As a result of the trend toward late childbearing, fertility preservation has become a major issue in young women with gynaecological cancer. Fertility-sparing treatments have been successfully attempted in selected cases of cervical, endometrial and ovarian cancer, and gynaecologists should be familiar with fertility-preserving options in women with gynaecological malignancies. Options to preserve fertility include shielding to reduce radiation damage, fertility preservation when undergoing cytotoxic treatments, cryopreservation, assisted reproduction techniques, and fertility-sparing surgical procedures. Radical vaginal trachelectomy with laparoscopic lymphadenectomy is an oncologically safe, fertility-preserving procedure. It has been accepted worldwide as a surgical treatment of small early stage cervical cancers. Selected cases of early stage ovarian cancer can be treated by unilateral salpingo-ophorectomy and surgical staging. Hysteroscopic resection and progesterone treatment are used in young women who have endometrial cancer to maintain fertility and avoid surgical menopause. Appropriate patient selection, and careful oncologic, psychologic, reproductive and obstetric counselling, is mandatory.
Cervical cancer
Fertility preservation is an important component of the overall quality of life of cervical cancer survivors. Excisional cone biopsies alone can be considered in women with stage IA1 cervical cancer and no lymphovascular space invasion or involvement. Standard treatment of women with more extensive disease confined to the uterus is radical hysterectomy with pelvic lymphadenectomy, which eliminates any possibility for future pregnancy. Selected women can be candidates for a radical trachelectomy procedure (conisation) with conservation of the uterus and ovaries. The procedure can be carried out with a cold knife, laser, or electrosurgical loop.
Radical trachelectomy
Radical trachelectomy has emerged as a valuable fertility-preserving treatment option for young women with early stage cervical cancer. Accumulating data confirm that, overall, oncological outcome is safe and obstetrical results promising. Radical vaginal trachelectomy (RVT) with laparoscopic lymphadenectomy is a fertility-preserving procedure that has recently gained worldwide acceptance as a method of surgically treating small invasive cervical cancers. Since the original description of RVT by Daniel Dargent et al. in 1994, over 1000 cases of women having undergone this technique have been reported, with over 250 live births reported in women after having this procedure. Patient selection for the procedure is extremely important for success. Accepted criteria for radical trachelectomy are women with an important desire for future fertility, squamous cell carcinoma, adenocarcinoma or adenosquamous, with exclusion of unfavourable histology, stage IA1 with lymphovascular invasion, Ia2, or IB1 of less than 2 cm, tumour limited to the cervix, and no evidence of lymphatic spread.
Morbidity associated with RVT is low, with tumour recurrence rates of between 4.2 and 5.3%, and mortality rates between 2.5 and 3.2%. Risk factors for recurrence are lesion size of more than 2 cm, lymphovascular involvement, and unfavourable histology (i.e. small-cell neuroendocrine tumours). Pregnancy rates vary from 41–79%, risk of second trimester miscarriage is twice the rate of general population, and preterm delivery is about 30%, but only 12% with significant prematurity. Infertility is found in up to one-third of women, and is related in most cases to cervical factors (i.e. cervical stenosis, decreased cervical mucus, surgical adhesion formation and subclinical salpingitis).
Radical trachelectomy can be carried out vaginally, abdominally, laparoscopically, and recently a robotic approach has been used. Radical trachelectomy, via a trans-sacral approach,has also been described in a woman with a history of rectal resection and radiotherapy for rectal cancer, who had unacceptable risks associated with a laparotomic approach.
Exploration
The abdomen and pelvis are examined systematically at the beginning of the operation by inspecting the peritoneal cavity, and includes a detailed examination of the fallopian tubes and ovaries. Frozen section of any suspicious lesion is required before starting the procedure, which should be abandoned in case of metastatic disease.
Pelvic lymphadenectomy
A laparoscopic, or open pelvic lymphadenectomy for abdominal radical trachelectomy, is carried out before the trachelectomy procedure ( Fig. 1 ). Pelvic nodes from the common iliac bifurcation proximally to the circumflex vein distally, including the pelvic nodes from the external iliac, internal iliac, and obturator regions, are removed and sent for intraoperative histology. In Fig. 1 a, a pelvic lymphadenectomy has been carried out. Iliac vessels and obturator nerve are completely exposed. In Fig. 1 b and c, a paracervical lymphadenectomy has been carried out. Sentinel lymph-node biopsy with frozen section is possibly the best and most efficient option to evaluate node status before starting the trachelectomy procedure ( Fig. 2 ). A sentinel lymph-node biopsy also increases the detection rate of lymph-node metastases by identifying unusual locations of sentinel lymph nodes that are not removed by standard lymphadenectomy. The procedure is abandoned if positive nodes are found and paraaortic lymph-node sampling is carried out. In Fig. 2 a, a single photon emission-computed tomography shows sentinel lymph nodes localised at the left external iliac area; Fig. 2 b, c and d show blue and hot external iliac sentinel lymph nodes.
Vaginal trachelectomy
Vaginal trachelectomy is begun by delineating an adequate vaginal margin of around 1–2 cm. Six to eight Kocher are placed circumferentially, and dilute xylo adrenaline solution is injected under the vaginal mucosa to reduce bleeding and facilitate dissection. The vaginal mucosa is incised, and the anterior and posterior aspects of the vaginal incision are folded together. Kocher clamps are removed and Krobach clamps are placed horizontally over the vaginal mucosa ( Fig. 2 ). In Fig. 3 , vaginal mucosa has been incised after xylo-adrenaline injection.
Development of retroperitoneal spaces
Rectovaginal space
The posterior cul-de-sac is opened posteriorly, the rectovaginal space is created and the proximal part of the rectovaginal ligament is divided.
Prevesical space
The specimen is tracted downwards and the prevesical space is entered and developed by sharp dissection.
Paravesical space
Two Kocher claps are placed at 1 and 3 o’clock positions on the vaginal mucosa, and Metzenbaum scissors are introduced in an antero-lateral direction to enter and develop the paravesical spaces on both sides. Once the prevesical and paravesical spaces are developed, the bladder pillar is dissected and isolated from the cardinal ligament. The ureter is identified by palpation at the mid-portion of the bladder pillar, pushed cephalad enabling safe transection of the uterovesical ligament distal to the ureter ( Fig. 4 ). Here, the paravesical space has been opened, the knee ureter has been identified, and the bladder pillar can be transacted, avoiding ureteral injury.
Parametrial dissection
Midportion of the parametrium is clamped or coagulated and divided. Only the descending branch of the uterine artery, the cervicovaginal branch, is coagulated or ligated and divided without disturbing the remaining blood supply to the uterus.
Amputation of the cervix
The cervix is transected about 1 cm below the internal cervical orifice, and the specimen is removed after vaginal section ( Fig. 5 ). Fig. 5 a and b show the cervix transected below the internal oriface. The endocervical canal can be identified.
A prophylactic permananent cerclage is placed at the level of the internal oriface to avoid cervical incompetence. A No. 8 French rubber catheter is inserted into the remaining cervix to avoid stenosis. In Fig. 6 , a No. 8 French rubber has been introduced into the endocervical canal to ensure permeability. The cervical stump is readapted and sutured to the vaginal mucosa.
A frozen section of the superior margin of the cervix is carried out to ensure safe negative endocervical margins. When the upper limit of the tumour is less than 5 mm, removing another 3–5 mm of the residual cervix is recommended to improve margin of tumour clearance. When the upper margin is involved, a radical hysterectomy should be carried out. Women should always be informed of this possibility before surgery.
A laparoscopic approach is carried out at the end to verify haemostasis and the integrity of pelvic structures.
Abdominal trachelectomy
Abdominal radical trachelectomy is identical to radical hysterectomy, with preservation of the uterine fundus by separation of the uterine cervix and the parametrium at the level of the internal os.
Development of retroperitoneal spaces
The procedure begins by opening the retroperitoneal space through the round ligament laterally. The broad ligament of the uterus is incised anteriorly down to the bladder reflection. The posterior leaf is incised above the psoas muscle in a cephalad direction, lateral and parallel to the ovarian vessels. The pararectal and paravesical spaces are developed using blunt dissection to expose the ureter and the iliac vessels on each side of the pelvis.
Paravesical space
Non-traumatic forceps are used. The surgeon develops the paravesical space, bound by the umbilical obliterated artery medially, the external iliac vein laterally, the ventral aspect of the cardinal ligament posteriorly, the pubic symphisis anteriorly, and the obturator fossa and muscle inferiorly. The posterior peritoneal layer with the ureter attached is retracted towards the midline, and the pararectal space is developed by separating the connective tissues between the internal iliac artery and the posterior leaf of the broad ligament.
Pararectal space
The pararectal space is bounded by the rectum and ureter medially, the sacrum dorsally, the pelvic sidewall and iliac vessels laterally, and the cardinal ligament anteriorly.
Bladder mobilisation
The peritoneal incision is continued down to the side of the bladder, the vesicouterine peritoneal fold is incised, and the bladder is completely detached from the mid-sagital cervix and the proximal third of the vagina. This dissection can be accomplished with either scissors or electrocautery. Cervical anterior margin is verified to ensure no disease spreads beneath the bladder.
Dissection of the ureter and division of the uterine artery
The ureter is dissected from its entry into the broad ligament to its intramural portion in the bladder. The ureter is first isolated from the posterior leaf of the broad ligament and displaced laterally by inserting the tip of the scissors between the ureter and the peritoneum proximal to the uterosacral ligament. An arterial branch, 2–3 mm below the common iliac bifurcation, should be identified and divided.
Between the paravesical and pararectal space, the thick bundle of parametrial tissue is exposed. The uterine artery is identified, ligated, coagulated, or clipped and divided as it crosses the ureter. The uterine vein running below the artery is then identified, divided and ligated. The artery is tracked upwards and dissected free from the underlying paracervix and from the ureter to expose the ureteral tunnel of Wertheim. The ureter is separated from the medial leaf of the broad ligament until it enters the parametrial tunnel. A ureteral branch from the uterine artery encountered at this point of the dissection may be coagulated with a bipolar device or clipped.
A right-angle clamp is introduced into the proximal tunnel on the superomedial surface of the ureter. The anterior leaf of the vesicouterine ligament is divided to progressively deroof the ureter to the bladder. The ureter is then rolled laterally and separated from its loose attachments to the dorsal aspect of the vesicouterine ligament, permitting to transect it. Troublesome venous bleeding can occur at this stage of the operation, and small vessels should be ligated or clipped to avoid bleeding.
Parametrial dissection
After unroofing the ureter, the parametrium is completely exposed and retracted while the ureter is displaced medially to allow division of the cardinal ligament. The paracervix is then clamped, coagulated with a bipolar device, clipped, or divided and suture ligated at the level of the ureteral tunnel. The deep component of the paracervix, caudal to the deep uterine vein, is not divided to preserve neural structures. In Fig. 7 , pararectal and paravesical spaces have been created and the parametrium is completely exposed.
