Radical Trachelectomy
Shannon Salvador
Susie Lau
Walter Gotlieb
Ria Malik
GENERAL PRINCIPLES
Definition
Radical trachelectomy (RT) is a fertility-preserving surgery for early-stage cervical cancer (IA1 with lymphovascular space invasion [LVSI], IB2 to IIA) where the probability of lymph node metastasis is very low. It is possible to conserve the uterine body with little risk of central pelvic or nodal recurrence following pelvic lymph node dissection and frozen-section analysis to exclude nodal involvement. The aim is to remove the diseased cervix with adequate tumor-free margins, along with the paracolpos (the surrounding equivalent of parametrium around the cervix and vagina). While the caudal margin includes an adequate vaginal cuff, the cranial resection margin has to allow at least 1 cm of cervical stump to be left behind.1,2 Also included in this procedure is a cerclage of the isthmus of uterus (using nonabsorbable suture material) to prevent cervical insufficiency in future pregnancies.
Differential Diagnosis
For stage IA1 cervical cancer without LVSI, a cold-knife conization is the preferred fertility-preserving surgery. Conization may be combined with pelvic lymphadenectomy (sentinel, if appropriate) for selected patients of LVSI positive stage IA1 disease, where at least a tumor-free margin, 3 mm, can be obtained.3 Although some authors have reported on less radical procedures (simple trachelectomy) for early cervical cancer,4,5,6 RT is the present standard fertility-preserving surgery for stages IA1, IB1, and IIA up to 2-cm lesion size. Some researchers have had success performing this fertility-preserving surgery in carefully selected lesions of up to 4 cm in size (bulky IB2 and IIA).7,8 Neoadjuvant chemo has also been used in selected cases to increase suitability for this surgery.9 In perimenopausal women, or those who do not wish to preserve fertility, the standard surgery has been radical type 3 hysterectomy.
Anatomic Considerations
The trachelectomy may be done through the vaginal route (as originally described by Dargent),1 or abdominal or laparoscopic/robotic routes.
The key anatomic considerations are isolation of ureter (ureterolysis).
To ensure an adequate cephalic tumor-free margin, a frozen section of the specimen from cephalic end should be sent.10,11
A 5- to 10-mm cervical stump needs to be left behind to maintain uterine continence.
Unlike a radical hysterectomy (RH), the main uterine artery is preserved and the specimen is devascularized by ligating the cervical branch of uterine artery. This may not always be possible, requiring the main uterine artery to be divided; however, this is not detrimental due to rapid development of collaterals with pelvic and ovarian vessels.12 Temporary ligation of infundibulopelvic ligament using vessel loops under tension may be employed to decrease blood flow from ovarian vessels.
Nonoperative Management
Patients who are not good surgical candidates due to spread of disease outside of the cervix, or suffer from severe medical comorbidities, are treated with concurrent chemotherapy and radiation.
Up to 15% of planned radical trachelectomies may be converted to RH on the basis of intraoperative findings and about one-fourth may require postoperative radiation or hysterectomy at a later date due to final pathology report.13
IMAGING AND OTHER DIAGNOSTICS
Preoperative imaging may be performed in larger lesions to exclude lymph node metastasis, deep invasion into the parametrial tissue or extension of cancer to the lower uterine segment. MRI correlation of vertical extent of tumor has been found useful.14,15 PET/CT may be useful for detection of metastatic lymph nodes.16
Pathology from the tumor should be confirmed for subtype and origin to ensure the cancer is of primary cervical origin. Most data about RT are available for squamous cell carcinoma, adenocarcinoma, and adenosquamous carcinomas of the cervix; and not for other types such as neuroendocrine tumors which are known for more aggressive courses.
PREOPERATIVE PLANNING
Consent
Patients planned for RT have to consent for RH in the event of intraoperative circumstances that may necessitate deviation from the plan of uterine conservation. Such situations may arise with positive lymph nodes on frozen section, positive upper margin of specimen such that sufficient cervical stump cannot be left in situ, hemorrhage, or tumor larger than 2 cm. Such discussion should also include the small but real possibility of postoperative chemoradiation or radiation alone in the event of an unfavorable final pathology report.17
Preoperative counseling should also include discussion with the patient regarding her probability for potential fertility given her age, previous issues with infertility, and other medical and/or social factors. This should include a review of the rates of pregnancy complications such as first trimester (20%) and second trimester (3%) miscarriage, and preterm delivery (25%).18
SURGICAL MANAGEMENT
Positioning
The patient is placed into dorsal lithotomy position with the buttock approximately 4 to 8 cm off the edge of the bed
onto a gel mat to provide cushioning and prevent slippage on the table.
The legs should be placed within adjustable stirrups to allow for repositioning of the legs during the procedure.
The patient must be secured to the bed with shoulder braces and chest straps, with the arms tucked at the patient’s sides in a neutral position to prevent injury. Adequate foam or gel padding around the arms and face must be used for patient protection.
Prior to docking the robot, the patient is placed into steep Trendelenburg position (35% to 40%) to assist with bowel mobilization into the upper abdomen. The robot can then be docked in the side position at an approximate 45-degree angle to the lower torso aligned with the border of the leg stirrup either on the left or right side depending on surgeon preference. This will allow access to the vagina for manipulation.
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