Simple vaginal trachelectomy in women with early-stage low-risk cervical cancer who wish to preserve fertility: the new standard of care?

OBJECTIVE: There is a trend toward less radical surgery in women with small-volume disease who wish to preserve fertility. The objective of our study was to evaluate the oncologic and obstetrical outcome of simple vaginal trachelectomy and lymph node assessment in patients with low-risk early-stage cervical cancer (<2 cm). METHODS: From May 2007 to January 2020, 50 patients underwent a simple vaginal trachelectomy/conization with laparoscopic sentinel lymph node mapping±complete pelvic node dissection. Patients underwent loop electrocautery excision (LEEP), cone/cervical biopsies, or simple trachelectomy. A preoperative pelvic MRI with gadolinium contrast was systematically performed in all cases. The size of the lesion was established by review of the LEEP, cone or trachelectomy specimen, MRI, and clinical examination. Data was collected prospectively in a computerized database. Descriptive statistics and the Kaplan-Meier estimate were used for analysis. RESULTS: The median age was 29 years (range: 21-44) and 35 (70%) patients were nulliparous. As per FIGO 2009 classification, 11 patients had stage IA1 with lymphovascular space invasion (LVSI), 13 patients had stage IA2, and 26 patients had stage IB1. Twenty-six patients had squamous histology, 20 patients adenocarcinoma, and four patients other histologies. On final pathology, lymph nodes were negative in 46 patients (92%), three patients had isolated tumor cells, and one patient had micrometastasis. Thirty patients (60%) had either no residual disease in the trachelectomy specimen (22) or residual dysplasia only (eight). With a median follow-up of 76 months (range: 1-140), only one local recurrence occurred which was treated initially with chemoradiation. She recurred again locally and underwent a pelvic exenteration: the patient progressed again and died of disease. The 5-year progression-free survival and overall survival was 97.9% and 97.6%, respectively. There were 40 pregnancies: five (12.5%) ended in the first trimester, one (2.5%) in the second trimester, and three (7.5%) were late preterm: all the others (30 or 75%) delivered >36 weeks and one pregnancy is ongoing. CONCLUSION: Simple trachelectomy/conization and lymph node assessment is an oncologically safe fertility-preserving surgery in well-selected patients with low-risk early-stage cervical cancer (<2 cm). Obstetrical outcomes are comparable to the general population.

Association between hospital surgical volume and perioperative outcomes of fertility-sparing trachelectomy for cervical cancer: A national study in the United States.

OBJECTIVE: To examine the association between hospital surgical volume and perioperative outcomes for fertility-sparing trachelectomy performed for cervical cancer. METHODS: This is a population-based retrospective observational study utilizing the Nationwide Inpatient Sample from 2001 to 2011. Women aged ≤45 years with cervical cancer who underwent trachelectomy were included. Annualized hospital surgical volume was defined as the average number of trachelectomies a hospital performed per year in which at least one case was performed. Perioperative outcomes were assessed based on hospital surgical volume in a weighted model, specifically comparing the top-decile centers to the lower volume centers. RESULTS: There were a total of 815 trachelectomies performed at 89 centers, and 76.4% of the trachelectomy-performing centers had a minimum surgical volume of one trachelectomy per year. The top-decile group had a higher rate of lymphadenectomy performance compared to the lower volume group (96.4% versus 82.4%, odds ratio [OR] 5.65, 95% confidence interval [CI] 2.81-11.4, P < 0.001). There was a significant inverse linear association between annualized surgical volume and the number of perioperative complications (P = 0.020). The top-decile group also had a lower rate of perioperative complications (9.7% versus 21.0%, P < 0.001) and prolonged hospital stay ≥7 days (2.0% versus 6.5%, P = 0.006) compared to the lower volume group. In a multivariable analysis, the top-decile group had a 65% relative decrease in perioperative complication risk compared to the lower volume group (adjusted-OR 0.35, 95%CI 0.20-0.59, P < 0.001). CONCLUSION: Fertility-sparing trachelectomy for young women with cervical cancer is a rare surgical procedure; <90 centers performed this procedure from 2001 to 2011 and most hospitals perform a small number of cases annually. Higher hospital surgical volume for trachelectomy may be associated with reduced perioperative morbidity.

Robotic-Assisted Laparoscopic Trachelectomy: A Standard Technique.

STUDY OBJECTIVE: To describe a standard reproducible technique for simple robotic- assisted laparoscopic trachelectomy. DESIGN: Step-by-step demonstration of the technique using videos and pictures (Canadian Task Force classification level 3). SETTING: The incidence of trachelectomy after supracervical hysterectomy has been increasing, given the popularity of supracervical hysterectomy. The most common indication for trachelectomy is symptomatic cyclic bleeding. Trachelectomy can be performed vaginally as well as laparoscopically with or without robotic assistance. This video demonstrates a standard reproducible technique for robotic-assisted trachelectomy in 2 women who underwent previous supracervical hysterectomy with a retained cervix. INTERVENTIONS: Robotic-assisted laparoscopic trachelectomy using a standard technique is demonstrated in 2 different examples. The steps include opening the vesicocervical peritoneum, creating a bladder flap and pushing the bladder down beyond the vaginal cuff, opening the remnant of the broad ligament and delineating the course of cervical branch of the uterine artery and ureter bilaterally, inserting a uterine manipulator with a colpotomizer under vision, performing desiccation of the cervical branches of the uterine artery, and performing colpotomy and closure of the vaginal cuff. CONCLUSION: Robotic-assisted laparoscopic trachelectomy is a safe and simple procedure that should be part of all general gynecologists' armamentarium. The described technique is reproducible and efficient and can be adopted for all cases requiring simple trachelectomy.

Margins for cervical and vulvar cancer.

Surgery is the primary treatment for vulvar cancer as well as early-stage carcinoma of the cervix. This article reviews the significance of margin status after surgery on overall survival, need for further surgical intervention, and role for possible adjuvant therapy. It summarizes the abundant literature on margin status in vulvar cancer and highlights the need for further investigation on the prognostic significance of margins in cervical cancer. In addition, it reviews other important operative considerations.

Radical Trachelectomy for Early-Stage Cervical Cancer: A Survey of the Society of Gynecologic Oncology and Gynecologic Oncology Fellows-in-Training.

OBJECTIVE: The aim of this study was to survey gynecologic oncologists and fellows-in-training regarding the role of radical trachelectomy (RT) and conservative surgery in patients with early-stage cervical cancer. MATERIALS AND METHODS: From June 2012 to September 2012, the Society of Gynecologic Oncology member practitioners (n = 1353) and gynecologic oncology fellows (n = 156) were sent group-specific surveys investigating current practice, training, and the future of RT for early-stage cervical cancer management. RESULTS: Twenty-two percent of practitioners (n = 303) and 24.4% of fellows (n = 38) completed the surveys. Of the practitioners, 50% (n = 148) report performing RT, 98% (n = 269) support RT as treatment for squamous carcinoma, and 71% (n = 195) confirm the use of RT for adenocarcinoma. Most practitioners offer RT treatment for stages IA2 to IB1 smaller than 2 cm (n = 209, 76.8%) regardless of grade (77.7%) or lymph vascular space invasion (n = 211, 79.3%). Only 8% (n = 23) of practitioners feel that RT is appropriate for stage IBI larger than 2 cm. Respectively, both practitioners and fellows most frequently perform robotic-assisted (47.0%, n = 101 and 59.1%, n = 13) and abdominal (40.5%, n = 87 and 68.2%, n = 15) RT approaches. After training, fellows project the use of robotic-assisted (71%, n = 22) or abdominal methods (58.1%, n = 18). Overall, 75% (n = 227) of practitioners and 60% (n = 23) of fellows speculate that over the next 5 years, less radical procedures will be used to manage early-stage cervical cancer. CONCLUSIONS: Our findings suggest that practitioners and fellows believe RT remains an option for early-stage cervical cancer patients. However, a significant proportion of all respondents believe that less radical surgery may be a future consideration for patients with low-risk early-stage cervical cancer.