortality rate of 3%.8,9 The current literature indicates that there is no difference between the rates of recurrence after the use of these techniques and the rates noted after radical hysterectomy or radiation therapy, when proper patient selection criteria are used.8,9

However, because of the difficulty of learning radical vaginal surgery, possible incomplete parametrial resection, and difficulty of performing VRT in patients with distorted cervicovaginal anatomy, abdominal radical trachelectomy (ART) with pelvic lymphadenectomy was introduced in 1997 as an alternative to VRT. This procedure follows steps identical to those of abdominal radical hysterectomy (ARH).10 However, ART has the disadvantages of significant blood loss, the need for a high rate of blood transfusions, the need for a large abdominal incision, and a requirement for a longer postoperative hospital stay.9 As another surgical approach, laparoscopic radical trachelectomy (LRT), which has the advantages of abdominal and laparoscopic approaches, has been introduced. However, the reports on the use of LRT are scant in the literature. To our knowledge only 16 cases of LRT have been reported to date, as case reports or small case series, by only a few authors.11–14

In this article, we report our results with the LRT technique, with respect to surgical, oncological and obstetrical outcomes.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgement
  13. References
  14. Supporting Information

Study population

From October 2004 to March 2009, LRT was performed on 32 young women with early stage cervical cancer who wished to preserve their fertility, at Asan Medical Centre (AMC, Seoul, Korea). The criteria for performing LRT in our centre are: (1) strong desire for fertility preservation; (2) age <40 years; (3) histologically proven, stage IA2–IB1 cervical cancer; (4) tumour size <2 cm in diameter; (5) limited endocervical involvement, as determined by colposcopic examination and/or magnetic resonance imaging (MRI); (6) no evidence of pelvic or para-aortic lymph node metastasis or other distant metastasis; and (7) exclusion of unfavourable histology (e.g. neuroendocrine carcinoma). For preoperative imaging, MRI was performed on all patients and fusion whole-body positron emission tomography/computed tomography (PET/CT) was performed on 16 patients. Informed consent was obtained from all patients before surgery.

After obtaining the approval of the AMC Institutional Review Board, demographic, clinicopathologic, surgical, and follow-up data were obtained from the patients’ medical records. All patients agreed to telephone interviews to assess their menstrual and obstetrical outcomes.

Surgical techniques of laparoscopic radical trachelectomy

The procedures of LRT used in this study (Video clip S1) are basically identical to those of laparoscopic radical hysterectomy (LRH), and thus ARH (Piver type III), except for the conservation of a thin rim of the cervix, the uterine body, the round ligament, both adnexae, the ovarian vessels, and/or the uterine artery.

Briefly, the procedure of LRT begins with laparoscopic para-aortic lymph node sampling and then pelvic lymph node dissection, in the usual manner. Intraoperative frozen section examinations of all retrieved para-aortic and pelvic lymph nodes were performed before the commencement of LRT to rule out tumour metastases to the lymph nodes. If positive lymph nodes were identified, LRT was abandoned. After developing the paravesical and pararectal spaces, the cardinal ligament was severed using Endo-GIA at the most lateral portion, and it was then freed as much as possible from the surrounding tissue. The round ligament was preserved in all cases. The uterine artery was saved in about half of the cases, but it was sacrificed in the rest of cases because of unintended intraoperative injury during traction. The ureter was dissected from the uterine artery using monopolar cautery, and anterior and posterior vesicouterine ligaments were dissected. And then, the parametrium and ureter were separated as much as possible from the bladder. The paracolpia were severed by monopolar cautery. The posterior cul-de-sac peritoneum was incised and the uterosacral ligaments were severed by monopolar cautery. All procedures were performed laparoscopically, except for the incision of the vaginal cuff, the transaction of the uterine cervix, and the reconstruction of the cervix. A vaginal cuff was incised 3 cm below the fornices. After the transection of the cervix at the isthmic portion, a specimen was opened along the endocervical canal and inspected. It was sent for frozen section examination to ensure that the vaginal, endocervical, and parametrial resection margins were tumour-free. The permanent cervico-isthmic cerclage operation was performed using Mersilone tape in all cases. The uterus was reconstructed to the upper vagina with absorbable sutures, and then the peritoneum was approximated with laparoscopic intracorporeal sutures.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgement
  13. References
  14. Supporting Information

Characteristics of patients

In five patients the planned LRT procedures were abandoned during the operations, and were converted to LRH operations instead, with or without adjuvant concurrent chemoradiation therapy, because intraoperative frozen section examinations revealed a parametrial extension of the tumour in one patient, and pelvic and/or para-aortic lymph node involvement in four patients. The characteristics and outcomes of these five patients are shown in Table 1.

Table 1.   Characteristics of patients in whom laparoscopic radical trachelectomy was abandoned
Patient No.AgeParityHistologyGradeTumour size (cm)LVSIDI1 (mm/mm)PMPALN2 (n/n)PLN2 (n/n)Adjuvant therapyRecur.OS (Mo)Status
  1. AdenoCa, adenocarcinoma; AWD, alive with disease; CCRT, concurrent chemoradiation; CDDP, cisplatin; DI, depth of invasion; LVSI, lymphovascular space invasion; Mo, months; N, negative; NED, no evidence of disease; No., number; OS, overall survival; P, positive; PALN, para-aortic lymph node; PLN, pelvic lymph node; PM, parametrium; TP, paclitaxel and cisplatin.

  2. 1Depth of tumour invasion/thickness of cervix.

  3. 2Number of involved lymph nodes/number of retrieved lymph nodes.

1270AdenoCa32P18/22N0/207/69CCRT TP #3Y47AWD
2330SCCa33P13/15P0/00/56CCRT TP #6N48NED
3350SCCa20.9N3/15N0/31/39NoneN29NED
4370SCCa23.1P18/18N0/2211/58CCRT CDDP #6N6NED
5250SCCa22.8P14/14N0/9  1/29CCRT CDDP #6N3NED

Table 2 shows the characteristics of the 27 patients who completed LRT. At the times of operation, 17 patients (63.0%) were unmarried. Fifteen patients underwent loop electrosurgical excision procedure (LEEP) before LRT. In eight of them (53.3%), no residual disease was seen when trachelectomy specimens were examined. Patients with stage-IIA cervical cancers are not eligible for LRT in our centre, but one patient with such a tumour was very eager to preserve her fertility despite her physician’s explanation of recurrence risk and poor disease prognosis. She underwent LRT and received postoperative adjuvant chemotherapy. The vaginal, endocervical and parametrial resection margins were tumour-free in all patients. No patient showed parametrial invasion by pathology report. The tumour invasion depths into the cervical stroma were more than half the stromal depth in one patient. No one had lymphovascular space invasion.

Table 2.   Characteristics of the 27 patients who completed laparoscopic radical trachelectomy
CharacteristicsVariables
  1. BMI, body mass index; FIGO, International Federation of Obstetrics and Gynecology; LEEP, loop electrosurgical excision procedure; LN, lymph node; LRH, laparoscopic radical hysterectomy; LRT, laparoscopic radical trachelectomy; LVSI, lymphovascular space invasion; SD, standard deviation.

Age, mean (range), years29 (22–37)
BMI, mean (range), kg/cm220.8 (17.5–24.6)
Parity, n (%)
020 (74.1)
1 5 (18.5)
2 2 (7.4)
Preoperative LEEP, n (%)
No12 (44.4)
Yes15 (55.6)
FIGO stage, n (%)
IB126 (96.3)
IIA 1 (3.7)
Tumour size, mean (range), cm1.7 (0.4–3.5)
<2 cm, n (%)19 (70.4)
≥2 cm, n (%) 8 (29.6)
Histology, n (%)
Squamous cell carcinoma20 (74.1)
Adenocardinoma 6 (22.2)
Adenosquamous carcinoma 1 (3.7)
Histologic grade of tumour, n (%)
Well differentiated 5 (18.5)
Moderately differentiated14 (51.9)
Poorly differentiated 8 (29.6)
Number of LNs retrieved
Para-aortic LNs, mean (range), n 4.3 (1–8)
Pelvic LNs, mean (range), n24.6 (8–50)
Total LNs, mean (range), n25.7 (8–50)

Surgical outcomes of the 27 patients who completed laparoscopic radical trachelectomy

Of 27 patients who completed LRT, para-aortic lymph node sampling was performed in seven patients (26.0%), and pelvic lymphadenectomy and cerclage operations were performed in all patients. The mean operating time was 290 min (range, 120–520 min). The mean estimated blood loss was 332 ml (range, 50–1000 ml). The mean preoperative haemoglobin level was 12.3 gm/dl (range, 9.1–14.6 gm/dl), the mean postoperative haemoglobin level was 10.1 gm/dl (range, 8.0–13.3 gm/dl), and the mean perioperative haemoglobin level change was 2.2 gm/dl (range, 0.1–6.1 gm/dl). Perioperative transfusion was required in six patients (22.2%), and the mean transfusion volume was 2.2 units (range, 2–3 units). There were no ureteral, bladder, vascular, or bowel injuries during the operations. There were no significant postoperative complications that required further management or reoperations. The mean postoperative hospital stay was 9 days (range, 4–18 days).

Oncological outcomes

The median follow-up time of the 32 patients was 31 months (range, 1–58 months). In five of these patients, LRT was converted to LRH because of parametrial invasion or lymph node metastasis, as shown by frozen biopsy. Of these five patients, four received concurrent adjuvant chemoradiation therapy, with two receiving three or six cycles of paclitaxel/carboplatin and two receiving six cycles of cisplatin. One patient had recurrent disease 7 months after LRH (Table 1). Of the 27 patients who completed LRT, only one received adjuvant therapy with paclitaxel and cisplatin. One patient experienced a recurrence 8 months after surgery. At initial surgery, she had FIGO (International Federation of Gynecology and Obstetrics) stage IIA disease, the tumour size had been 3 cm in diameter, and the invasion depth of the tumour into the cervical stroma was 0.8 cm (compared with the full cervical thickness of 1.5 cm). In this patient, the vaginal, endocervical, and parametrial resection margins were tumour-free. There was no parametrial invasion, no lymphovascular space invasion, and no lymph node metastasis. The vaginal fornix was, however, involved. This patient received three cycles of adjuvant chemotherapy with paclitaxel and cisplatin. She suffered a recurrence in the uterine cervix and right pelvic side wall, and received concurrent chemoradiation therapy. However, she died of disease 12 months after initial surgery.

Reproductive outcomes of the 27 patients who completed LRT

Regular menstruation returned in 24 patients 3 months after surgery. In the remaining three patients, the follow-up time was too short to estimate the menstrual pattern after surgery. Eight patients complained of decreased menstrual flow compared with preoperative status. Three patients complained of newly developed severe dysmenorrhoea requiring analgesics. On transvaginal ultrasonography, hematocolpos associated with cervical stenosis was detected in these patients. They underwent recannulation, and then the hematocolpos subsided. At the times of interview by telephone, 15 patients were still unmarried. Amongst the 12 married patients, six patients attempted to conceive and three succeeded. Of them, two patients suffered a miscarriage in the first trimester and another patient underwent caesarean section at 36 weeks of gestation, and a healthy baby was born without congenital anomaly. The remaining three patients are attempting to conceive, and one of them is receiving fertility treatment (in vitro fertilisation and embryo transfer). In most cases, the patients were instructed by their physicians to try to conceive 6–12 months after surgery. All patients said they were satisfied with the results of the surgery.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgement
  13. References
  14. Supporting Information

Radical hysterectomy has been the standard treatment for early stage cervical cancer, and recent advances in laparoscopic oncological surgery have seen LRH become a reasonable alternative treatment. These operations yield 5-year survival rates of 75–90% in most cases. One of the major shortcomings of these operations, however, is the complete loss of fertility. Recently, cervical cancer cases diagnosed during reproductive years are increasing in number because of the development of organised screening programs for cervical cancer and increases in the number of older women having children.2 Conservative management of early stage cervical cancer in young patients who want to preserve their fertility is therefore required.

The first successful systematic conservative surgical approach for early stage cervical cancer was laparoscopic-assisted vaginal radical trachelectomy (LAVRT), which involves laparoscopic pelvic lymph node dissection and removal of the cervix, together with surrounding parametrial and paracervical tissues, via a vaginal route, up to the isthmus. After the first description by Dargent and colleagues, over 790 instances of the use of these techniques have been reported in the literature, with over 302 pregnancies and 190 live births reported following these procedures (Table 3).7,15–21 The LAVRT procedure became a fertility-preserving technique that has recently gained worldwide acceptance as a method of surgically treating small invasive cancers of the cervix. In LAVRT, however, the shortcomings are: (1) the difficulty of learning radical vaginal surgery, and (2) possible incomplete parametrial resection.9 Several authors reported that ART, an abdominal variation of VRT, provides: (1) a wider parametrial resection, which enables the procedure to be performed on larger lesions; (2) a lower intraoperative complication rate; (3) expansion of the criteria for radical trachelectomy to patients with distorted cervicovaginal anatomy, in whom a vaginal approach may not be feasible; and (4) abdominal routes familiar to gynaecologic oncologists, because this procedure is basically identical to radical hysterectomy.10,22–24 To date, several authors have reported their experiences with this procedure, and the short-term results seem to be promising (Table 3). 10,22,25–29 Another surgical approach for radical trachelectomy is LRT, which has the advantages of both the abdominal approach and the laparoscopic approach. Although LRH became a reasonable alternative to radical hysterectomy because of recent advances in laparoscopic oncological surgery, reports on the use of LRT are scant (Table 3).11–14 In our series, the surgical outcomes were acceptable and the morbidity rate was very low. The oncological outcomes were also favourable, although the follow-up time was relatively short. We think the obstetrical outcomes were also promising because all patients reported the return of regular menstruation, and three of six patients who attempted to conceive succeeded. We therefore think that LRT may be a reasonable alternative to radical hysterectomy in young patients who want to preserve their fertility. Of course, more patients, and longer follow-up times, are needed to confirm these findings. As a result of the increasing use of robotic surgery in gynaecologic oncology, there have been several case reports on robot-assisted laparoscopic radical trachelectomy,30–32 suggesting that this may be a feasible alternative to radical hysterectomy.

Table 3.   Reports on radical trachelectomy using various techniques
Author (year) [Reference]Number of PatientTrache-lectomy typeFailure caseAge (years)FIGO stageHistologyTumour size (cm)LVSIOperating time (min)Estimated blood loss (ml)Hospital stay (days)Median follow-up (months)Pregnancy1st trimester loss2nd trimester lossPreterm birthTerm birthRecurrence rateDeath rate
SCCAdeno or AdenoSCCOthers
  1. ART, abdominal radical trachelectomy; FIGO, International Federation of Obstetrics and Gynecology; LARVT, laparoscopic-assisted vaginal radical trachelectomy; LVSI, lymphovascular space invasion; NR, nor reported; RVT, radical vaginal trachelectomy; SCC, squamous cell carcinoma.

  2. aAll cases are included in Ungar et al.’s report.

Burnett et al. (2002)1521LARVT230 (23–41)IA2–IIA12901.1 (0.3–3.0)2318 (180–480)293 (minimal–850)3 (2–5)31.5 (22–44)3011100
Schlearth et al. 2003)1612LARVT4 RVT6230.9 (22–44)IA2–IB460<2 (2) >2 (2)1NR203 (50–600)3.2 (2–8)47 (28–84)4 22 00
Covens et al. (2003)1793LARVT030IA1–IB242440<2 (85) >2 (8)31180300130 (1–103)NRNRNRNRNR74
Plante et al. (2004)1882LARVT1031 (21–42)IA1–IIA42300<2 (64) >2 (8)14252 (100–455)254 (25–1200)3.7 (1–9)60 (6–156)NRNRNRNRNR32
Hertel et al. (2006)19108LARVT832 (21–41)IA1–IB175330<238253 (115–402)NR8 (3–23)29 (1–128)183 12 42
Shepherd et al. (2006)20123LARVT030.6 (21–45)IA2–IB183364NR39NRNRNR45 (1–120)55 in 28 women14720832
Marchiole et al. (2007)21135LARVT1732IA1–IIA902531.66 ± 0.9143179 ± 54NRNR95 (31–234)NRNRNRNRNR75
Sonoda et al. (2008)2443LARVT231 (20–40)IA1–IB124190  330 (220–480)100 (50–300)3 (3–7)21 (3–60)11213110
Smith et al.a (1997)101ART0NRIBNRNRNRNRNRNRNRNRNRNRNRNRNRNRNRNR
Rodriguez et al. (2001)223ART026.3IA1–IA2210NR1260–270200–7004–59–312NRNRNR100
Ungar et al.a (2005)2333ART330.5 (23–37)IA2–IB22622<62NRNR14 (12–22)47 (14–75)3100200
Cibula et al. (2005)253ART0NRIA2–IB1NRNRNRNRNRNR350–3500NRNRNRNRNRNRNRNRNR
Bader et al. (2005)261ART034IB110011NRNRNR6NRNRNRNRNR10
Aburustum et al. (2008)2722ART333 (23–43)IB191301.6 (0.9–2.5)9298 (180–425)250 (50–700)4 (3–6)12 (1–35)NRNRNRNRNR00
Rene Pareja et al. (2008)2815ART030 (25–38)IA2–IB11140<25265 (200–330)400 (200–1000)3 (2–7)32 (5–32)3001200
Olawaiye et al. (2009)2910ART 31 (26–38)IA1–IIA3700.25–1.8NR288 270–330)500 (400–600)6283001100
Pomel et al. (2002)117LRT0NRNRNRNRNRNRNR180–220NRNRNRNRNRNRNRNRNRNR
Lee et al. (2003)122LRT030, 34IB1, IB12002.5, NR1365, 340900, 40018, 712, 9NRNRNRNRNR00
Cibula et al. (2005)131LRT036IB11000.8NR25025064NRNRNRNRNR00
Bafghi et al. (2006)146LRT030IA2–IB1NRNRNRNR1NRNRNR252100111
Present series32LRT529 (22–37)IB1–IIA20701.7 (0.4–3.5)0290 (120–520)332 (50–1000)9 (4–18)31 (1–58)3201011

In our series, the estimated blood loss and perioperative haemoglobin changes were not high. However, the rate of perioperative transfusion was relatively high. This was because anaesthesiologists arbitrarily made a decision on transfusion without strict criteria for transfusion. The operating time in our series of patients was comparable with those reported for LAVRT, ART, or LRT (Table 3). In most studies comparing laparoscopic and laparotomic surgery for gynaecologic cancers, operating times were similar. However, laparoscopic surgery has been found to offer several advantages, including a decrease in blood loss and transfusion requirements, shorter hospital stay, fewer complications and improved cosmetic outcomes.33–35 Because our study included only patients undergoing laparoscopic surgery, we cannot make the comparison. It is likely, however, that LRT may offer advantages in these aspects compared with the ART group. To confirm this, further evaluation is required. The mean postoperative hospital stay in our series was 9 days. In general, hospital stays following laparoscopy are longer in Korea than in western countries. Because the charge for admission is very low and there is extensive insurance coverage for cancer patients in Korea, most patients who undergo laparoscopic surgery want to remain in the hospital postoperatively as long as laparotomy patients, although this is against the usual medical advice regarding patient discharge. In short, the relatively long postoperative hospital stay of the laparoscopy group patients is common in the Korean medical environment, and is not specific to our hospital or to our series. Nevertheless, the length of hospital stay of patients undergoing laparoscopy was significantly shorter than previously found in patients undergoing laparotomy. For example, when we compared hospital stays of LRH and ARH patients with early cervical cancer, we found that the mean lengths of stay were 10 and 18 days (P = 0.001), respectively.34 In a comparison between early endometrial cancer patients undergoing laparoscopic-assisted vaginal hysterectomy (LAVH) plus pelvic lymph node dissection (PLND) and those treated by total abdominal hysterectomy (TAH) plus PNLD, we found that the mean lengths of hospital stay were 10 and 14 days (P < 0.001), respectively.33 We also found that the hospital stay was significantly shorter for patients undergoing both laparoscopic and laparotomic staging for treatment of early ovarian cancer (9 versus 15 days; P = 0.002).35

It is still unclear whether the surgeon should complete the radical hysterectomy or stop the procedure and administer chemoradiotherapy if a frozen biopsy reveals parametrial involvement or lymph node metastasis. One rationale for not performing radical hysterectomy is to avoid the morbidity of combined treatment in the absence of a synergistic advantage.36,37 Another rationale is to improve the delivery of radiation therapy with the uterus in situ.36 Alternatively, completion of radical hysterectomy before chemoradiotherapy may enhance pelvic control and survival.38–41 Although we completed radical hysterectomy in patients found to have parametrial involvement or lymph node metastasis during radical surgery, further study is warranted.

In our series, regular menstruation returned in most patients. However, a considerable number of patients complained of decreased menstrual flow, and one patient complained of newly developed severe dysmenorrhoea. These symptoms may result from the partial obstruction of the remaining cervical canal. Because all patients underwent cerclage operations, cervical isthmic stenosis, a complication reported in about 15% of patients,19 may be exacerbated. Persistent haematometra as a result of stenosis compromises both fertility and quality of life, and often requires dilatation of the cervical ostium, which must be performed several times in the same patient to obtain optimal results.42 In our series, definite haematometra has not been documented in any patients to date. We think that postoperative follow-up examinations including ultrasonography are important, however, for the evaluation of haematometra in patients with decreased menstrual flow.

One adverse outcome after radical trachelectomy is preterm delivery, which may be caused by: (1) an increased risk of infection because of a decreased infection barrier caused by the shortening of the cervix, and the absence of a cervical mucus plug; (2) cervical incompetence; or (3) decreased uterine blood flow.43 The latter can also lower placental perfusion and lead to immaturity of the fetus. During VRT, both uterine arteries are usually preserved, with uterine perfusion after VRT commonly remaining unchanged. During ART, however, both uterine arteries are usually divided, to dissect the cardinal ligaments and the ureters from the uterine arteries. Some surgeons have suggested dissection and reanastomosis of uterine arteries during ART to preserve uterine blood flow, but this procedure has not been satisfactory.10,44 Another method that may preserve uterine arteries is skeletonisation of the internal iliac and uterine arteries, and preservation of these arteries during dissection of the cardinal ligaments and ureters:44 this is the approach used in our series to preserve both uterine arteries. In about 50% of our patients, however, the uterine arteries were damaged because of traction or uterine manipulation. Most of these uterine arterial injuries occurred during the first half of our study period, with few being observed later in the study period, suggesting that meticulous manipulation of the uterine artery by an experienced surgeon should lead to the preservation of uterine arteries in most patients.

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgement
  13. References
  14. Supporting Information

In conclusion, the preliminary results from our small series indicate that LRT may be a safe and useful alternative to radical hysterectomy in women with IB1 cervical cancer who want to preserve their fertility. For optimal results, patient selection is very important. A large prospective study is needed to confirm our data.

Contribution to authorship

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgement
  13. References
  14. Supporting Information

JHK: substantial contributions to the conception and design of the study, analysis and interpretation of data, and drafting the article. JYP: substantial contributions to the conception and design of the study, acquisition of data, ad the analysis and interpretation of data. DYK, YMK, and YTK: substantial contributions to the conception and design of the study, analysis and interpretation of data, and revising the article critically for important intellectual content. JHN: substantial contributions to the conception and design of the study, analysis and interpretation of data, and the final approval of the version to be published.

Details of ethics approval

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgement
  13. References
  14. Supporting Information

This study was approved by the Institutional Review Board of Asan Medical Centre (AMC, Seoul, Korea) on 17 March 2009 (reference number: 2009-0110).

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgement
  13. References
  14. Supporting Information
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Supporting Information

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgement
  13. References
  14. Supporting Information

Video Clip S1. Surgical techniques of fertility-sparing laparoscopic radical trachelectomy for young women with early stage cervical cancer.

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BJO_2446_sm_Suppmat.suppl0KSupporting info item

Please note: Wiley Blackwell is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.