What is radical trachelectomy? How many types are there?
Radical trachelectomy (also known as radical cervicectomy) is a form of fertility-preserving surgery performed in early-stage cervical cancer. It was first applied vaginally in 1986 by the French surgeon Daniel Dargent. Over the years, abdominal applications have come to the fore due to various advantages. Minimally invasive (laparoscopic and robotic) methods are also used occasional.
In this organ-sparing approach, part of the surgical procedure is similar to classical (type 3) or modified (type 2) Radical Hysterectomy. But differs from Radical Hysterectomy in terms of preserving the uterine body, removing the cervix along with the surrounding tissue (parametrium) and anastomosis (joining) the remaining uterine part with the vagina. This way, the fertility potential of the young patient with cervical cancer is preserved.
According to studies conducted, the pathological features of the tumor were found to be suitable for the fertility-preserving approach in almost half of the cervical cancer cases under the age of 40. On the other hand; today, approximately 45% of cervical cancers are seen under the age of 45 (about 20% under the age of 40) and as the rate of first pregnancies in advanced ages is gradually surging the demand for this types of surgery rises day by day.
Nowadays, Radical trachelectomy is mostly applied as “Abdominal Radical Trachelectomy” as we also practice. We were the first in our country to perform Abdominal Radical Trachelectomy operation in 2007 and it is still a surgery performed by very few people and centers.
To whom and in what situations does it apply?
Patient selection for radical trachelectomy is very important, and the targeted results can only be achieved when this procedure is performed in tumors and patients with certain criteria. First of all, it should be known that; Radical Trachelectomy is not a standard approach for the treatment of early-stage cervical cancer, and it is only necessary when fertility preservation is required. For example, under normal circumstances, a standard treatment of Stage 1a2 cervical tumor should be a modified (Type2) Radical Hysterectomy, but Radical Trachelectomy will be considered when fertility preservation is required. Studies have shown that; 40% of cervical cancer cases that would be planned to be treated with Radical hysterectomy under normal conditions also meet the requirements for Radical trachelectomy. The following conditions must be met for radical trachelectomy:
- Presence of strong fertility desire and need.
- Under
- Absence of an untreatable cause of infertility and uterine structural abnormality
- The tumor is limited to the cervix and is ≤2 cm, and there is no evidence of lymph node metastasis or distant metastasis (FIGO 2018 Stage 1a1, 1a2 or 1b1). Stromal depth should not exceed 1 cm (or half the stromal thickness). In addition, there should be no endocervical involvement (ECC negative). Note: Only those with LVI (+) stage 1a1 tumors are candidates for radical trachelectomy. Conization is sufficient as a fertility-preserving approach in those with LVI (-).
- Tumor being of “squamous” or well-differentiated “adeno” or “adenosquamous” type (not having negative histological types such as small cell, sarcoma, poorly differentiated adeno ca, papillary serous, indiferan etc.)
- Presence of sufficient distance (ideally >15 mm or at least >10 mm) between the tumor upper level and the “internal os” (upper orifice of the cervical canal) in the preoperative MRI evaluation.
- Patient's informed and conscious consent to the procedure.
- As a special case, if a cervical cancer has been diagnosed in the first half of pregnancy, a chance can be given to continue the pregnancy by performing Radical abdominal trachelectomy instead of Radical hysterectomy.
Although radical trachelectomy is primarily an oncological surgical intervention performed for cancer, this procedure may also be needed in benign diseases where fertility preservation is required (eg, endometriosis with progressive hydronephrosis, lower segment or cervical fibroids).
In another special case, if a tumor develops in the remaining cervix in a patient who has previously undergone Subtotal Hysterectomy due to a benign disease, the surgery to be performed (even if not for fertility preservation) will also be called Radical trachelectomy.
In which situations is it dangerous to apply?
History of pelvic radiotherapy, advanced stage of tumor, parametrial involvement, presence of unfavorable histological types, less than 10 mm MRI distance measurement between the upper border of the tumor and the “internal os”, presence of a hypoplasic or severe structural abnormality of the uterus, abnormal ovarian functions (eg, AMH<1) and infertility problem that cannot be corrected with treatment, in these types of cases Radical Trachelectomy should not be performed.
In the scientific literature, although Radical Trachelectomy applications are becoming more common in tumors larger than 2 cm (up to 6 cm) and in cases with vaginal involvement (Stage 2A1) after tumor reduction with preoperative (neoadjuvant) chemotherapy, extreme caution should be exercised when deciding on Radical Trachelectomy in this group of patients. In our practice, although we conduct trachelectomy in 2-3 cm exophytic (outgrowth) tumors under certain conditions (SCC histology, LVI negative, etc.), we neither perform, nor recommend nor find trachelectomy safe for tumors larger than 3 cm.
For how long should one wait for trachelectomy after LEEP or Conization?
Although not absolutely necessary, it is recommended to take 4-6 weeks for signs of acute inflammation to subside. However, in our practice, we prefer not to wait more than 3 weeks to avoid treatment delay.
How is radical trachelectomy performed? What are the technical details?
Abdominal radical trachelectomy operation can be performed under general or epidural anesthesia. We prefer general anesthesia in cases where there is no obstacle. The abdomen is accessed with a transverse (transverse) or sub-umbilical midline (mid-line) incision in the lower abdomen. In transverse cuts, some cutting of the abdominal (rectus) muscle may be necessary to provide adequate field of view. Then, the intra-abdominal organs, peritoneum (peritoneum), parametrium (tissue around the uterus), and lymph nodes are carefully evaluated for possible disease involvement. If no signs of disease are found in these areas, the operation is continued as planned, namely as Radical Trachelectomy. Otherwise, this procedure is abandoned and return to Radical Hysterectomy.
The uterus vessels are tied and cut around the area where iliac vein emerges or with close proximity. At this stage, the ascending branch of the uterine artery can be preserved. Special care should be taken not to damage the ovarian vessels during dissection of the ureters from the parametrium, as these vessels will often be the only source of circulation to the part of the uterus that will later be used. The procedure is carried out similarly to how radical hysterectomy is performed. At these stages, we care about preventing post-operative bladder dysfunction by using nerve (hypogastric plexus) sparing technique. After cutting the uterosacral ligaments and parametrium, a colpotomy (vaginal incision) is made to remove the appropriate length of vagina. At this stage, contact of the cervical tumoral tissue into the interior part of the abdomen and tumor scattering should be avoided. Then, the cervix is cut from the appropriate region to leave a sufficient amount of remnant (residual) cervix while the radical trachelectomy material is removed and sent for “frozen” examination in order to evaluate surgical margin. After making sure that sufficient “clean (negative)” margin is obtained according to the “Frozen” result, “cerclage” is performed using the right material and technique (we routinely perform the “cerclage” application). After that, "uterovaginal anastomosis" (joining/connection) is performed using the appropriate suture material and technique. After confirming adequate blood supply (circulation) of the remaining uterine tissue , the closure phase of the surgery starts.
Here we have described the procedures many key points, technical details and variations in its simplest form. To prevent serious complications that may occur during or after surgery including in a uterine loss, each stage of the procedure requires experience, attention and meticulousness in order to achieve the desired oncological and fertility goals.
Are lymph nodes necessarily removed during radical trachelectomy?
It is the first and important step to evaluation lymph nodes before proceeding to radical trachelectomy. Although preoperative CT, MR and PET/CT examinations provide valuable information about lymph nodes, small and microscopic metastases may not be detected by these methods. Therefore, intraoperative observation and evaluation is essential for regional lymph nodes. During the operation, pelvic (external iliac, internal iliac, obturator and common iliac) lymph nodes of both sides are removed and sent for frozen examination. If the frozen result is “clear”, the operation will proceed as planned. Otherwise, Radical hysterectomy should be performed. Instead of systematic lymph dissection during lymph nodes evaluation, "Sentinel" lymph node biopsy (SLNB) technique can also be used to avoid lymph dissection complications by removing a more limited number of lymph nodes.
Is it possible to return to hysterectomy (removal of the uterus) in a person who has undergone surgery by planning a radical trachelectomy?
Conversion to radical hysterectomy (uterus loss) may occur in 9-10% of cases. Conversion to or revert to hysterectomy is required if:
- Detection of lymph node involvement or other signs of disease outside the uterus (eg, parametrial involvement, peritoneal metastasis, etc.),
- Detection of positive margin (positive endocervical margin) in the extracted specimen or failure to obtain sufficient “clean/negative margin”. Or if the remnant cervix falls below 5 mm after resection.
- Observation of signs of circulatory disorder in the remaining uterus during the procedure due to the vascular structures being affected.
- Hysterectomy becomes inevitable to control life-threatening bleeding that may occur during surgery.
Apart from these, hysterectomy is sometimes required in early postoperative period due to serious infection and bleeding related to the surgical field.
Is additional treatment needed after radical trachelectomy?
Except for cases that had to undergo radical hysterectomy during the surgery, the need for adjuvant chemo-radiotherapy (CT-RT) arises in 4-5% of the cases (as a result of postoperative detailed pathology). Although RT predominantly results in loss of fertility function, pregnancies have been reported in patients who received this treatment in the postoperative period. Therefore, postoperative adjuvant CT-RT is recommended only in cases with “high-risk” findings (lymph node involvement, margin positivity, parametrial involvement), while application of adjuvant chemotherapy (CT) with 4-6 courses of Taxan + Carboplatin stands out for the “intermediate-risk” (deep, ie >1 cm or 50% stromal invasion, LVSI, large tumor diameter) group. GnRH agonists are also often given to protect the ovaries during the chemotherapy if required.
How long is the radical trachelectomy operation and hospital stay?
In our practice, Radical Trachelectomy operation takes about 4 hours. There has been no need for intensive care in our practices so far. In general, the length of stay and the need for blood transfusion in Abdominal Radical Trachelectomy are similar to Radical hysterectomy. Most of our patients are discharged after a 3-night stay.
How long does it take to return to normal life after radical trachelectomy? What should be considered?
Returning to normal life after radical trachelectomy varies from person
to person. In cases where nerve-sparing surgery is performed, there is an
advantage of early urinary catheter removal and unimpaired bladder-intestinal
functions. Sometimes it may be necessary to leave the urinary catheter in
place for 10-14 days. If a probe has also been placed in the uterus, we
usually remove it at the first check-up
in the 7-8th day. During this period, it is crucial for patients to regularly use the given drugs,
especially antibiotics. Wound care and pain control are not a problem, particularly
in lower abdomen transverse incisions.
Usually, it is possible to return to daily routine physical and social activities within two weeks. Additional time should pass for exercise and sports activities. The things that patients are advised to pay attention to are not different from radical hysterectomy and other pelvic surgeries. Sexual intercourse should be delayed long enough to allow the new attachment site to fuse (at least 6-8 weeks). We recommend post operative sexual intercourse after confirming the expected healing findings during vaginal examination performed after the second menstrual period.
What are the early and late complications of radical trachelectomy?
Various complications may occur during surgery, in the days following surgery, or in the late period. The rate of early postoperative serious complications is around 3% and the risk of mortality related to the operation is below 0.1%.
Some of the complications are bleeding, organ (bladder, ureter, nerve, vessel, bowel) injuries, intestinal obstruction, bladder atony, ureter-bladder fistulas (1%), urinary tract infection (the most common complication), peritonitis, pelvic abscess, and hematoma. These are (non-specific) problems that can be seen in other pelvic-abdominal surgeries such as lymphedema, lymphocyst, thromboembolism, wound infection, wound dehiscence and hernia formation. The following complications may be specifically encountered with radical trachelectomy:
- Anastomotic infection, separation
- Uterine necrosis (requiring hysterectomy)
- Cerclage erosion or protrusion (extrusion) 15%
- Cervical/isthmic stenosis (+/-hematometra) 10%
- Asherman's syndrome (intrauterine adhesions) and amenorrhea 10%
- Menstruation problems (dysmenorrhea, menstrual irregularity, metrorrhagia) 25%
- Chronic vaginal discharge 15%
- Ovarian insufficiency (POI) (rare)
- Dyspareunia (painful sexual intercourse) (rare)
What measures can be taken to reduce complications?
There are many measures and practices some of which we have developed, that
can be taken to prevent or minimize complications specific to Radical
trachelectomy, such as uterine ischemia/necrosis (gangrene),
anastomotic infection/separation, Asherman (intrauterine adhesion), suture
erosion, cervical stenosis, bladder dysfunction and lymphedema. We always share
our knowledge and experience with fellow health professionals who asks for information
and help regarding the aforementioned measures and practices.
How are patients followed up after radical trachelectomy?
Regardless of the pathological features of the treated tumor, women who
remain HPV positive after trachelectomy or who have re-infection with HPV are
at high risk for recurrence. It is very important for women who have not
yet been vaccinated to have HPV vaccines during the follow-up period to reduce risk
of future re-infection and cancer recurrence in the remaining cervix.
Follow-up is very crucial since most of the recurrences will develop from the remaining (new) cervix and in such a case there will still be a chance for curative treatment. In addition to disease recurrence, patients are followed up for late complications (cervical stenosis, lymphedema, etc.). Check-ups are made every 3-4 months for the first two years, every 6 months for the 3-5th years, and annually thereafter (up to the 10th year). When abnormal bleeding, menstrual changes or any other symptom (pain, vaginal discharge, urinary and intestinal symptoms, weight loss, etc.) develops, a doctor should be consulted regardless the date of follow- up appointment.
General and pelvic examination, abdominal ultrasound, TVUS, cytology (pap-smear) and colposcopy are routinely performed in the follow-up. Along with cytology, HPV-testing should be done at certain interval (co-test). When needed, pelvic/abdominal MRI and other advanced imaging methods are used. In the first 2 years, especially strict clinical and radiological follow-up is required. During this period although TVUS is used as a routine imaging method, we are in favor of having pelvic MRI at 6, 12 and 24 months. However, it should be taken into account that MRI interpretation may be difficult due to anatomical changes and may cause false positive results. Again, depending on anatomical changes (especially because of cell loss from the lower uterine segment and atypical endometrial cells), cytology could also be false positives (2%).
What are the oncological outcomes of radical trachelectomy?
If patient selection criteria have been followed properly, recurrence is less than 5% and death due to disease is less than 2.5%, and these rates are similar to recurrence and death rates in patients at the same stage who underwent radical hysterectomy. Relapses may occur in the new cervix (cervix-vaginal junction), parametrium, pelvic side wall, lymph nodes, or distant sites. Ovarian metastases are rare. Cervical-vaginal junction recurrences may be confused with hematoma (blood collection), scarring (post-surgical tissue thickening), or mucosal prolapse (sagging).
What are the fertility chances after radical trachelectomy? Can pregnancy occur naturally?
Infertility is seen in 30% of patients and the majority (70%) is due to cervical factor. Insufficient cervical mucus production, fibrosis and stenosis (stenosis) may be present. Stenosis develops in 10% of cases and sometimes requires dilatation. Another common cause of infertility is Asherman's syndrome (intrauterine adhesion) and is seen in 10% of cases after abdominal radical trachelectomy. It is thought that this condition develops due to uterine ischemia, excessive manipulation or endometritis. Rarely, ovarian insufficiency (failure) or pelvic adhesions may cause infertility.
What are the chances of pregnancy? What kind of problems can be encountered during pregnancy?
According to various studies, the chance of achieving a pregnancy spontaneously or with treatment after trachelectomy is between 16% and 80%. In general, pregnancy rates appear to be slightly higher with the vaginal approach (the opposite is true for oncologic outcomes). The chance of pregnancy after abdominal radical trachelectomy is around 45%, and nearly 70% of them result in live (preterm or term) birth. Abortion (miscarriage) is seen at a rate of 15-20% (first trimester pregnancy loss rates are similar to the normal population, but second trimester abortion rates have doubled). Early (preterm) labor is seen at a rate of 30%, and the reason is cervical insufficiency due to shortened cervix and premature rupture of membranes (PROM) due to subchronic chorioamnionitis. More than 50% of pregnancies reach term (>37 weeks). There is no consensus on the effectiveness of precautions like the use of prophylactic antibiotics, vaginal irrigation, monitoring of cervical length with TVUS and strict bed rest to prevent pregnancy complications. Evidently applying cerclage during the trachelectomy procedure reduces the risk of second trimester miscarriage and premature birth. However, there are also those who apply cerclage after pregnancy, with the thought that this practice (performing a cerclage at the time of trachelectomy) may cause cervical stenosis and erosion. We prefer performing routine cerclage application during the operation.
What is the ideal waiting time before getting pregnant after radical trachelectomy?
There is no consensus on the ideal waiting time. Even if there are those who suggest a short waiting period of 3 months after simple trachelectomy, it is generally recommended to wait 6-12 months before getting pregnant after radical trachelectomy. In our practice, we recommend waiting for 1 year in order to complete the microscopic wound healing, to achieve full absorption of the sutures used in utero-vaginal anastomosis, to ensure the adaptation of the organism to the new anatomy, to ensure the disease is under control, and to psychosocially prepare the mother-to-be for pregnancy.
What should be the mode of delivery after radical trachelectomy?
If an abdominal cervical “cerclage” is performed during Abdominal Radical Trachelectomy or after conception, delivery must be by cesarean section. If by any chance, a pregnancy has come to the later weeks without cerclage and the expectant mother insists on a vaginal delivery, which may technically be possible, there is high risk in terms of uterine injury (even rupture) from the fibrotic cervix, and that can result to life-threatening bleeding.
Should the remaining part of the uterus be removed after having a child?
The necessity of removing the uterus (complementary hysterectomy) after achieving pregnancy and live birth is unclear and controversial. We do not have enough data to comment on this issue. We do not routinely perform hysterectomy after delivery, but we recommend hysterectomy to patients with persistent positive HPV test or cervical cytology results, abnormal bleeding or problems related to cervical stenosis.
If the disease recurs after radical trachelectomy, how is it treated?
Tumors smaller than 2 cm and without LVSI have a very low recurrence rate (around 3%). Depending on the location and extent of recurrence, the treatment method would be surgery, radiotherapy, chemotherapy, targeted drug therapy, immunotherapy or various combinations of them. The most common site of recurrence is the new cervix-vaginal junction. Relapses in this localization have higher surgical chance (hysterectomy or pelvic exenteration) along with better treatment responses. Good results are also obtained in isolated lymphatic metastases.