Fertility-sparing surgery for young women with early-stage cervical cancer

Authors


Sir,

We read with great interest the paper regarding laparoscopic radical trachelectomy by Kim et al.1 We agree that there is a paucity of data on abdominal radical trachelectomy,2 let alone laparoscopic radical trachelectomy (LRT), as there is greater experience with the vaginal approach.3,4 This is not an unexpected finding, for this fertility-sparing procedure was introduced as a vaginal procedure, and is taught as such in most cancer centres in Europe and Canada.

To address concerns related to the morbidity and radicality of the vaginal procedure in terms of incomplete parametrial resection, we would like to recapitulate the surgical principles of radical vaginal trachelectomy.

  •  The bladder is mobilised and the paravesical space is entered.
  •  By opening the paravesical space, the bladder pillars are identified and then divided.
  •  The ureter is then palpated and reflected superiorly, using a finger to roll the ureter cranially and out of the surgical field.
  •  Both the cardinal and uterosacral ligaments are taken as far lateral as necessary in order to obtain adequate paracervical tissue.
  •  Decision on the length of the cervix excised depends on the histopathology and the position of the upper proximal limit of the tumour. This is easier to do directly under vision by a vaginal approach.

If the above principles are adhered to then oncological safety would be maximised, surgical injury would be minimised, and the radicality of the vaginal procedure would not be compromised.

Pre-operative assessment should include the size of the tumour, its exact location and the distance from the isthmus and, therefore, upper endocervical canal, as well as the likelihood of obtaining at least 1cm clearance of normal tissue surrounding the residual carcinoma. In this study endocervical involvement is determined by colposcopic examination and/or magnetic resonance imaging (MRI). We rely on the latter for two essential measurements are obtained: the length of the endocervical canal and the length of the uterine cavity to the fundus. These are required during the procedure to ensure that the correct length of the cervix is being resected in order to give an adequate clearance of normal cervical stroma beyond the tumour. This information cannot be obtained during a colposcopic examination. In the methodology, stage-1A2 disease was a criterion for LRT, and such a subgroup can be managed by knife cone biopsy, providing the nodes are negative. A case series on abdominal radical trachelectomy included nearly 20% with stage-1A disease.2 Hence, the abdominal approach would appear easier compared with the vaginal approach with respect to the radicality of the procedure. It is alarming that the uterine artery was severed in approximately 50% of cases, and there is a one in five chance of patients who are otherwise fit and healthy receiving a blood transfusion, with its associated inherent risks, albeit small.

Vaginal surgery should be taught safely and adequately in any general obstetric and gynaecology training programme. The step to radical vaginal surgery is then a logical progression during a fellowship programme. This is in conjunction with the laparoscopic techniques required for pelvic node dissection, which is carried out as the initial step of assessing suitability for vaginal trachelectomy. Shepherd et al.3 reported that 790 cases have been carried out vaginally worldwide. This procedure should be performed by a gynaecological oncologist, and, if not familiar with such a procedure, all patients should then be referred to a specialist with the appropriate expertise working within a cancer centre.

In our endeavours to remind readers of the surgical technique for radical vaginal trachelectomy, we hope that all concerns have been allayed. Appropriate patient selection is crucial before embarking on any surgical procedure in order to minimise surgical morbidity.

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