Trachelectomy in Early Cervical Cancer

Cervical cancer is a malignant neoplasm arising from cells originating in the cervix uteri. It is routinely screened by Papanicolaou’s (Pap) smear and human papilloma virus (HPV) is considered as one of its etiological agents. Cervical cancer is the second most common cancer in reproductive age and its diagnosis is increasing in young age as a result of effective and widespread screening programs (1). Cervical cancer is the seventh most common cancer in developed countries. In 2004, around 30,750 new cases of invasive cervical cancer were diagnosed in Europe. In 2012, around 12,170 new cases were discovered in USA and the estimated deaths were 4,220. Unfortunately, the incidence of new cases is much more in developing countries due to inefficient screening programs (2). Due to effective and widespread screening programs and the delay in childbearing age, many women are diagnosed at a time which there is a strong demand for fertility sparing surgery (3). Radical hysterectomy and pelvic lymphadenectomy are the conventional treatment for early stage cervical cancer, but this results in loss of fertility (4). Fertility preservation is one of the most important issues to be discussed with the patient. In the last 20 years, laparascopy assisted radical vaginal trachelectomy (RVT) and radical abdominal trachelectomy have developed that have good documented long term oncological and pregnancy outcome. RVT is a fertility-sparing technique first described by Daniel Dargent in 1994 (5), involving the removal of the cervix, the parametrium, and cuff of vagina, while maintaining the patient’s uterine fundus and adnexae. This procedure, in combination with a laparoscopic pelvic lymphadenectomy, is the most common and accepted fertility-sparing procedure for early cervical cancer. RVT begins with laparoscopic pelvic lymphadenectomy. The vaginal procedure is started by circumferential incision in the upper vagina. The supracervical ligament is cut, and the bladder base is mobilized. Posteriorly, the pouch of Douglas is opened and the pararectal spaces are exposed. The uterosacral ligaments are then divided. The vesicovaginal ligaments are then identified, and the paravesical spaces are entered laterally. Then the ureters and uterine arteries are identified. The cardinal ligaments are then divided. The cervix is amputated below the cervical isthmus (5,6). Although RVT associated with laparoscopic pelvic lymphadenectomy is the most used surgical procedure, radical trachelectomy (RT) may be performed either abdominally or vaginally (laparoscopic or robotic). It is estimated that around 40% of candidates for radical hysterectomy can undergo RT, but 12% of these cases will Abstract Objectives: To review the role of trachelectomy as a method of fertility preservation instead of traditional radical hysterectomy in early cervical cancer. Materials and Methods: We conducted our original study through research in PubMed for all original studies and reviews published in the last 10 years. We reviewed the data available on trachelectomy in early stage cervical cancer whether through abdominal route or vaginal route and laparoscopic lymphadenectomy. Moreover, we reviewed the oncologic outcome, recurrence rate and its effect on subsequent pregnancies. Results: We found that recurrence and death rates seem to be comparable between radical trachelectomy (RT) and radical hysterectomy. Complications of RT include chronic vaginal discharge, abnormal uterine bleeding, dysmenorrhea, inflammation and ulcer due to cerclage, amenorrhea, and cervical stenosis. Although around 70% can get pregnant after RT, there are increased complications of pregnancy after this procedure mainly 2nd trimester miscarriages and preterm deliveries. Conclusion: RT is a useful technique associated with an excellent pregnancy rate in fertility-preserving surgery to treat early stage cervical cancer. Selection of suitable patients for conservative treatment is the best important point for getting a good result without any recurrence or complication.