Fertility-sparing Trachelectomy Research Articles

Trends in immediate postoperative complications of trachelectomy for early-stage cervical cancer by surgical approach

Objectives: Given recent data demonstrating improved cervical cancer outcomes for open radical hysterectomy, further understanding of surgical and cancer outcomes for fertility-sparing trachelectomy is needed. We examined trends in the use of minimally-invasive (MIS) versus open approach to trachelectomy for early-stage cervical cancer and compared post-operative complications during the index hospitalization. Methods: We performed a retrospective cohort study of women age 45 years and younger with cervical cancer undergoing fertility-sparing trachelectomy in the 2010-2015 National Inpatient Sample. Hospital-level data was used to obtain nationwide estimates of patient characteristics, surgical complications, and length of stay. We compared MIS versus open approach to trachelectomy and compared complications for each using logistic regression models. Results: Nationwide, 523 women underwent fertility-sparing trachelectomy for cervical cancer. The mean age of women undergoing trachelectomy was 33, and 38% (95% CI 29-47) of trachelectomies were done using MIS. Mean length of stay was 2.0 days (95% CI 1.6-2.4) for MIS and 3.5 days (95% CI 3.0-4.0) for open trachelectomies. The overall complication rate was 23% (95% CI 15-31), and there was no statistically significant difference in the odds of a post-op complication for MIS versus open trachelectomy for cervical cancer (14 vs. 29%, OR 0.39, 95% CI 0.14-1.10). Bleeding complications were the most common (10%, 95% CI 4-16). Conclusions: While there was a trend towards slightly lower immediate post-operative complication for MIS trachelectomy, there was no statistically significant difference in immediate post-operative morbidity between open and MIS approaches. Until further data is available to compare cancer outcomes between these approaches, preference may be for open trachelectomy given similar post-operative morbidity.

The validity of the subsequent pregnancy index score for fertility-sparing trachelectomy in early-stage cervical cancer

To evaluate timing and a prediction model for pregnancy in early-stage cervical cancer patients who underwent fertility-sparing trachelectomy. Retrospective cohort. Academic multicenter. Women ages <45 years with clinical stage I-II cervical cancer were enrolled between 2009 and 2013 (n = 393). Planned fertility-sparing trachelectomy. Cumulative incidences and clinicopathological characteristics of those who developed subsequent pregnancy were examined. There were 77 (21.6%) women who had subsequent pregnancies after fertility-sparing trachelectomy with 1-, 2-, and 5-year cumulative pregnancy rates of 2.8%, 6.2%, and 17.4%, respectively. The median time to develop subsequent pregnancy was 3.2 years. In a competing risk analysis, women had a higher risk of recurrent cancer than conception during the first 11 months postsurgery. On multivariable analysis, younger age, being married, and postoperative reproductive treatment were independently associated with an increased chance of developing a subsequent pregnancy. The subsequent pregnancy index (SPI) score to predict the likelihood of having pregnancy was proposed, and it was calculated based on age, marital status, and reproductive treatment (2, 2, and 4 points, respectively). Women with a higher SPI score had significantly higher subsequent pregnancy rates (5-year pregnancy rate; the score was 3 in 4.7% of cases; 4 to 5 in 11.3%; 6 to 7 in 27.4%; and 8 in 50.8%), but they had similar recurrence rates (5.0%). The SPI score proposed in our study is useful in predicting subsequent pregnancy in women with early-stage cervical cancer undergoing fertility-sparing trachelectomy.

Association between hospital surgical volume and outcomes of fertility-sparing trachelectomy for early-stage cervical cancer

Association between hospital surgical volume and outcomes of fertility-sparing trachelectomy for early-stage cervical cancer

Association between hospital surgical volume and perioperative outcomes of fertility-sparing trachelectomy for cervical cancer: A national study in the United States

ObjectiveTo examine the association between hospital surgical volume and perioperative outcomes for fertility-sparing trachelectomy performed for cervical cancer. MethodsThis is a population-based retrospective observational study utilizing the Nationwide Inpatient Sample from 2001 to 2011. Women aged ≤45 years with cervical cancer who underwent trachelectomy were included. Annualized hospital surgical volume was defined as the average number of trachelectomies a hospital performed per year in which at least one case was performed. Perioperative outcomes were assessed based on hospital surgical volume in a weighted model, specifically comparing the top-decile centers to the lower volume centers. ResultsThere were a total of 815 trachelectomies performed at 89 centers, and 76.4% of the trachelectomy-performing centers had a minimum surgical volume of one trachelectomy per year. The top-decile group had a higher rate of lymphadenectomy performance compared to the lower volume group (96.4% versus 82.4%, odds ratio [OR] 5.65, 95% confidence interval [CI] 2.81–11.4, P < 0.001). There was a significant inverse linear association between annualized surgical volume and the number of perioperative complications (P = 0.020). The top-decile group also had a lower rate of perioperative complications (9.7% versus 21.0%, P < 0.001) and prolonged hospital stay ≥7 days (2.0% versus 6.5%, P = 0.006) compared to the lower volume group. In a multivariable analysis, the top-decile group had a 65% relative decrease in perioperative complication risk compared to the lower volume group (adjusted-OR 0.35, 95%CI 0.20–0.59, P < 0.001). ConclusionFertility-sparing trachelectomy for young women with cervical cancer is a rare surgical procedure; <90 centers performed this procedure from 2001 to 2011 and most hospitals perform a small number of cases annually. Higher hospital surgical volume for trachelectomy may be associated with reduced perioperative morbidity.

Fertility-sparing trachelectomy for early-stage cervical cancer: A proposal of an ideal candidate

ObjectiveTo propose an ideal patient candidate with early-stage cervical cancer for undergoing fertility-sparing trachelectomy. MethodsThis nationwide, multicenter, retrospective study was conducted by the Japan Society of Obstetrics and Gynecology involving women aged <45 years with clinical stage I-II cervical cancer who had planned fertility-sparing trachelectomy and pelvic lymphadenectomy between 2009 and 2013 (n = 393). Ideal candidates were defined to have a tumor size of ≤2 cm, no lymph node metastasis, no deep stromal invasion, and no high-risk histology (n = 284, 69.6%). Less-ideal candidates were defined to have any one of these four characteristics (n = 109, 30.4%). Propensity score inverse probability of treatment weighting was used to assess survival outcomes. ResultsLess-ideal candidates were more likely to undergo hysterectomy conversion (22.9% versus 3.2%), receive postoperative radiotherapy (11.9% versus 0.4%), or chemotherapy (32.1% versus 3.2%) compared with ideal candidates (all, P < 0.05). The weighted model revealed that among those who underwent trachelectomy (ideal candidates, n = 275 and less-ideal candidates, n = 84), less-ideal candidates had significantly decreased disease-free survival (5-year rates: 85.5% versus 95.5%; HR 3.93, 95% CI 1.99–7.74; P < 0.001) and cause-specific survival (92.5% versus 98.6%; HR 5.47, 95% CI 1.68–17.8, P = 0.001) compared with ideal candidates. Similarly, less-ideal candidates were significantly associated with decreased disease-free survival compared with ideal candidates among those who were young age, had small tumors or squamous histology, and underwent surgery alone (all, P < 0.05). ConclusionLess-ideal candidates had approximately four-fold higher recurrence risk and cancer mortality compared with ideal candidates. Ideal candidates for fertility-sparing trachelectomy for early-stage cervical cancer proposed in our study may be useful as the future framework for developing guidelines for fertility-sparing trachelectomy in Japan.

Oncological and obstetric outcomes after fertility-sparing radical abdominal trachelectomy for early stage cervical cancer: a tertiary centre’s 10 years’ experience

The aim of this study is to present our clinical experience about fertility-sparing procedures in early stage cervical cancer and its obstetrical and oncological outcomes. Between the years 2006 and 2016, a total of 22 early stage cervical cancer patients who underwent a fertility-sparing radical abdominal trachelectomy in our clinic were retrospectively analysed. The median age was 33 (range: 28–39) years. The median follow-up was 47 (range: 22–125) months. Five patients (22.7%) had Stage IA1, three patients had (13.6%) Stage IA2, and 14 patients (63.6%) had Stage IB1 disease. Only one patient had a recurrence. A pregnancy was obtained in five patients (22.7%) and one of them (20%) had a live birth. A pregnancy was obtained spontaneously in two patients (40%), whereas assisted reproductive techniques were used in three of the patients (60%). A miscarriage occurred in two patients (40%), and one of them was within the first trimester and the other was within the second trimester.Impact statementWhat is already known on the subject? Currently, the first-line treatment of early stage cervical cancer is surgery. However, a fertility-sparing trachelectomy is the most widely adopted approach in the reproductive aged patients who have a desire to be pregnant later.What does this study add? In the literature, there is a growing number of studies on this subject. However, it would take time to obtain adequate knowledge. We believe that our study would contribute to the existing data.What are the implication of these findings for clinical practice? This study is important as it indicates that a multidisciplinary approach is required to preserve fertility among gynaecologic oncologists and the outcomes would be reflected into the clinical practice. In addition, we believe that our study would pave the way for further studies regarding this subject among oncologists.

Trends in Use and Survival Associated With Fertility-Sparing Trachelectomy for Young Women With Early-Stage Cervical Cancer.

To assess the trends in use of trachelectomy in the United States and to examine the outcomes of the procedure compared with hysterectomy in young women with cervical cancer. Data were analyzed from women younger than 50 years of age with stage IA2-IB2 cervical cancer treated with hysterectomy or trachelectomy from 2004 to 2014 who were registered in the National Cancer Database. After propensity score matching, we used Cox proportional hazard models to examine the association between treatment and survival. We identified 15,150 patients with cervical cancer, including 14,714 (97.1%) who underwent hysterectomy and 436 (2.9%) who underwent trachelectomy. Trachelectomy rates increased from 1.5% in 2004 to 3.8% by 2014 (P<.001). The greatest increase in the rate of trachelectomy was seen in women younger than 30 years of age (4.6% in 2004 to 17.0% in 2014, P<.001). Among women who underwent trachelectomy, 29.6% had tumors greater than 2 cm in diameter. In a multivariable model, younger women and those more recently diagnosed were more likely to undergo trachelectomy, whereas Medicaid recipients (risk ratio 0.39, 95% CI 0.28-0.54) and the uninsured (risk ratio 0.67, 95% CI 0.45-1.00) were less likely to undergo trachelectomy. After propensity score matching, there was no association between trachelectomy and the risk of mortality (hazard ratio 1.24, 95% CI 0.70-2.22) (mortality rate was 6.0% for hysterectomy vs 5.2% for trachelectomy). Similarly, 5-year survival rates were similar between trachelectomy and hysterectomy for all of the stages examined. Use of trachelectomy for early-stage cervical cancer has increased in the United States, particularly among women younger than 30 years of age. Within this population, survival is similar for trachelectomy and hysterectomy.