Total Laparoscopic Radical Trachelectomy Research Articles

Successful Birth in a Case of Cervical Cancer Following Total Laparoscopic Nerve Sparing Radical Trachelectomy with Sentinel Node Dissection and Preventive Cerclage

Successful Birth in a Case of Cervical Cancer Following Total Laparoscopic Nerve Sparing Radical Trachelectomy with Sentinel Node Dissection and Preventive Cerclage

The Surgical Morbidity And Oncological Outcome Of Total Laparoscopic Radical Trachelectomy Versus Total Laparoscopic Radical Hysterectomy For Early Stage Cervical Cancer: A Retrospective Study With 11-Year Follow-Up.

ObjectiveThe objective of this study was to evaluate the surgical morbidity and oncological outcome of total laparoscopic radical trachelectomy (TLRT) and total laparoscopic radical hysterectomy (TLRH) in patients with early-stage cervical cancer.MethodsWe performed a retrospective study to compare the outcomes of patients with stage IB1 cervical cancer who underwent TLRT to patients treated with TLRH from January 2005 to December 2016.ResultsForty-six patients underwent TLRT and 73 patients underwent TLRH between January 2005 and December 2016. The median age was 30 (19–40) years for TLRT group compared to 43 (31–65) years for TLRH group. No significant difference was found for the tumor size, histology, and pathology grade between TLRT group and TLRH group. In the TLRT group, the median operative time was 200 mins (range, 150–360 mins) and the median blood loss was 200 mL (range, 50–400mL). In the TLRH group, the median operative time was 240 mins (range, 180–380) and the median blood loss was 250mL (range, 10–1500mL). The median follow-up time was 80 months for TLRT group and 72 months for TLRH group. No patient in TLRT group developed recurrence. However, there were 2 recurrences diagnosed in the TLRH group.ConclusionTLRT appears to have equal surgical morbidity and oncological outcome to TLRH in stage IB1 cervical cancer. Intraoperative complications did not differ significantly between these two groups. However, postoperative complications were fewer observed in TLRT. Because of the natural limitations of the retrospective study, the clinical value should be confirmed by multi-institutional prospective trial in the future.

Rubbing salt on the wound.

The quotation ‘People who peek through key-holes have to expect an occasional poke in the eye’ comes to mind in view of the recently published LACC Trial in the New England Journal of Medicine showing significantly worse survival following ‘keyhole’ surgery (laparoscopic or robotic) in early stage cervical cancer (Ramirez et al. N Engl J Med 2018;379:1895–904). A second study in the same edition reinforced the results by also showing a worse survival with ‘keyhole’ surgery (Melamed et al. N Engl J Med 2018;379:1905–14). This must be considered to be as unfortunate as having ‘both eyes poked at the same time via the same keyhole’. Before gynaecological oncologists have regained full sight, comes this third publication focusing on fertility-sparing surgery in early stage cervical cancer which ‘rubs salt on the wound’ by also showing excellent survival with an abdominal approach. The study by Li et al. (BJOG 2019; 126:1169–74) the largest published series on abdominal radical trachelectomy (ART) demonstrating a 98.6% 5-year survival, agrees well with the abdominal arm in the LACC trial of 99% 3-year survival and contrasts significantly with the laparoscopic arm of 93.8% 3-year survival. In addition, the results are comparable to previous publications on ART and add substantially to the literature (previously, 866 cases with a cumulative mortality rate of 1.4%). Of interest are the results on tumours larger than 2 cm with a recurrence rate of 5.3% compared with 2.0% in tumours <2 cm (nonsignificant P value). Analysis of the New England Journal of Medicine publications identified that it was in this sub-group specifically there were the greatest differences in recurrences. It is also in this sub-group that survival differences are the greatest compared with vaginal radical trachelectomy (cumulative recurrence rate of 23.9%), which also utilises a laparoscopic approach (BJOG 2019;126:1169–74). Data following total laparoscopic radical trachelectomy are limited. Consistent with this, is the FIGO 2018 re-classification of cervix cancer reducing the cut-off between IB1 and IB2 tumours from 4 to 2 cm (Bhatla et al. Int J Gynaecol Obstet 2018;143 (Suppl 2):22–36). Where does all this leave us? Is the problem the surgeon or the tools or the procedure? Many are questioning the surgical techniques in order to retain a minimally invasive approach including the use of manipulators, the CO2 pneumoperitoneum, tumour exposure to the peritoneum and the surgical radicality. It's also time to reflect. Fertility-sparing or not, why have different surgeons/centres been advocating different surgical procedures/approaches? One explanation is the Collingridge dilemma stating that technological advances contain two components; (1) information: where the effects of technological advances cannot be predicted until they are extensively developed and widely used in clinical practice, and (2) power: where control (by the use of robust clinical evaluations) is difficult when the technology has become entrenched (Collingridge. The Social Control of Technology. London, UK: Palgrave Macmillan, 1981). This is highlighted by the Pacing problem, where innovations develop exponentially while control mechanisms develop incrementally. The solution would be the Precautionary principle, where innovations should not be embraced until developers can prove they will not cause harm. Critics argue this will not eliminate innovations developing in the wrong direction but result in no innovations developing at all. Although it is painful to have to revert back to an abdominal route, the solace is that ‘rubbing salt on the wound’, regardless of the additional pain, will help the wound recover faster. And so, for women with a stage IB2 cervical tumour (FIGO 2018) who wish to preserve fertility, the recommended operation should be an ‘abdominal’ radical trachelectomy. None declared. A completed disclosure of interests form is available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Type B Laparoscopic Radical Trachelectomy with Uterine Artery Preservation for Stage IB1 Cervical Cancer

Radical trachelectomy has emerged as a valuable fertility-preserving treatment option for young women with early-stage cervical cancer [1]. Laparoscopic radical trachelectomy performed by trained surgeons can be a feasible and safe therapeutic option as a fertility-sparing surgical technique [2,3]. To the best of our knowledge, this is the first time the total laparoscopic approach of radical trachelectomy is being published. In this video, rather than the description of the technique step by step, we show how to conserve uterine arteries even if the importance of such conservation is questionable. A case report. A tertiary referral center in Strasbourg, France. A 37-year-old patient with no medical history who presented with stage IB1 invasive epidermoid cervical cancer. In this video, we describe the fertility-sparing surgical procedure consisting of type B total laparoscopic radical trachelectomy with uterine artery preservation. The procedure consists of the following 10 steps: step 1, bilateral pelvic lymphadenectomy and opening of the para vesical fossa; step 2, opening of the pararectal fossa in between the ureter and the internal iliac artery on each side; step 3, ureteric dissection up to the ureteric canal; step 4, opening of the vesicouterine space and section of the vesicouterine ligament; step 5, posterior dissection with division of the uterosacral ligament approximately 20 mm from the uterine insertion; step 6, section of the descending branch of the uterine artery and skeletonization of the ascending branch up to the uterine isthmus level; step 7, trachelectomy with a monopolar hook; step 8, laparoscopic isthmovaginal stitches; step 9, laparoscopic cerclage; and step 10, peritoneal closure. The operative time was 420 minutes. The intraoperative blood loss was <200 mL. The operation was performed successfully with no intraoperative complications. The resection margins were safe. The patient was discharged on day 4. After 2 months, no late complications or recurrence were detected, and the patient had normal menstruation. Type B laparoscopic radical trachelectomy with uterine artery preservation appears to be a safe option for women who intend to maintain their desire for a future pregnancy.

Total laparoscopic radical trachelectomy in early cervical cancer: review of the outcomes from a ‘Buddy’ Operating Institute

Total laparoscopic radical trachelectomy in early cervical cancer: review of the outcomes from a ‘Buddy’ Operating Institute

Northern Irish Experience of Total Laparoscopic Nerve Sparing Radical Trachelectomy: National Data on Surgical, Oncological and Reproductive Outcomes

Northern Irish Experience of Total Laparoscopic Nerve Sparing Radical Trachelectomy: National Data on Surgical, Oncological and Reproductive Outcomes

21. Total laparoscopic radical trachelectomy as a fertility sparing technique in early cervical cancer in a ‘Buddy’ operating institute: Demonstration of technique and review of outcomes

21. Total laparoscopic radical trachelectomy as a fertility sparing technique in early cervical cancer in a ‘Buddy’ operating institute: Demonstration of technique and review of outcomes

Laparoscopic radical trachelectomy: technique, feasibility, and outcomes.

Background and Objectives:Our objectives are to describe our surgical technique for laparoscopic radical trachelectomy, to evaluate its feasibility, and to present the perioperative results at Hospital Italiano de Buenos Aires, Argentina.Methods:We analyzed 4 patients who underwent laparoscopic radical trachelectomy for early-stage cervical cancer between December 2011 and May 2013.Results:Four patients were included in this study. Total laparoscopic radical trachelectomy was performed in all cases. The mean age was 26 years (range, 19–32 years), the mean body mass index was 21 (range, 18–23), and the mean length of hospital stay was 33 hours (range, 24–36 hours). The mean operative time was 225 minutes (range, 210–240 minutes), and no complications were reported. During the postoperative period, only 1 patient presented with left vulvar edema, which resolved spontaneously. The pelvic and parametrial lymph nodes, as well as the vaginal cuff and cervical resection margins, were negative for malignancy in all cases. On average, 18 pelvic lymph nodes (range, 15–20) were removed. The tumor stage was IB in all 4 patients, and the mean tumor size was 17 mm (range, 12–31 mm). No patient required conversion to laparotomy.Conclusion:We consider laparoscopic radical trachelectomy, performed by trained surgeons, a feasible and safe therapeutic option as a fertility-sparing surgical technique, with good perioperative outcomes for women with early-stage cervical cancer with a desire to preserve their fertility. Minimally invasive surgery provides the widely known benefits of this type of approach.

Neoadjuvant Intra-Arterial Chemotherapy Followed by Total Laparoscopic Radical Trachelectomy in Stage IB1 Cervical Cancer

Neoadjuvant Intra-Arterial Chemotherapy Followed by Total Laparoscopic Radical Trachelectomy in Stage IB1 Cervical Cancer

Total laparoscopic radical trachelectomy in the treatment of early-stage cervical cancer

Fertility preservation in early-stage cervical cancer by total laparoscopic radical trachelectomy (TLRT) is gaining acceptance as more cases are published in the literature. The objective is to review all the literatures regarding TLRT especially over the last 12 months and to describe the technique, the operative outcomes, the oncologic outcomes and the obstetric outcomes of this procedure. As the number of cases reported in the literature increases, the effectiveness of TLRT for treating early-stage cervical cancer continues to gain support. Under the enhanced vision of the laparoscopy, it is easy to preserve the ascending branches of the uterine arteries and to divide the ligaments surrounding the cervix and vagina. Since TLRT was first reported, about 140 cases of TLRT have been reported. The tumour recurrence rate is 2.9%. Fifty-nine out of 140 patients attempted to conceive after TLRT, and forty-six patients succeeded. There were 17 miscarriages, 14 preterm births and 11 term births. TLRT appears well tolerated and effective when performed in centres with appropriate experience of laparoscopic techniques. Continued research and clinical trials are needed to further elucidate the equivalence or superiority of TLRT to conventional methods in terms of obstetric outcome and patients' quality of life.

Neoadjuvant intra-arterial chemotherapy followed by total laparoscopic radical trachelectomy in stage IB1 cervical cancer

To support the feasibility and safety of neoadjuvant intra-arterial chemotherapy followed by total laparoscopic radical trachelectomy in stage IB1 cervical cancer with tumor larger than 2 cm. A retrospective study. University-affiliated gynecologic oncology department. Patients with stage IB1 cervical cancer with tumor size larger than 2 cm who wish to preserve fertility. Neoadjuvant intra-arterial chemotherapy followed by laparoscopic radical trachelectomy. Data regarding neoadjuvant chemotherapy operational time, blood loss, recurrence, and subsequent pregnancies were recorded. Other published reports on neoadjuvant chemotherapy followed by radical trachelectomy were reviewed. Seven patients had a laparoscopic radical trachelectomy after neoadjuvant intra-arterial chemotherapy for stage IB1 cervical cancer. Median tumor diameter evaluated by colposcopy was 3.3 cm (range, 2.5-4.0 cm), tumor histotype was all squamous. All patients showed complete or partial response to neoadjuvant chemotherapy, and they were all treated with total laparoscopic radical trachelectomy. One patient had no menses after treatment. After a median 66 months (range, 12-90 months) of follow-up time, no recurrence was observed. Only four patients attempted to conceive and two succeeded. Neoadjuvant intra-arterial chemotherapy followed by total laparoscopic radical trachelectomy may become a useful option for women with cervical cancer with a tumor size larger than 2 cm who wish to preserve fertility. Ovarian protection warrants further investigation.

Total Laparoscopic Radical Trachelectomy in the Treatment of Early Squamous Cell Cervical Cancer: A Retrospective Study with 8-Year Follow-Up

Total Laparoscopic Radical Trachelectomy in the Treatment of Early Squamous Cell Cervical Cancer: A Retrospective Study with 8-Year Follow-Up

Obstetric outcomes of patients undergoing total laparoscopic radical trachelectomy for early stage cervical cancer

ObjectiveTo assess the obstetric outcomes of our total laparoscopic radical trachelectomy (TLRT) cases for early stage cervical cancer. Materials and methodsA total of 56 patients who underwent TLRT between December 2001 and August 2012 were reviewed retrospectively using clinicopathological, surgical, and follow-up data from patients' medical records. ResultsWe performed this operation on 56 patients during the study period. The mean age of these 56 patients was 31.9years (range 22–42years). Fifty-three patients' fertility was preserved without requiring post-operative adjuvant treatment. Twenty-five women attempted to conceive, of whom 13 succeeded for a total of 21 pregnancies (52% pregnancy rate). Ten of these 21 pregnancies were the result of assisted reproductive technologies. Of those, 5 resulted in first trimester miscarriages, 2 in second trimester miscarriages, and 13 in live births. Ten pregnancies reached the third trimester. Preterm premature rupture of membranes (8/13, 61.5%) was the most common complication during pregnancy. The rate of preterm delivery was 47.6%. Three patients delivered at 22–28weeks of gestational age. Two of these babies showed permanent damage: one has cerebral palsy; the other has developmental retardation. One pregnancy is ongoing. ConclusionTLRT is a useful technique associated with an excellent pregnancy rate in fertility-preserving surgery to treat early stage cervical cancer.

Total laparoscopic radical trachelectomy in the treatment of early squamous cell cervical cancer: A retrospective study with 8-year follow-up

ObjectiveThe objective of this study was to evaluate the surgical, oncologic, and obstetrical outcomes of total laparoscopic radical trachelectomy (LRT) in patients with early-stage squamous cell cervical cancer who want to preserve their fertility. MethodsTwenty-five patients with early-stage cervical cancer were treated by total LRT from January 2005 to December 2012. Data regarding operational time, blood loss, intraoperative-and post-operative complications, recurrence, and subsequent pregnancies were recorded. Other published reports on LRT were also reviewed. ResultsThe median age of the patients was 29years (range 22–34years). The median surgical time was 232min (range, 180–340min). The median blood loss was 120ml (range, 50–200ml), and the median length of hospitalization was 3.3days (range, 2–4days). The median time to return to daily activities was 2days (range, 1–3days). No intra-operative complications occurred; three patients had post-operative complications. The median follow-up time was 66months (range, 1–82months), and no recurrences were observed. Twelve patients attempted to conceive during the follow-up, and nine succeeded. ConclusionsIn this retrospective analysis, total LRT was an effective and safe procedure for patients with early-stage cervical carcinoma who wished to preserve fertility. A larger prospective study with long-term pregnancy and survival analyses is warranted.

Uterine artery-preserving laparoscopic radical trachelectomy for early cervical cancer: Technical aspects

Radical trachelectomy is increasingly used for patients with early cervical cancer as an alternative to radical hysterectomy, who want to preserve their fertility [1]. Radical trachelectomy can be performed using minimal invasive techniques such as laparoscopy or robotics [2–4]. Laparoscopic radical trachelectomy (LRT) is generally classified into two types: total LRT of which all procedures are conducted via laparoscopy and laparoscopically-assisted vaginal radical trachelectomy (LAVRT) in which lymph node dissection and radical trachelectomy are performed via laparoscopy and vaginal route, respectively [3,4]. In the present surgical film, we introduce our LRT technique combining the foregoing types, which consists of 70% laparoscopic and 30% vaginal approaches. This technique was originally developed by one of the authors (JHN). LRT is usually performed after pelvic lymphadenectomy. This procedure leaves the paravesical and pararectal spaces widely open, the obturator fossa exposed down to the levator muscle, and the cardinal ligament isolated caudal to the uterine artery. The cardinal ligament is divided without ligation of the ascending branch of the uterine artery. The ureter is dissected from the peritoneum and mobilized with its adventitial tissue. The descending and ascending branches of the uterine artery were identified. The descending branch was divided and the ascending branch was mobilized up to the level of transaction of the cervix. After incising the vesicouterine ⁎ Corresponding author at: Department of Obstetrics and Gynecology, Ajou University School of Medicine, San 5, Woncheon-dong, Youngtong-gu, Suwon 443-721, Republic of Korea. Fax: +82 31 219 5245. E-mail address: drchang@ajou.ac.kr (S.-J. Chang). 0090-8258/$ – see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.ygyno.2012.04.039 and rectovaginal peritoneum, the vesicouterine and rectovaginal ligaments are divided. All these procedures are performed laparoscopically, and then the vaginal phase follows. The anterior and posterior colpotomy is made, the paracolpium is divided and the cervix is transected at the isthmic portion. The cervical cerclage is performed and the vagina and the uterus is reanatomosized. This technique seems to have some advantages — shorter time for reanastomosis compared to total LRT and more convenient and complete dissection of the ureter and parametrium compared to LAVRT. Moreover, the preservation of the uterine artery may be associated with more favorable restoration of the reproductive function (Fig. 1). Conflict of interest statement The authors have no conflicts of interest to disclose. Appendix A. Supplementary data Supplementary data to this article can be found online at http:// dx.doi.org/10.1016/j.ygyno.2012.04.039. Fig. 1. Colposcopic view of the site of vaginouterine reanastomosis on postoperative 6 months. 278 S-J. Chang et al. / Gynecologic Oncology 126 (2012) 277–278

Editors’ Choice

Editors’ Choice

Robotic Uterine Artery Preservation and Nerve-Sparing Radical Trachelectomy With Bilateral Pelvic Lymphadenectomy in Early-Stage Cervical Cancer

The aim of the study was to evaluate the safety and feasibility of robotic uterine artery preservation and nerve-sparing radical trachelectomy with pelvic lymphadenectomy using the da Vinci surgical system. Three patients who were diagnosed with early-stage cervical cancer underwent robotic uterine artery preservation and nerve-sparing radical trachelectomy with bilateral lymphadenectomy from January 2010 to March 2010. The data were compared with those of 4 cases of total laparoscopic nerve-sparing radical trachelectomy that were performed from July 2004 to May 2005 and were previously reported. In the robotic group, the mean console time was 275 minutes (range, 240-305 minutes). The mean postoperative hemoglobin change was 0.4 g/dL (range, 0.2-0.6 g/dL). The mean estimated blood loss was 23 mL (range, 15-40 mL), which is less than that of the laparoscopic group. There were no metastases detected in any of the cases, and the resection margins were negative in both groups. The robotic uterine artery preservation and nerve-sparing radical trachelectomy with pelvic lymphadenectomy were efficient in reducing blood loss and feasible methods such as other approaches.

Uterine Artery Sparing Robotic Radical Trachelectomy and Pelvic Lymphadenectomy in Patients with Early-Stage Cervical Cancer

This video demonstrate techniques of fertility sparing operation for cervical cancer patient, uterine artery sparing total laparoscopic radical trachelectomy using by da Vinci Robotic system. The first Objectives of this video is to demonstrate techniques about both uterine artery sparing result in better blood flow to endometrium, the second is to display adequate dissection line of isthmus, the third is nerve sparing method for better quality of life in young patient. Last is robotic re-anastomosis technique. This case is 27 years old single women, cervical cancer stage IB1 adenocarcinoma. Right uterine artery is preserved but deeper uterine veins are identified and dissected by fine delicate robotic bipolar forceps and scissors. We can preserve right uterine artery to isthmic area which divide descending and ascending branches. And then we can preserve inferior hypogastric plexus and hypogastric nerve. This type of complex operations can be by Robotic system more easily.

Total Laparoscopic Nerve-Sparing Radical Trachelectomy

To evaluate the feasibility and operative morbidity of a total laparoscopic nerve-sparing radical trachelectomy with pelvic lymphadenectomy. Between July 2004 and May 2005, this procedure had been undergone to four consecutive young patients with early cervical cancer (one with stage IA2, three with stage IB1). It was distinguished from the conventional radical trachelectomy in that it consisted of a reanastomosis of uterine corpus and upper vagina via laparoscopic approach, and an autonomic nerve-sparing dissection under the magnified laparoscopic view. The mean operative time and blood loss was 250 minutes and 185 mL, respectively. The pathologic diagnosis was all squamous cell carcinoma. There were no node metastasis and cancer-free cervical margin. Any wound defect and leakage from a stump were not found. There were no neurologic impairments such as bladder hypotonia. The mean follow-up period was 34 months. Only one patient (Case 1) received concurrent chemo-radiation due to recurrence, followed by no further sign of progression. Unfortunately, there has not been any pregnancy yet. A total laparoscopic nerve-sparing radical trachelectomy is feasible and without any increase of morbidity, and has the potential to improve surgical outcomes, compared with a conventional radical trachelectomy.

Case Report : Management Of Pregnancy And Delivery After Total Laparoscopic Radical Trachelectomy

Case Report :Management of Pregnancy and Delivery After Total Laparoscopic Radical TrachelectomyBackground: The recent increase of cervical carcinoma in younger women has led us to introduce a total laparoscopic radical trachelectomy (TLRT) Our procedure has wider parametrial resection than the vaginal radical trachelectomy (VRT). We applied our TLRT to patients with both adenocarcinoma and squamous cell carcinoma with a diameter less than 20mm and could obtain a 15mm surgical margin. Cases: Between 2002 and 2008 we performed 38 cases of TLRT. Nine patients became pregnant. Two cases resulted in miscarriage. Two cases were missed abortions. Two cases are currently 23 weeks and 26 weeks. Three cases reached the 3rd-trimester and delivered. Two patients had PROM at 26 and 34 weeks. One had a poor biological profiling score at 36 weeks. All underwent emergency cesarean sections. Unexpectedly, we didn't experience any trouble during the cesarian sections of patients at 34 and 36 weeks but observed the enlargement of the lower uterus despite having removed the isthmus. Conclusion: RT has long been accepted as the standard fertility-sparing procedure. Although we had concerns about the uterus function disorder because of the wider resectioning of the parametrium in our procedure, 3 patients became pregnant and have infants. Our TLRT meets the fertility-sparing parameters while extending the radicality, making it an effective treatment for patients who require more extensive resection.