Radical Trachelectomy for the Treatment of Early-Stage Cervical Cancer

Abstract

OBJECTIVE: To assess surgical, oncologic, and pregnancy outcomes in patients undergoing radical vaginal, abdominal, or laparoscopic trachelectomy for the treatment of early-stage cervical cancer, using a methodic review of published literature. DATA SOURCES: PubMed, EMBASE, and Cochrane Library sources, including ClinicalTrials.gov, were searched from 1990–2019 with terms “cervical cancer” and “(vaginal, abdominal, open, minimally invasive, or laparoscopic) radical trachelectomy.” Grey literature and unpublished data were omitted. METHODS OF STUDY SELECTION: After removal of duplicates from a combined EndNote library of results, 490 articles were reviewed using Covidence software. Two reviewers screened titles and abstracts, and then screened full texts. Selection criteria included articles that reported radical trachelectomy with lymph node assessment as primary therapy for cervical carcinoma, with stated follow-up intervals and recurrences. TABULATION, INTEGRATION, AND RESULTS: Variables of interest were manually extracted into an electronic database. A total 47 articles that reported on 2,566 women met inclusion criteria. Most tumors were of squamous histology (68.5%), stage IB1 (74.8%), 2 cm or less (69.2%), and without lymphovascular invasion (68.8%). Of planned trachelectomies, 9% were converted intraoperatively to hysterectomy. Separated by route of trachelectomy, 58.1%, 37.2%, and 4.7% were performed using radical vaginal, abdominal, and laparoscopic approaches, respectively. With median follow-up of 48 months (range 2–202 months) across studies, median recurrence rate was 3.3% (range 0–25%); median time to recurrence was 26 months (range 8–44 months). Median 5-year recurrence-free and overall survival were 94.6% (range 88–97.3%) and 97.4% (range 95–99%), respectively. The posttrachelectomy pregnancy rate was 23.9%, with a live-birth rate of 75.1%. CONCLUSION: Radical trachelectomy for fertility-preserving treatment of cervical cancer is widely reported in the literature, though publications are mainly limited to case reports and case series. Reported follow-up periods infrequently meet standard oncologic parameters but show encouraging recurrence-free and overall survival rates and pregnancy outcomes. Higher-level evidence needed for meta-analysis is lacking. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42019132443.

Reduced response to controlled ovarian stimulation after radical trachelectomy: A pitfall of fertility‐sparing surgery for cervical cancer

“…In addition, trachelectomy can be performed not only by laparotomy, but also by vaginal and laparoscopic surgery, and the decreased response to COS may be a problem specific to laparotomy. Vaginal RT has a superior pregnancy rate to that of abdominal RT 6 and may also be superior in terms of maintaining ovarian reserve, which involves the preservation of blood flow from the uterus to the ovaries. So, it is also important to accumulate infertility treatment data after each RT procedure.…”

“…Radical trachelectomy (RT) is a fertility‐sparing treatment for early‐stage uterine cervical cancer and has been reported to have oncological and reproductive benefits 1‐5 . However, the pregnancy rate after RT is not high 6 . Especially in abdominal RT cases, the postoperative pregnancy rate is reported to be only 10.4% and needs to be improved 6 .…”

“…[1][2][3][4][5] However, the pregnancy rate after RT is not high. 6 Especially in abdominal RT cases, the postoperative pregnancy rate is reported to be only 10.4% and needs to be improved. 6 But the difficulties in infertility treatment after RT have not been extensively discussed, except for cervical stenosis and Asherman syndrome.…”

“…6 Especially in abdominal RT cases, the postoperative pregnancy rate is reported to be only 10.4% and needs to be improved. 6 But the difficulties in infertility treatment after RT have not been extensively discussed, except for cervical stenosis and Asherman syndrome. 7,8 In vitro fertilization (IVF) is often required after RT because of difficult natural pregnancy or cervical factor infertility, such as cervical stenosis.…”

Practical issues and research trends of oncofertility in gynecologic cancer

“…According to a recent meta-analysis, there is no substantial difference between vaginal, abdominal, laparoscopic, and robotic radical trachelectomies in terms of oncological treatment outcomes and post-treatment pregnancy outcomes [13][14][15]. In cases of cervical cancer with tumors larger than 2 cm, research has been undertaken to determine if radical trachelectomy can be performed after the tumor decreases in size as a result of neoadjuvant chemotherapy [16].…”