Fertilität nach radikaler Trachelektomie bei Patientinnen mit frühem Zervixkarzinom

New developments in the surgical therapy of cervical carcinoma

For almost a century abdominal radical hysterectomy has been the standard surgical treatment of early-stage macroscopic carcinoma of the uterine cervix. The excessive parametrial resection of the original procedures of Wertheim, Okabayashi, and Meigs has later been "tailored" to tumor extent. Systematic pelvic and eventually periaortic lymph node dissection is performed to identify and treat regional disease. Adjuvant (chemo)radiation therapy is liberally added to improve locoregional tumor control when histopathological risk factors are present. The therapeutic index of the current surgical treatment, particularly if combined with radiation, appears to be inferior to that of primary chemoradiation as an oncologically equivalent therapeutic alternative. Several avenues of new conceptual and technical developments have been used since the 1990s with the goal of improving the therapeutic index. These are: surgical staging, including sentinel node biopsy and nodal debulking; minimal access and recently robotic radical hysterectomy; fertility-preserving surgery; nerve-sparing radical hysterectomy; total mesometrial resection based on developmentally defined surgical anatomy; and supraradical hysterectomy. The superiority of these new developments over the standard treatment remains to be demonstrated by controlled prospective trials. Multimodality therapy including surgery for locally advanced disease represents another area of clinical research. Both neoadjuvant chemotherapy followed by radical surgery, with or without adjuvant radiation, and completion surgery after (chemo)radiation are feasible and have to be compared to primary chemoradiation as the new nonsurgical treatment standard. Surgical treatment of postirradiation persisting or recurrent cervical carcinoma has been traditionally limited to pelvic exenteration for central disease. Applying the principle of developmentally derived anatomical compartments increases R0 resectability. The laterally extended endopelvic resection allows even the extirpation of a subset of visceral pelvic side wall tumors with clear margins. Many questions regarding the indication for these "ultraradical" operations, the surgery of irradiated tissues, and the optimal reconstructive procedures are still open and demand multi-institutional controlled trials to be answered.

Abdominal radical trachelectomy: two new surgical techniques for the conservation of uterine arteries

The objective of this study was to develop two new techniques for the conservation of uterine arteries in abdominal radical trachelectomy. Abdominal trachelectomy with conservation of uterine arteries was performed in two patients with cervical carcinoma. In the first case, the internal iliac artery was divided at 2.0 cm from the bifurcation of the common iliac artery. The internal iliac artery and uterine artery were skeletonized along their lengths to the lateral cervix. The dissected internal iliac artery was then reanastomosed following the radical trachelectomy. In the second case, the technique was similar to that of the first except that the internal iliac artery was not divided. Intraoperative observation and postoperative color Doppler ultrasound were used to confirm the patency of the uterine arteries. The operative time of the two patients was 390 min. and 350 min, respectively. Doppler flow studies demonstrated that the uterine arteries were patent in both cases. Resistance index of the left and the right uterine artery was 0.58 and 0.61, respectively, in the first case, and 0.60 and 0.63, respectively, in the second case. Reanastomosis of the internal iliac arteries or skeletonization of the internal iliac arteries are both feasible methods to conserve the uterine arteries during abdominal radical trachelectomy.

Laparoscopic-assisted radical vaginal hysterectomy (LARVH): prospective evaluation of 200 patients with cervical cancer

OBJECTIVE

The purpose of this study was to determine the survival of cervical cancer patients treated with laparoscopically assisted radical vaginal hysterectomy (LARVH). We quantify morbidity and correlate survival with known risk factors.

METHODS

Between August 1994 and June 2002, 200 patients with cervical cancer (TNM stage 1a1, L1 n = 6, 1a2 n = 21, 1b1 n = 89, 1b2 n = 26, 2a n = 11, 2b n = 45, 3a n = 1, 4 n = 1; squamous cell carcinoma 76.5%, adenocarcinoma 23.5%) were treated with LARVH (type II n = 102, type III n = 98).

RESULTS

Paraaortic lymphadenectomy was performed in 170 (85%) patients and pelvic lymphadenectomy was performed in all 200 patients. In 26 (13%) patients positive lymph nodes were found. Major intraoperative injuries occurred in 6% of patients. Postoperative complications occurred in 8% of patients. Incidence of complications decreased significantly when comparing the first half with the second half of patients. After a median follow-up time of 40 months, overall 5-year survival could be projected to 83%; 18.5% of patients experienced recurrence with 35% exclusively extrapelvic and 11% of patients died of recurrence. Independent prognostic factors for recurrence-free survival were tumor stage, lymph node status, and combined involvement of lymphovascular and angiovascular space. In the absence of these risk factors projected 5-year survival was 98%.

CONCLUSION

Patients with tumor <4 cm, negative lymph nodes, and the absence of the combination of angio- and lymphovascular space involvement can be identified by laparoscopic staging and are ideal candidates for LARVH.