Robotic versus vaginal radical trachelectomy for reproductive-aged women with early cervical cancer: a multi-center Canadian study (097)

1879 Comparison of MRI, PET-CT, and Frozen Biopsy in The Evaluation of Lymph Node Status Before Fertility-Sparing Robotic or Laparoscopic Radical Trachelectomy in Early Stage Cervical Cancer

to analyze oncological, obstetrical, and surgical results of young early-stage cervical cancer patients who underwent radical trachelectomy (RT) surgery and wished to maintain their fertility. a retrospective cohort study was carried out concerning cases attended at the Brazilian National Cancer Institute Gynecology Oncology Service. Patients who underwent RT between January 2005 and January 2021 were included. A total of 32 patients with median age of 32 years old, 62.5% of whom were nulliparous, were assessed. Concerning cancer type, 65.6% squamous cell carcinoma (SCC) cases, 31.2% adenocarcinoma cases and 3.1% adenosquamous carcinoma cases were verified. Stage IA2 was evidenced in 12.5% of the patients and stage IB < 4cm in 87.5%. Regarding surgical approaches, 68.25% of the patients underwent vaginal RT (VRT), 18.75%, abdominal RT (ART), 9.3%, the robotic radical trachelectomy (RORT) and 3.1%, video laparoscopy radical trachelectomy (VLRT). The median number of removed lymph nodes was 14, with only two detected as positive. Two cases of positive surgical margins were noted. A total of 3.1% intraoperative and 31.25% postoperative complications were observed, with cervical stenosis being the most common. The recurrence rate of the study was 3.1%, with a median follow-up time of 87 months, where 3.1% deaths occurred. The pregnancy rate of the study was 17.85% (5/28), with 54.5% evolving to live births and 45.5% evolving to abortion. Radical trachelectomy is a feasible procedure presenting good oncological results and acceptable pregnancy rates.

Open vs minimally invasive radical trachelectomy in early-stage cervical cancer: International Radical Trachelectomy Assessment Study

Robotic Versus Laparoscopic Radical Trachelectomy for Early-Stage Cervical Cancer: Case Report and Review of Literature

Fertility sparing surgery for treatment of early-stage cervical cancer: Open vs. robotic radical trachelectomy

Fertility preservation in patients with early cervical cancer: Radical trachelectomy

To evaluate whether certain patients with early-stage cervical cancer are candidates for less radical surgery when considering fertility-sparing surgery. Prospective cohort study. Two gynecologic cancer centers (St Thomas' Hospital, London; and West Kent Gynaecological Cancer Centre, Maidstone). Women with early-stage cervical cancer (n = 66) undergoing fertility-sparing surgery, either simple (SVT) or radical vaginal trachelectomy (RVT). Prospective clinical data collection and review of patient notes, pathology and radiology data, and pregnancy outcomes. Postoperative complications, surgical specimen histologic analysis, follow-up data, and obstetric outcome. A total of 66 women underwent either SVT (n = 15) or RVT (n = 51), with pelvic lymphadenectomy, for stage IA2 or IB1 cervical cancer. There was no residual disease in the SVT specimen in 53% versus 29% after RVT. Clear surgical margins in 100% of SVT specimens with residual disease versus 94% after RVT. Two patients had positive lymph nodes after RVT; one of these declined adjuvant treatment until after egg harvesting and subsequently died of disease (1.5%). Median follow-up was 96 months (range, 12-120 months). One patient had a mid vaginal recurrence (1.5%). Twenty-four women have tried to conceive to date, with 14 women having 17 live births. Live birth pregnancy rate was 70.8%. It is possible to select patients for a less radical fertility-sparing procedure through identification of measurable low-risk factors and thus reduce the morbidity caused by conventional RVT. The selection criteria should be stringent and applied within the setting of a cancer center.

Oncologic outcomes and the impact of minimally invasive surgery in early-stage cervical cancer patients undergoing radical trachelectomy: A retrospective multicenter cohort study from the Korean Gynecologic Oncology Group Study (KGOG 1048).

Radical trachelectomy represents an alternative for early stage cervical cancer in patients who want to preserve fertility. This procedure can be performed by vaginal, open or minimal invasive approach. The robotic approach may offer some advantages, especially for the surgeon´s ergonomics. Since the evidence is still scarce, larger studies are needed. Our objective is to present a retrospective review of our experience with robotic radical trachelectomy. Descriptive study carried out in Clinico San Carlos University Hospital, Madrid, Spain. We included all our patients with early stage cervical cancer that wished to preserve fertility, from 2023 to 2022. The surgery included bilateral pelvic lymphadenectomy followed by radical trachelectomy and cervical cerclage after confirmation of absence of nodal metastasis. Demographic data of the study population, perioperative and oncological outcomes were analyzed. Seven patients who underwent radical robotic trachelectomy were studied. Median patient age was 30 (range 23-35) years. Median body mass index was 24 (range 19-28). Tumor histology was squamous cell carcinoma in 57% (4) and adenocarcinoma in 43% (3) of the patients. Median surgical time was 285 (range 247-315) min. The median of pelvic nodes obtained was 15 (range 12-40). Two postoperative complications were observed. One patient tried to conceived and had preterm labor. One patient died of the disease. In selected cases, robotic radical trachelectomy is a safe option for patients that wish to preserve their fertility with similar rates of oncological safety and complications than open procedures and a shorter recovery time.

Dear Editor, We read with interest the recent systematic review by Xu et al. which assessed the efficacy and safety of radical trachelectomy (RT) and radical hysterectomy (RH) for patients with early cervical cancer (1). The authors concluded that RT has similar efficacy and safety as RH for early cervical cancer surgical treatment. Moreover, it reduced blood loss and urine residual volumes and shortened the duration of post-operative hospital stay. The significant limitations of this meta-analysis (conclusions for all outcomes apart from five-year recurrence-free survival rate and blood transfusion based on only two trials) highlight the challenge of deciding which surgical procedure is optimal in treating the cancer. Overall, we agree with the authors and believe that, provided the treatment center and availability of trained personnel are appropriate, the gynecological surgeon should primarily consider either abdominal RT or vaginal RT, and not RH. This should only apply for patients diagnosed with early stage cervical cancer who wish to preserve their fertility. Vaginal RT is the standard treatment of 0–2cm size tumors. Our judgment, however, is that abdominal RT and vaginal RT should be equally considered for the treatment of these tumors. This is for two reasons. First, as the techniques for abdominal RT and routine radical hysterectomy are extremely similar, more trainee surgeons should potentially be able to master the operative techniques of abdominal RT relatively easily because radical hysterectomy is universally taught and reproducible in any gynecologic oncology center. Secondly, abdominal RT is a safer option with regards to bulky, exophytic or >2cm tumors because it offers an extensive radicality of parametrial, sacrouterine and pelvic lymphatic tissue resection. We cautiously predict that in our international cohort of more than 100 abdominal RT patients, it is this more extensive radicality which is the main contributing factor to our 98% survival rate, with two additional patients presenting with a recurrence (2). Ultimately, we believe that for patients wishing to preserve their fertility and diagnosed with early stage cervical cancer, the next stage of trachelectomy research should be a treatment comparison between abdominal and vaginal RT in a large-scale, multi-center, prospective randomized trial of abdominal RT vs. vaginal RT vs. cone biopsy and lymphadenectomy for lesion size 0–2cm, correlating recurrence rates and fertility outcomes as primary end-points. If fertility is no longer an issue, then vaginal RT vs. RH is also a valid trial. No such trials exist in the literature. We do not believe that it is ethically acceptable to do a trial of abdominal RT compared to vaginal RT for lesion size 2–4cm because of Dargent's high recurrence rates after vaginal RT of tumors >2cm (6/27) (3). Secondary aims should try to define the incidence of specific post-operative complications within the three trial groups, arrive at a more suitable method of pre-operative patient selection for a specific procedure and investigate how to apply adjuvant therapy in node positive patients. A closer look at surgical techniques employed in the formation of a neocervix, application of a permanent cervical cerclage suture (and timing: during abdominal RT or pregnancy) and the process of re-anastomosis are also worthy of study. To provide quality assurance of surgical technique between hospitals, a limited number of centers with recognized surgical skills to perform this procedure should be included first. Another trial option may be to randomize patients between either ‘a radical trachelectomy and lymphadenectomy (any approaches)’ and ‘simple trachelectomy and lymphadenectomy’ for small volume lesions, as recent literature is slowly suggesting that radical surgery is probably not necessary in most cases. We hope that information gained from the research proposed above would greatly improve our understanding of fertility-sparing surgery and ultimately demonstrate its appropriateness in treating the patient group highlighted in this study, with respect to oncological safety and pregnancy outcomes. The authors have stated explicitly that there are no conflicts of interest in connection with this article. None to declare.

Fertility-sparing radical abdominal trachelectomy for cervical carcinoma: Technique and review of the literature

Response to: “Fertility-sparing radical abdominal trachelectomy for cervical carcinoma: technique and review of the literature”

Cervical cancer is the fourth most common cancer in women worldwide [1]. The standard treatment for early-stage cervical cancer such as the International Federation of Gynecology and Obstetrics (FIGO) stage IB is radical hysterectomy combined with bilateral pelvic lymph node assessment [2]. Radical trachelectomy is a safe alternative for young women who wish to preserve fertility [3]. The 5-year survival rate is excellent, ranging from 73.4% to 97.5% [4-6]. However, those radical procedures have significant morbidity, mainly as a result of the removal of the parametria. The parametrectomy is the most challenging part of the procedure and major complications have been reported such as blood loss, bladder and rectal dysfunction, sexual dysfunction, and fistula formation [7-12]. In recent years, the value of radical hysterectomy or trachelectomy in early-stage cervical cancer has been questioned. Parametrial involvement in early-stage cervical cancer with favorable prognostic factors can be as low as 1% [13-15]. Several reports have suggested that less radical surgery such as cervical conization, simple trachelectomy or simple hysterectomy with pelvic lymph node assessment is probably sufficient in well-selected early-stage cervical cancer to achieve excellent oncologic outcomes [16-19]. Reade et al. [13] recently summarized those reports and identified 476 women with early-stage cervical cancer managed with non-radical surgery. The reported recurrence rate was 1.5% and the rate of cancer-related death was 0.5%. Although level I evidence is still missing, this report suggests that non-radical surgery is probably a safe option in low-risk early-stage cervical cancer patients.

Radical trachelectomy is a valid alternative for the treatment of early-stage cervical cancer in young women who wish to preserve fertility potential. Recent data indicate that even less radical surgery could be performed in low-risk cases. The objective of our study was to evaluate the safety of simple vaginal trachelectomy and node assessment in patients with low-risk, early-stage cervical cancer (<2 cm). From May 2007 to July 2016, 35 women underwent a simple vaginal trachelectomy with laparoscopic sentinel lymph node mapping + pelvic node dissection. Data were collected prospectively in a computerized database. Descriptive statistics and Kaplan-Meier estimate were used for analysis. Patients' median age was 29 years, and 24 (69%) were nulliparous. Eight had stage IA1 with lymphovascular space invasion, 9 a stage IA2, and 18 a stage IB1. Nineteen (54%) had squamous histology, 13 (37%) had adenocarcinoma, and 3 had other histologic findings. The median operating room time was 148 minutes (90-240 minutes), and median blood loss was 50 mL (25-200 mL). On final pathology, lymph nodes were negative in all patients, except 2 cases with isolated tumor cells. Twenty-two patients (63%) had either no residual disease in the trachelectomy specimen (n = 15) or residual dysplasia only (n = 7). With a median follow-up of 42 months (1-100 months), 1 local recurrence occurred treated initially with chemoradiation and then a pelvic exenteration. The recurrence-free survival at 48 months is 96.7%. There were 25 pregnancies: 5 (20%) ended in the first trimester, 2 delivered prematurely at 34.4 and at 35 weeks, and all the others (18 [72%]) delivered at more than 36 weeks. Based on our experience, simple trachelectomy and nodes appear to be a safe fertility-preserving surgery in well-selected patients with small-volume cervical cancer. Obstetric outcome appears favorable.

Radical vaginal trachelectomy (RVT) combined with laparoscopic pelvic lymphadenectomy: Prospective multicenter study of 100 patients with early cervical cancer