Robotically Assisted Laparoscopic Ovarian Transposition in Women with Lower Gastrointestinal Cancer Undergoing Pelvic Radiotherapy

Abstract

Background Pelvic radiotherapy (RT) is a standard component of the management for patients with locally advanced rectal cancer or squamous cell carcinoma of the anus. Pelvic RT leads to permanent and irreversible ovarian failure in young women. This study aimed to determine the effectiveness of robotically assisted laparoscopic ovarian transposition (OT) before RT in women with rectal or anal cancer who wanted to preserve normal ovarian function. Methods The study reviewed the medical records of all patients treated at our institution from August 2009 to October 2014 who received robotically assisted laparoscopic OT for rectal or anal cancer before RT. Clinical and hormonal data were abstracted to determine ovarian function. Results The study identified 22 women with rectal (n = 20) or anal (n = 2) cancer. The median age of the women was 39 years (range 26–45 years). For one patient, OT was technically not feasible. The postoperative course was uneventful in all but one case. Follow-up data on ovarian function were unavailable for 3 patients. The median times from RT initiation to the last gynecologic or hormonal evaluation were 9 months (range 5–47 months) and 10.5 months (range 5–47 months), respectively. At the last gynecologic or hormonal follow-up visit, ovarian function was preserved in 12 (67%) of 18 evaluable patients, including 9 (90%) of 10 patients 40 years of age or younger and 3 (38%) of 8 patients older than 40 years (P = 0.07). Conclusions Robotically assisted laparoscopic bilateral OT is safe and can lead to preservation of ovarian function in two-thirds of patients with low gastrointestinal cancer undergoing pelvic RT. It should be considered in this setting, especially for women age 40 years or younger, to avoid premature menopause and its associated sequelae.

New promising strategies in oncofertility

“…Reproductive and oncologic outcomes of robotically assisted laparoscopic ovarian transposition have proven this modality is safe. A recent study found that the use of robotically assisted laparoscopic ovarian transposition leads to preservation of ovarian function in two-thirds of patients with lower gastrointestinal cancer undergoing pelvic radiotherapy [72]. To prevent ovarian remigration, it is recommended that oophoropexy be timed to coincide with treatment.…”

Laparoscopic ovarian transposition before pelvic chemoradiotherapy in a young female patient with rectal cancer – a video vignette

“…According to the Ferti PROTEKT guidelines, chemotherapy (QT) regimens for colorectal cancer treatment are considered to be low to medium risk in terms of fertility failure . However, pelvic radiation with a cumulative dose of 50 Gy – usually administered for rectal cancer – has been reported to induce premature failure of ovarian function in more than 90% of patients . Laparoscopic OT has previously been described in the literature as a suitable surgical approach for preserving ovarian hormonal function .…”

“…Fertility preservation can be also achieved by combination with additional procedures (e.g. ovarian cortex biopsy and vitrification) . Therefore, OT should be considered in women under 40 years of age with adequate ovarian follicle reserve (defined as anti‐Müllerian hormone levels > 1.0 ng/ml and follicle‐stimulating hormone levels < 10 mIU/ml) who have a very low risk of ovarian micro‐metastasis and are receiving chemotherapy with low gonadotoxic effects (e.g.…”

“…This involves transection of the utero‐ovarian ligament with subsequent mobilization and fixation of the ovaries laterally and anteriorly to the antero‐superior iliac spines bringing them outside the pelvic brim and distant from the radiotherapy field. Recent studies have reported an efficacy rate for fertility preservation of 70–90% after adequate patient selection . When performed in women older than 40 years, the efficacy rate decreases to 38% .…”

“…Recent studies have reported an efficacy rate for fertility preservation of 70–90% after adequate patient selection . When performed in women older than 40 years, the efficacy rate decreases to 38% .…”