Fertility-Sparing Radical Abdominal Trachelectomy




BACKGROUND



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There are an estimated 42,910 new cases of cervical carcinoma in the United States and the European Union annually.1,2 Approximately 28% of all cervical carcinomas are diagnosed in women younger than 40 years of age.3 Women throughout the developed world are postponing childbearing for professional, economic, and other personal reasons. This postponement of childbearing accompanied with the comparatively young age at which many women are diagnosed with cervical carcinoma has posed new challenges in the management of this disease.



The standard surgical management for early-stage cervical carcinoma is a radical abdominal hysterectomy and pelvic (with or without paraaortic) lymph node dissection. This treatment obviously eliminates the possibility of future conception. In recent decades, there has been an increased emphasis on tailoring treatment to provide fertility-sparing options without compromising oncologic outcomes. The radical vaginal trachelectomy with laparoscopic pelvic lymphadenectomy is a fertility-preserving procedure first described in 1994 by Dargent et al.4



Subsequently, numerous investigators have reported their experience with this technique. In addition to the vaginal approach, a fertility-sparing abdominal radical trachelectomy, and a minimally invasive approach have been described in the literature.5,6 These procedures have received widespread acceptance as fertility-sparing surgical options for select patients with early-stage invasive carcinomas of the cervix.7




INDICATIONS AND CLINICAL APPLICATIONS



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Appropriate candidates for fertility sparing radical trachelectomy for patients with cervical cancer are those with stages IA1 with lymphovascular invasion, IA2, and IB1 disease. In other words, the tumor should be confined to the cervix without spread to the vagina, parametria, or the lower uterine segment, such that the radical trachelectomy can completely encompass the malignancy with negative surgical margins. Patients who will most likely need postoperative adjuvant whole pelvic radiation therapy following surgery (such as those with suspicious pelvic nodes or possible parametrial invasion) are not ideal candidates for the procedure. There should be no evidence of metastatic disease.



The patient must have a strong desire to preserve her fertility and must be of an age in which future fertility is a reasonable possibility. The procedure has been successfully performed on patients with squamous, adeno, and adenosquamous histologies but is not recommended for small-cell carcinoma or sarcomas due to their overall poor prognosis.




ANATOMIC CONSIDERATIONS



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The uterus is a fibromuscular organ. It has 2 portions: an upper muscular corpus and a lower fibrous cervix. The cervix is generally 2 to 4 cm in length and divided into 2 portions: the portio vaginalis, which is the part protruding into the vagina, and the portio supravaginalis, which lies above the vagina and below the corpus. The adnexa is comprised of the fallopian tubes and ovaries. The fallopian tubes are bilateral tubular structures that connect the endometrial cavity to the peritoneal cavity. The ovaries are bilateral, white, flattened oval structures that store ova. The lateral pole of the ovary is attached to the pelvic wall by the infundibulopelvic ligament, which contains the ovarian artery and vein. Medially, it is connected to the uterus through the utero-ovarian ligament. The round ligaments are extensions of the uterine musculature and represent the homologue of the gubernaculum testis. They begin as broad bands that arise on each lateral aspect of the anterior corpus, pass lateral to the deep inferior epigastric vessels and enter each internal inguinal ring, terminating in the labia majora. The midline uterus is ­connected to the pelvic sidewall by a double layer of peritoneum. Within the upper 2 layers of the broad ligament, lies the fallopian tubes, round ligaments, and ovaries. The cardinal and uterosacral ­ligaments are at the lower margin of the broad ligament.



The blood supply to the genital organs comes from the ovarian arteries and uterine and vaginal branches of the internal iliac arteries. A continuous arterial arcade connects these vessels on the lateral border of the adnexa, uterus, and vagina. The blood supply of the upper adnexal structures comes from the ovarian arteries that arise from the anterior surface of the aorta. They connect with the upper end of the marginal artery of the uterus. The uterine artery originates from the internal iliac artery. It joins the uterus near the junction of the corpus and cervix. The uterine artery gives off small branches to form the marginal artery. The ureter passes laterally under the uterine artery at the level of the internal cervical os.



Lymphatic drainage of the cervix is primarily to the obturator, internal, and external iliac lymph nodes. However, lymphatic drainage has been documented to the presacral and lower paraaortic lymph nodes.



There are several planes and potential spaces that must be understood to facilitate the performance of a radical trachelectomy. The vesicovaginal spaces are bound caudally by the fusion of the junction of the proximal one-third and distal two-thirds of the urethra with the vagina, ventrally by the urethra and bladder, cephalad by the peritoneum, forming the vesicocervical reflection. The paravesical spaces are paired spaces adjacent to the bladder. The medial border is the bladder and obliterated umbilical artery. The lateral border is the obturator internus. The pararectal spaces are paired spaces adjacent to the rectum. The space is bordered medially by the ureter, uterosacral ligament, and rectum. The lateral border is the hypogastric vessels and pelvic sidewall. The rectovaginal space is caudally bordered by the apex of the perineal body, laterally by the uterosacral ligament, ureter, and rectal pillars, and ventrally by the vagina, and dorsally by the rectum.




PREOPERATIVE PREPARATION



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Box 4-1 KEY SURGICAL IMENTATION




  • Collin-Buxton–type clamp



  • Zeppelin clamps



  • Wertheim clamp



  • Free Ferguson needle



  • #1 Prolene suture




Although preoperative imaging is not part of standard International Federation of Obstetrics and Gynecology (FIGO) staging, many authorities recommend a preoperative magnetic resonance imaging (MRI) of the pelvis prior to planned radical trachelectomy. MRI can help assess tumor size, potential parametrial invasion, and the amount of ­disease-free tissue above the malignancy that will be needed for uterovaginal reconstruction. Computed tomography, positron emission tomography, and vaginal and rectal ultrasonography have all been utilized to preoperatively evaluate the ­carcinoma.



Prior to the procedure, the patient should have the ­standard tests and evaluations for a major abdominal surgical procedure. In most institutions, patients are extensively counseled preoperatively that if negative surgical margins cannot be achieved as determined on frozen section pathologic analysis, then standard radical hysterectomy will be performed.




SURGICAL PROCEDURE



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Box 4-2 MASTER SURGEON’S PRINCIPLES




  • Create your surgical spaces and mobilize your ­ureter prior to the initiation of the trachelectomy



  • Care is taken not to destroy the uterine cornua or the utero-ovarian pedicle



  • Care is taken not to injure the fallopian tube or ­disrupt the utero-ovarian ligament



  • The knot for the permanent cerclage should be posteriorly tied and placed prior to the reconstruction




Fertility-Sparing Radical Abdominal Trachelectomy



The aim of the radical abdominal trachelectomy is to resect the cervix, the upper 1 to 2 cm of the vagina, parametrium, and paracolpos in a similar manner to type 3 radical hysterectomy, but instead sparing the uterine fundus. We will describe an open procedure; however, similar surgical principles can be applied to a laparoscopic or robotic surgical approach. To better demonstrate and magnify the anatomic planes and structures, some of the operative pictures provided in this chapter are from a robotic radical abdominal trachelectomy.



First, after laparotomy or trocar site placement, bilateral, complete pelvic lymphadenectomy is performed in a similar manner to patients undergoing a radical abdominal hysterectomy. The limits of nodal dissection are the deep circumflex iliac vein caudally and the proximal common iliac artery cephalad (Figure 4-1). Any suspicious lymph nodes are sent for frozen-section analysis. A fertility-sparing approach should be abandoned if positive lymph nodes are identified. Sentinel lymph node identification is also a reasonable option and may allow for pathologic ultrastaging of these sentinel nodes.8 The removal of para-aortic and sacral nodes is also considered for lesions stage IB1 or greater.


Jan 12, 2019 | Posted by in GYNECOLOGY | Comments Off on Fertility-Sparing Radical Abdominal Trachelectomy
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