Clinical Study On Fertility-sparing Treatment For The Patients With Early Stage Cervical Cancer

BackgroundCervical cancer is the second commonest female malignancy to threat women's health and fertility worldwide, it remains the leading cause of death in gynecologic cancer. About half a million new cases presented annually and 80% of these occur in developed countries. Although the incidence and death rates has been reduced with the widespread use of cervical cancer screening programmes. As more women are delaying child-bearing for social pressures and profession, an increase in the number of cervical cancer patients are now being diagnosed in women at a relatively young age (24–35 years) and early stages.The management of early stage cervical cancer remains dilemma, particularly in these patients who desire to preserve fertility.The routine treatment for early stage cervical cancer requires either surgical therapy, including radcial hysterectomy combined pelvic lymphadenectomy or chemoradiation therapy. Both lead to loss of reproductive function. Preservation of fertility has become the major concern when these young women are counseled with regard to the effects of treatment for cervical cancer. Over the past decade, radical trachelectomy (RT) with pelvic lymphadenectomy is a fertility-preserving treatment option that has been shown to be an effective treatment for early-stage cervical cancer and gains an acceptable live birth rate. To date, RT has been performed via laparotomy, vaginal or laparoscopic approach. To our knowledge, these three techniques have not been directly compared.ObjectiveBased on the technique of the laparoscopic vaginal radical trachelectomy (LVRT) and abdominal radical trachelectomy (ART), we sequentially performed 23 modified abdominal radical trachelectomy (MART), 7 total laparoscopic radical trachelectomy (LVRT) and 2 LVRT. The goal of this clinical study was to compare the inclusion and exclusion criteria, surgical and pregnancy outcomes in addition to operative complication utilizing these three surgical approaches for fertility-sparing RT in patients with early stage cervical cancer.MethodPatient characteristics and surgical principle1. Patient characteristics and preoperotive preparation(1) Recording individual pathological characteristics, including tumor stage, histology and differentiation grade; (2) Measuring the length of the endocervical canal and assessing the involvement of both paracervical and pelvic lymphatic tissue with the MRI/CT, preoperative prophylactic antibiotics for one week were administered to exclude clinically palpable suspicious nodes in MRI/CT scan; (3) Measuring the resistance index (RI) of both uterine arteries pre- and postoperatively through transvaginal sonography; (4) The preoperative preparation of these MART, TLRT and LVRT is identical to the laparotomy, laparoscopic or vaginal procedure, respectively.2. Techniques (1) Between October 2002 to May 2011, depending on the surgical experience of our team and clinical indication, fertility-sparing RTs are being performed by laparotomy, laparoscopic or vaginal approach. We initially began performing modified abdominal radical trachelectomy (MART) in 2002, now twenty-three patients underwent MART; between 2009 to 2011, we started performing total laparoscopic radical trachelectomy (TLRT) for six patients; in 2011, laparoscopic vaginal radical trachelectomy (LVRT) was attempted in both case with stage IB1 cervical squamous cell cancer. All these RT were performed following the negative frozen section of the dissected pelvic lymphatic tissue.(2) The step-by-step to RT procedure as follow: 1) Pelvic lymphadenectomy commence with coagulation and transection of the round ligament. Anterior and posterior leaves of the broad ligament are then opened and fully widened parallel to the axis of external iliac vessels; 2) Systematic lymphadenectomy, including deep inguinal, external iliac, internal iliac and obturator lymph nodes, reach the bifurcation of the common iliac vessels. Notably, during resection of the internal iliac lymph nodes, care is taken to preserve the bilateral uterine arteries at their origin; 3) The dissected lymphatic tissue is submitted to intraoperative histology. Negativity of pelvic nodes was considered essential condition for continuation in procedure; 4) RT is initiated with the incision of the vesicouterine peritoneum. Sequently, identification and dissection of the vesicouterine space is performed laterally and caudally to expose the vesicouterine ligament and ensure the necessary margin of the upper vagina; 5) After dissecting the pararectal fossa, the proximal portion of the ureter is mobilized from the retroperitoneum down to where it crossed under the uterine artery; 6) By unroofing the ureter and dissecting the loose connective tissue between the ureter and the uterine artery, the ureter could be separated from the uterine artery; 7) The anterior leaf of the vesicouterine ligament is then dissected up to the level of the ureteral entry into the bladder. By dividing the vesicouterine ligament and pushing the ureter laterally we can entirely separate the ureter from the parametrium-paracolpium; 8) The caudal portion of the cardinal ligaments and uterosacral ligaments are then divided; 9) Subsequently, the descending branches of the uterine arteries are coagulated and dissected at the isthmus. The upper third of the vagina is circularly incised 2 cm below the cervicovaginal junction; 10) The assistant reverses the cervix by the clamps, and a circumferential incision is made at the level of isthmus using a unipolar instrucment. During this step, care is taken to preserve the skeletonized uterine arteries; 11) The amputated cervix and vaginal cuff are removed vaginally en bloc with adequate bilateral parametrium; 12) With consideration of the negative frozen sections of the endocervical margin (>5 mm clear margin), cerclage and vaginal-isthmic anastomosis are performed with 1-0 absorbable sutures, respectively; 13) Suturing the surgical incision routinely; 13) To avoid formation of adhesions, the Foley catheter was placed in the endocervical canal, which was removed on the 2nd postoperative day.ResultThirty-two patients underwent an attempt at a fertility-sparing radical trachelectomy; and MART was attempted in 23 patients (71%) and TLRT in 6 patients (21%) and LVRT in 2 patients. One patient of 7 TLRTs underwent completion hysterectomy because of the positive frozen section of the trachelectomy margin.The median histologic length was 2.55±0.29cm (2.20-2.95cm, n=23) in the MART group, as compared to 2.09±0.13cm (1.85-2.25cm, n=6) in the TLRT group (P=0.003). Median operating time was greater in the TLRT group, 240±37.2min (210-310min, n=6) versus 204±25.7min (160-228min, n=23) (P=0.009). Median operating time was greater in the VRT group, 204±25.7 min (160-228 min, n=23) versus 240±37.2 min (210-310 min, n=6) (P=0.009). Median blood loss was much in the MART group, 297±59 min (220-450 min, n=23) versus 208±6 min (150-320min, n=6) (P=0.003). The mean follow up interval was longer in the MART group (69±19 versus 13±5 months).Conclusion:1. We have found that more paracervical tissues specimens could be dissected via MART vs. TLRT. Moreover, the TLRT is a potentially less invasive alternative to MART. More data on the pathologic difference, the rate of recurrence, the fertility rate and pregnancy outcome following the procedure are required to fully evaluate the therapeutic efficacy of MART, TLRT and LVRT.Further study is necessary to determine if this will translate into a clinical difference, specifically if ART will afford women with tumors larger than 2 cm the opportunity to benefit from fertility-sparing surgery.