Surgical and obstetrical outcomes after laparoscopic radical trachelectomy and pelvic lymphadenectomy for early cervical cancer

High- or Intermediate-Risk Histologic Features in Patients with Clinical Early-Stage Cervical Cancer Planned for Fertility-Sparing Surgery: A Systematic Review

BACKGROUND

Fertility-sparing surgery (FSS) is a viable option for young women with early-stage cervical cancer (ECC); however, certain risk factors may necessitate additional treatments and impact fertility. This review examines the prevalence of these risk factors and available treatment options.

METHODS

A systematic search was conducted of studies including patients with ECC (IA1 with LVSI, IA2, IB1 (FIGO 2009)) who underwent FSS.

RESULTS

Sixty-four articles, comprising a total of 4118 women planned for FSS, were included. High- or intermediate-risk histologic features were found in 638 (15.5%) women: 5.1% had positive lymph node(s), 4.1% had positive resection margins, 0.3% had parametrial involvement, 1.0% had unspecified high-risk features, and 5.1% had intermediate-risk histology (primarily based on the Sedlis criteria). Adjuvant treatment impaired fertility in all women with adjuvant hysterectomy and/or (chemo)radiation (58.7%). Adjuvant chemotherapy was given to 1351 (32.8%) patients, which may reduce fertility.

CONCLUSIONS

Fertility preservation could be achieved in most women; but high- or intermediate-risk factors necessitate more extensive surgery or radiotherapy leading to infertility. Adjuvant chemotherapy could be an alternative treatment option considering its effectiveness, safety and higher change in fertility preservation. The low incidence of parametrial involvement justifies waiving parametrectomy in tumors < 2 cm.

Oncologic results of fertility sparing surgery of cervical cancer: An updated systematic review

BACKGROUND

Several techniques can be proposed as fertility sparing surgery in young patients treated for cervical cancer but uncertaincies remain concerning their outcomes. Analysis of oncological issues is then the first aim of this review in order to evaluate the best strategy.

RESULTS

Data were identified from searches of MEDLINE, Current Contents, PubMed and from references in relevant articles from January 1987 to 15th of September 2021. We carry out an updated systematic review involving 5862 patients initially selected for fertility-sparing surgery in 275 series.

FINDINGS

In patients having a stage IB1 disease, recurrence rate/RR in patients undergoing simple conisation/trachelectomy, radical trachelectomy/RT by laparoscopico-vaginal approach, laparotomic or laparoscopic approaches are respectively: 4.1%, 4.7%, 2.4% and 5.2%. In patients having a stage IB2 disease, RR after neoadjuvant chemotherapy or RT by laparotomy are respectively 13.2% and 4.8% (p = .0035). After neoadjuvant treatment a simple cone/trachelectomy was carried out in 91 (30%) patients and a radical one in 210 (70%) cases. But the lowest pregnancy rate is observed in patients undergoing RT by laparotomy (36%).

CONCLUSIONS

The choice between these treatments should be based above all, on objective oncological data that strike a balance for each procedure between the best chances for cure and the fertility results. In patients having a stage IB1 disease, oncological results are quite similar according to the procedure used. In patients having a stage IB2 disease, RT by open approach has the lowest RR. Anyway the lowest pregnancy rate is observed in patients undergoing RT by laparotomy.

Fertility-Sparing Surgery for Early-Stage Cervical Cancer: A Systematic Review of the Literature

OBJECTIVE

This systematic review aimed to evaluate oncologic and reproductive outcomes after fertility-sparing surgery (FSS) for early-stage cervical cancer (early CC).

DATA SOURCES

Ovid MEDLINE, Ovid EMBASE, and Cochrane CENTRAL were searched from 1980 to the present using Medical Subject Headings terms; other controlled vocabulary terms; and keywords related to fertility, cervical cancer, and surgical techniques.

METHODS OF STUDY SELECTION

A total of 2415 studies were screened, with 53 studies included. Studies reporting recurrences with a median follow-up of 12 months in early CC (International Federation of Gynecology and Obstetrics 2009 stages IA with lymphovascular space invasion, IB, or IIA) of traditional histologic type undergoing FSS were included.

TABULATION, INTEGRATION, AND RESULTS

The studies were grouped by intervention, including vaginal radical trachelectomy (VRT), abdominal radical trachelectomy (ART), minimally invasive radical trachelectomy (MIS-RT), and conization or simple trachelectomy (ST), and studies involving neoadjuvant chemotherapy (NACT). Combined rates of recurrence (RR), cancer death (CDR), pregnancy (PR), and live birth (LBR) were calculated per procedure on the basis of all included studies that reported outcomes on that procedure. The results were as follows: VRT: RR 4%, CDR 1.7%, PR 49.4%, and LBR 65.0% ART: RR 3.9%, CDR 1.4%, PR 43.2%, and LBR 44.0% MIS-RT: RR 4.2%, CDR 0.7%, PR 36.2%, and LBR 57.1% Cone or ST: RR 4.2%, CDR 0.8%, PR 55.1%, and LBR 71.9% NACT: RR 7.5% and CDR 2.0% CONCLUSION: FSS of early CC with VRT, ART, or MIS-RT have comparable oncologic outcomes in carefully selected patients, with reproductive outcomes favoring VRT. Data on nonradical FSS with cone or ST are less robust but support similar oncologic outcomes to radical trachelectomy with fewer reproductive complications. NACT in this setting requires more investigation before routine implementation into practice.

Trachelectomy for reproductive-aged women with early-stage cervical cancer: minimally invasive surgery versus laparotomy

BACKGROUND

A recent trial demonstrated decreased survival in women with early-stage cervical cancer who underwent radical hysterectomy via minimally invasive surgery compared with laparotomy; however, outcomes following trachelectomy have yet to be studied.

OBJECTIVE

To examine trends, characteristics, and survival of reproductive-aged women with early-stage cervical cancer who underwent minimally invasive trachelectomy.

STUDY DESIGN

This is a retrospective study examining the National Cancer Database between 2010 and 2015. Women aged <50 years who underwent trachelectomy for stage IA2-IB cervical cancer were grouped by mode of surgery. Clinicopathologic characteristics and outcomes were compared between minimally invasive surgery and laparotomy groups.

RESULTS

A total of 246 women were included, 144 (58.5%, 95% confidence interval, 52.4%-64.7%) of whom had trachelectomy with a minimally invasive surgery approach. Median age was similar between the minimally invasive surgery and laparotomy groups (median, 31 vs 29 years, P = .20). There was a significant increase in the use of minimally invasive surgery from 29.3% in 2010 to 75.0% in 2015 (P < .001). Specifically, minimally invasive surgery became the dominant approach for trachelectomy by year 2011 (54.8%). Hospitals registered in the West (75.0% vs 25.0%) were more likely, whereas those registered in the Midwest (46.9% vs 53.1%) were less likely, to perform minimally invasive surgery (P = .02). Median follow-up was 37 months (interquartile range, 23-51) for the minimally invasive surgery group and 40 months (interquartile range, 26-67) for the laparotomy group. During follow-up, there were 11 (5.3%) deaths, 4 (3.5%) in the minimally invasive surgery group and 7 (7.6%) in the laparotomy group (P = .25).

CONCLUSION

Minimally invasive surgery has become the dominant modality for trachelectomy in reproductive-aged women with stage IA2-IB cervical cancer after year 2011. Survival of women with stage IA2-IB cervical cancer who underwent trachelectomy is generally good regardless of surgical modality. Although our study showed no difference in survival between the minimally invasive surgery and laparotomy approaches, effects of MIS on survival remain unknown and further study is warranted.

Type B Laparoscopic Radical Trachelectomy with Uterine Artery Preservation for Stage IB1 Cervical Cancer

STUDY OBJECTIVE

Radical trachelectomy has emerged as a valuable fertility-preserving treatment option for young women with early-stage cervical cancer [1]. Laparoscopic radical trachelectomy performed by trained surgeons can be a feasible and safe therapeutic option as a fertility-sparing surgical technique [2,3]. To the best of our knowledge, this is the first time the total laparoscopic approach of radical trachelectomy is being published. In this video, rather than the description of the technique step by step, we show how to conserve uterine arteries even if the importance of such conservation is questionable.

DESIGN

A case report.

SETTING

A tertiary referral center in Strasbourg, France.

PATIENT

A 37-year-old patient with no medical history who presented with stage IB1 invasive epidermoid cervical cancer.

INTERVENTION

In this video, we describe the fertility-sparing surgical procedure consisting of type B total laparoscopic radical trachelectomy with uterine artery preservation. The procedure consists of the following 10 steps: step 1, bilateral pelvic lymphadenectomy and opening of the para vesical fossa; step 2, opening of the pararectal fossa in between the ureter and the internal iliac artery on each side; step 3, ureteric dissection up to the ureteric canal; step 4, opening of the vesicouterine space and section of the vesicouterine ligament; step 5, posterior dissection with division of the uterosacral ligament approximately 20 mm from the uterine insertion; step 6, section of the descending branch of the uterine artery and skeletonization of the ascending branch up to the uterine isthmus level; step 7, trachelectomy with a monopolar hook; step 8, laparoscopic isthmovaginal stitches; step 9, laparoscopic cerclage; and step 10, peritoneal closure.

MEASUREMENTS AND MAIN RESULTS

The operative time was 420 minutes. The intraoperative blood loss was <200 mL. The operation was performed successfully with no intraoperative complications. The resection margins were safe. The patient was discharged on day 4. After 2 months, no late complications or recurrence were detected, and the patient had normal menstruation.

CONCLUSION

Type B laparoscopic radical trachelectomy with uterine artery preservation appears to be a safe option for women who intend to maintain their desire for a future pregnancy.