Radical vaginal trachelectomy

Trachelectomy and Cerclage Placement as Fertility-Sparing Surgery for Cervical Cancer-An Expert Survey

Background/Objectives: Fertility-sparing surgery (FSS) is a standard practice for managing early stage cervical cancer, yet significant variation exists in clinical approaches worldwide. Our objective was to ascertain current practices and preferences for cerclage use among expert centers globally regarding FSS in patients with early stage cervical cancer. Methods: We conducted a cross-sectional survey from May to July 2023 involving expert centers identified through their scientific contributions and participation in international workgroups and conferences.. The survey, comprising 27 questions, evaluated existing practices in FSS. Results: Out of the centers surveyed, 21 (36.2%) gynecologic oncologists responded. For tumors <2 cm, 86% of centers preferred radical trachelectomy, primarily via the vaginal approach, while 13.6% favored a simple trachelectomy. Three experts preferred simple trachelectomy (13.6%). For tumors >2 cm, 47.6% utilized neoadjuvant chemotherapy before trachelectomy. Others did not offer FSS or performed an abdominal radical trachelectomy. Over time, there has been a shift towards less radical surgeries for tumors <2 cm and increased use of neoadjuvant chemotherapy for larger tumors. Some abandoned the minimally invasive surgical approach. Nearly all experts (90.5%) placed a cerclage immediately following trachelectomy. Conclusions: The majority of experts opt for radical trachelectomy in early stage cervical cancer, with immediate cerclage placement being a common practice. However, considerable international variations highlight the urgent need for standardized guidelines and further research to optimize treatment strategies, balancing oncological safety with fertility outcomes.

Oncological outcomes after vaginal and robotic-assisted radical trachelectomy in patients with cervical cancer - A single-center prospective cohort study

OBJECTIVE

The aims of this study are to evaluate the oncological outcomes of robotic-assisted radical trachelectomy (RART) compared with radical vaginal trachelectomy (RVT) for localized early-stage cervical cancer in a national cohort.

METHODS

RVT was introduced in 2003 in Denmark and nationally centralized to Copenhagen Univeristy Hospital. In 2014 the procedure advanced to a robotic-assisted approach. Perioperative and oncological data has been prospectively reported to the Danish Gynecological Cancer Database (DGCD) which is continuously developed and updated. All patients undergoing radical trachelectomy were included in this prospective cohort study. Data was extracted from DGCD and manually validated through electronic medical journals and The Danish Pathology Registry.

RESULTS

A total of 206 patients underwent radical trachelectomy, with 78 patients undergoing RART and 128 patients undergoing RVT. No significant differences were observed in the microscopic free margins of the trachelectomy specimens. A total of seven (5.5%) patients undergoing RVT and two (2.6%) patients undergoing RART had recurrences (p = 0.403). No significant differences in recurrence-free survival were found between the groups, both in the unadjusted (HR 0.51 (0.11-2.47)) and adjusted analyses (HR 0.80 (0.16-3.96)).

CONCLUSIONS

In this large single-center cohort, oncological safety of RART is equal to RVT for patients with localized cervical cancer and a fertility desire.

Overview of fertility sparing treatments for cervical cancer

Until the late 1980s, the mainstay of treatment for cervical cancer has been either hysterectomy or radiotherapy. From the mid to late 1990s, surgical treatments have been focussed more on sparing fertility by preserving the corpus of the womb with trachelectomy or even conserving part of the cervical stroma with a cone biopsy. In carefully selected cases, less radical treatment that preserves the uterus has been considered safe. However, these approaches can be associated with specific operative and obstetric complications such as stitch ulceration, cervical stenosis, late miscarriage, and premature labour. Most guidelines agree that the management of such patients should be centralised in a unit with specialist gynaecological oncology, radiology, and histopathology services supported by specialist cancer nurses.