Challenging dogma: radical conservation surgery for early stage cervical cancer in order to retain fertility

Abstract

Introduction: Cervical cancer is the second commonest cancer to affect women with over half a million cases world-wide yearly. Screening programmes have reduced the incidence and death rate dramatically in Western societies. At the same time, professional and social pressures may delay child bearing such that a significant number of women will present with early stage disease, but be anxious to retain their fertility potential. Standard treatment by radical hysterectomy or radiotherapy has good results, but inevitably renders the women infertile. The rationale for extensive surgery resecting parametrium or destructive radiotherapy treating the whole pelvis in all cases of cervical cancer has been questioned.

Patients and methods: Lessons learnt from the less radical surgical approach to breast cancer can be applied to cervical cancer whilst still observing Halstead's principles of surgical oncology. Wide, local excision of early stage small tumours by radical vaginal trachelectomy combined with a laparoscopic pelvic lymphadenectomy utilises modern technology with traditional surgery. Radical vaginal trachelectomy comprises the distal half of a radical abdominal (Wertheim's) or vaginal (Schauta's) hysterectomy. An isthmic-vaginal anastomosis restores continuity of the lower genital tract after insertion of a cerclage that is necessary to maintain competence during future pregnancies.

Results: A total of 142 cases were performed between 1994 and 2006, most (98%) in women with Stage 1B carcinoma of the cervix with a mean follow-up of 57 months. Twelve (9%) had completion treatment, 11 with chemo/radiotherapy and one radical hysterectomy. There were four recurrences (3%) among the women who did not have completion treatment, and two (18%) in those that did. There were 72 pregnancies in 43 women and 33 live births in 24 women. The 5-year accumulative pregnancy rate among women trying to conceive was 53%. Delivery was by classical caesarean section in a high-risk fetomaternal units with 8 babies (25%) born before 32 weeks.

Conclusions: Radical vaginal trachelectomy appears safe when performed in centres with appropriate experience of radical vaginal surgery and laparoscopic techniques. The impact of this new approach questions traditional teaching whilst preserving potential fertility in hitherto impossible circumstances.

Figure 1

Patient in an extended lithotomy position to allow a vaginal approach for a radical vaginal trachelectomy.

Figure 2

The distal or first part of a Schauta's radical vaginal hysterectomy.

Figure 3

A circumferential incision is made using cutting diathermy around the cervix to include a 2-cm cuff of vagina.

Figure 4

The bladder is separated and pushed proximally to identify the bladder pillars.

Figure 5

A Hegar 6 dilator is inserted into the cervical and isthmic canal and the excision completed with cutting diathermy.

Figure 6

Radical vaginal trachelectomy specimen.

Figure 7

Vagino-isthmic anastomosis.

Figure 8

Appearance following surgery.