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


Authors’ Reply


We wish to thank Drs Kolomainen and Shepherd1 for their interest in and comments regarding our article.2 As they suggested, vaginal radical trachelectomy is an appropriate and sufficient surgical treatment for young female patients with early-stage cervical cancer who wish to preserve their fertility.3 If a gynaecologic oncologist adheres to the principles proposed by Kolomainen and Shepherd,1 the best outcomes will be achieved. However, in our experience, vaginal radical trachelectomy is not the optimal surgical approach for Asian women with early-stage cervical cancer, because their vaginas are relatively narrow compared with those of Western women. In addition, as most women requiring radical trachelectomy are nulliparous, a narrow vagina can be an obstacle to satisfactory parametrectomy using vaginal radical trachelectomy. This is also true for adolescent or childhood patients, or patients with a distorted vaginal anatomy. In these cases, abdominal or laparoscopic radical trachelectomy can be a more practical surgical treatment option.

If we consider performing radical trachelectomy only in patients with small tumours of <2 cm in diameter, vaginal radical trachelelctomy can be performed satisfactorily in most cases. However, some patients with large tumours may wish to undergo radical trachelectomy. In our experience, the size of the resected parametrium in vaginal radical trachelelctomy is smaller than that in laparoscopic radical trachelectomy. We believe that this does not originate from the surgeon’s expertise in vaginal radical surgery, but is an innate shortcoming of vaginal radical surgery. We would therefore like to recommend abdominal or laparoscopic radical trachelectomy rather than vaginal radical trachelectomy, as it achieves wider excision of the parametrial tissue in patients with larger tumours. Considering the several advantages of laparoscopy over laparotomy, we believe that laparoscopic radical trachelectomy is the preferred surgical approach.

In our series, uterine arteries were severed in approximately half of the patients, although most of these uterine arterial injuries occurred during the first half of the study period. As it is still unclear whether the preservation of uterine arteries improves reproductive outcomes, in the past we did not perform meticulous surgical techniques to preserve uterine arteries. In fact, many surgeons deliberately sacrifice uterine arteries during abdominal radial trachelectomy. Currently, however, we skeletonise internal iliac arteries and uterine arteries, and attempt to preserve them during dissection of cardinal ligaments and ureters using meticulous surgical techniques. Therefore, uterine arteries were preserved in almost all cases during the second half of the study period.

As Kolomainen and Shepherd1 indicated, transfusion was performed relatively frequently in our series, although the estimated blood loss and perioperative haemoglobin changes were not high. We assume that this was not because of uterine arterial injury but because the anaesthesiologists arbitrarily decided on transfusion without any strict criteria for its use.

Another point made by Kolomainen and Shepherd1 regarded the indications for radical trachelectomy. Ours included stage-IA2 disease, as is universally accepted.4,5 Although Kolomainen and Shepherd suggested that cold-knife conisaton is sufficient treatment for patients with stage-IA2 disease, it is still being debated whether IA2 disease can be treated safely using only cold-knife conisation.