Robotic Radical Trachelectomy with an Abdominally Placed Vaginal Cerclage

Abstract

Study Objective To demonstrate a robotic radical trachelectomy where-in a vaginal purse-string suture was placed abdominally in order to contain the cervical tumor. Design A case report. Setting A tertiary referral center. Patients or Participants A 32-year-old gravida 0 presented with stage IB1 squamous cell carcinoma of the cervix. Pelvic MRI demonstrated a tumor the size of 1.5cm where the upper margin of the lesion was >2 cm from the uterine isthmus. PET/CT was without evidence of metastatic disease. Interventions The patient desired future fertility and opted for a robotic radical trachelectomy. The patient was placed in dorsal lithotomy position. No intrauterine manipulator was placed. ICG dye was injected onto cervix for delineation of pelvic sentinel lymph nodes. Bilateral pararectal, paravesical, and obturator spaces were developed after which bilateral pelvic sentinel lymph nodes were removed with negative frozen results. The uterine arteries were skeletonized and separated from their ureteral attachments. The rectovaginal and vesicovaginal spaces were developed. The bilateral paracervix were transected off. 2-0 prolene suture was utilized to place a purse-string suture onto upper vagina. The colpotomy was then performed circumferentially and cervix was amputated about 1 cm below the uterine isthmus. Trachelectomy specimen margins were negative. The upper vagina was then reconstructed to the lower uterine segment. A pediatric foley was placed into the lower uterine segment to minimize the risk of cervical stenosis. Measurements and Main Results Robotic radical trachelectomy was performed without any complications, where-in a uterine manipulator was avoided and a purse-string suture was placed onto upper vagina to minimize tumor manipulation and prevent spillage into peritoneal cavity, respectively. Conclusion We believe that if MIS surgeons adhere to basic oncologic surgical principles, we will be able to provide our patients with proven MIS benefits without compromising oncological safety.