Does Radical Trachelectomy Represent a Realistic Approach in Early Stage Cervical Cancer?
Georgios Androutsopoulos*, Georgios Michail, Panagiotis Panas and Georgios Adonakis
Department of Obstetrics and Gynaecology, University of Patras, Greece
Submission: October 08, 2018;Published: November 15, 2018
*Corresponding author: Georgios Androutsopoulos MD, PhD, Assistant Professor, Division of Gynaecological Oncology, Department of Obstetrics and Gynaecology, University of Patras, Medical School, Rion 26504, Greece.
How to cite this article: Androutsopoulos G, Michail G, Panas P, Adonakis G. Does Radical Trachelectomy Represent a Realistic Approach in Early Stage
Cervical Cancer?. Open Access J Surg. 2018; 10(1): 555776. DOI: 10.19080/OAJS.2018.10.555776.
Nowadays, cervical cancer (CC) represents a major clinical problem as it is the most common malignancy of the female reproductive system and the fourth most common cancer in the general female population [1,2]. The disease most commonly affects young patients, sometimes before completion of childbearing [1,2]. In this case, the type and extend of surgical treatment should be carefully individualized based on disease stage, histologic subtype, fertility issues and performance status [3-8].
Especially in young patients with FIGO stage IB1 CC and strong desire for fertility preservation, radical trachelectomy represents a realistic treatment option [3,8-13]. The procedure was initially described in 1994 by Daniel Dargent as a vaginal operation [9,14]. Few years later, Richard Smith proposed the abdominal approach as an alternative . The selected patients should have tumor size less than 2cm, no involvement of the upper endocervical canal and negative pelvic and para-aortic lymph nodes [3,8-13,16-18]. Moreover, all patients should have a very detailed counseling regarding disease recurrence, oncologic outcome, fertility and pregnancy issues and perinatal outcome [3,5-8,11,13,18-20].
However, radical trachelectomy should not be offered in patients with aggressive (small cell neuroendocrine carcinoma) or potentially aggressive (gastric type adenocarcinoma, minimal deviation adenocarcinoma) histologic subtypes of CC, even at early stage disease [3,8,10,13,21-23]. Preoperatively all patients should have a thorough investigation with pelvic MRI, examination under anesthesia and cystoscopy, in order to assess tumor size as well as extent and proximity to internal cervical os [3,8,12,24-26]. The procedure could be performed using either the vaginal or the abdominal approach [8,9,15,27]. Pelvic lymphadenectomy with or without SLN mapping, should be performed before starting radical trachelectomy [8,9,27,28]. The excised lymph nodes should be examined using ultrastaging approach and in case of metastasis, the operation should be abandoned [8,9,27-29].
In vaginal radical trachelectomy the cervix, upper vagina and paracolpos/para-vaginal tissues should be excised en bloc, as in a type B radical hysterectomy [3,8,9]. Moreover, pelvic lymph nodes
could be excised laparoscopically . Respectively, in abdominal radical trachelectomy the cervix, upper vagina (1-2cm), parametrium and paracolpos/para-vaginal tissues should be excised en bloc, as in a type C radical hysterectomy [3,8,11,15,27]. Abdominal operation represents a less conservative approach and provides wider parametrial resection compared with vaginal procedure [3,8,11,15-17,27,30]. The resection margins of the provided surgical specimen should be examined in detail with multiple frozen sections [8,29,31]. In case of clear resection margins to the endocervix, the excisional procedure has been already completed and the reconstructive procedure could be started [8,11,27,31]. In case of positive resection margins or lymph node metastasis, either radical hysterectomy or primary chemo-radiotherapy should be performed [8,10,23,27,29,31-33].
Perioperative morbidity rates in young CC patients treated with radical trachelectomy are relatively low and quite acceptable for a radical surgical procedure [8,10,29,30,34]. Moreover, patients have less significant perioperative complications compared with others treated with radical hysterectomy [8,35]. Intraoperative complications are significantly more common in vaginal radical trachelectomy (5.6%) compared with the abdominal approach (0.7%) [8,10,29,30,34,36]. On the other hand, postoperative complications are significantly more common in abdominal radical trachelectomy (35%) compared with vaginal operation (7.5%) [8,10,29,34,36]. This is mainly because abdominal approach is a more extensive surgical procedure providing wider parametrial resection [8,10,29,30,34,36].
Bladder hypotonia, urinary tract infection, deep venous thrombosis, pulmonary embolism, lymphatic cyst and Genito-femoral nerve palsy, are the most common early postoperative complications in patients having radical trachelectomy [8,10,23,29,34,36,37]. Cervical stenosis, chronic pelvic pain and lymphoedema, are the most common late postoperative complications [8,10,23,34,36]. Despite differences regarding the width of parametrial resection, both types of radical trachelectomy provide similar oncologic outcomes [ 8,30]. Recurrence rates are quite similar for both surgical approaches, rated at approximately 3.8% for the abdominal and 4.8% for the vaginal procedure[8,10,16,17,23,29,34,36,38,39]. Mortality rates
have small differences, at about 0.4% for the abdominal and
2.9% for the vaginal approach [8,10,16,17,23,29,34,36,38,39].
In CC patients with stage IB1 disease, radical trachelectomy and
radical hysterectomy provide similar disease-free survival rates at
Tumour size represents a major prognostic factor in young
CC patients treated with radical trachelectomy [8,10,33]. When
using the vaginal procedure in CC patients with tumor size greater
than 2cm, the risk of disease recurrence is more than 12% (range
12% to 29%) [8-10,17,18,29,33,34,40]. Recent studies regarding
abdominal operation in CC patients with tumor size between 2
and 4cm, have shown very promising results and this is probably
because of the wider parametrial resection [8,17,32,40]. There
are some differences regarding fertility issues among patients
treated with radical trachelectomy, based on the type of operation
used [8,10,17,29]. Pregnancy rates are significantly higher
among patients having the vaginal procedure (55%), compared
with others treated with the abdominal approach (16%)
[8,10,17,29,36,41]. This could be easily explained by the fact that
abdominal radical trachelectomy represents a less conservative
Moreover, there are some pregnancy issues (miscarriages and
preterm labor) related with the impaired cervical function among
patients having radical trachelectomy [3,8,10,17,29,41-43]. First
trimester miscarriage rates have significant differences based on
the type of operation, at about 12% for the abdominal and 20%
for the vaginal approach [8,23,29,36,38,41]. Second trimester
miscarriage rates have also great differences according to the type
of procedure, at approximately 12% for the abdominal and only
3% for the vaginal operation [8,23,29,36,41]. Preterm labor rates
are quite similar for both surgical approaches, at approximately
16% for the abdominal and 18% for the vaginal procedure
[8,29,36]. All patients treated with radical trachelectomy should
have an elective cesarean section at 38 weeks of gestation, as
there is increased risk of uncontrolled cervical injuries during
vaginal delivery .
In conclusion, radical trachelectomy represents an acceptable
treatment option for carefully selected young patients with FIGO
stage IB1 CC and strong desire for fertility preservation, without
any compromise in oncologic outcome. However, all patients
should have a thorough preoperative assessment and a very
detailed counseling regarding disease recurrence, oncologic
outcome, fertility issues and possible pregnancy complications
related with impaired cervical function.