Uterine artery-preserving laparoscopic radical trachelectomy for early cervical cancer: Technical aspects

Department of Obstetrics and Gynecology, Ajou University School of Medicine, Suwon, Republic of Korea.
Gynecologic Oncology (Impact Factor: 3.77). 05/2012; 126(2):277-8. DOI: 10.1016/j.ygyno.2012.04.039
Source: PubMed


Radical trachelectomy is increasingly used for patients with early cervical cancer as an alternative to radical hysterectomy, who want to preserve their fertility [1]. Radical trachelectomy can be performed using minimal invasive techniques such as laparoscopy or robotics [2-4]. Laparoscopic radical trachelectomy (LRT) is generally classified into two types: total LRT of which all procedures are conducted via laparoscopy and laparoscopically-assisted vaginal radical trachelectomy (LAVRT) in which lymph node dissection and radical trachelectomy are performed via laparoscopy and vaginal route, respectively [3,4]. In the present surgical film, we introduce our LRT technique combining the foregoing types, which consists of 70% laparoscopic and 30% vaginal approaches. This technique was originally developed by one of the authors (JHN). LRT is usually performed after pelvic lymphadenectomy. This procedure leaves the paravesical and pararectal spaces widely open, the obturator fossa exposed down to the levator muscle, and the cardinal ligament isolated caudal to the uterine artery. The cardinal ligament is divided without ligation of the ascending branch of the uterine artery. The ureter is dissected from the peritoneum and mobilized with its adventitial tissue. The descending and ascending branches of the uterine artery were identified. The descending branch was divided and the ascending branch was mobilized up to the level of transaction of the cervix. After incising the vesicouterine and rectovaginal peritoneum, the vesicouterine and rectovaginal ligaments are divided. All these procedures are performed laparoscopically, and then the vaginal phase follows. The anterior and posterior colpotomy is made, the paracolpium is divided and the cervix is transected at the isthmic portion. The cervical cerclage is performed and the vagina and the uterus is reanatomosized. This technique seems to have some advantages - shorter time for reanastomosis compared to total LRT and more convenient and complete dissection of the ureter and parametrium compared to LAVRT. Moreover, the preservation of the uterine artery may be associated with more favorable restoration of the reproductive function (Fig. 1).

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    • "To overcome the limitations associated with parametrial resection and the difficulties in learning vaginal radical trachelectomy, abdominal radical trachelectomy has been introduced [5,7]. Another approach, laparoscopic radical trachelectomy (LRT), is also a treatment of choice because it is minimally invasive [8,9]. The reproductive outcome of patients who underwent either a vaginal or abdominal radical trachelectomy is well known [5,6,10]; however, the reproductive outcome of women who underwent LRT is not yet known. "
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    ABSTRACT: The objective of this study was to estimate the reproductive outcome of young women with early-stage cervical cancer who underwent fertility-sparing laparoscopic radical trachelectomy (LRT). We performed a retrospective review of the medical records of patients with early-stage cervical cancer who underwent LRT. Clinicopathological data were obtained from patient medical records, and reproductive outcome data were obtained from patient medical records and telephone interviews. Fifty-five patients who underwent successful LRT were included in this study. The median age of patients was 32 years (range, 22 to 40 years), and the median follow-up time after LRT was 37 months (range, 3 to 105 months). Menstruation resumed in all patients after LRT, with fifty patients (90.9%) and five patients (9.1%) reporting regular and irregular menstruation, respectively. Six patients (10.9%) presented with cervical stenosis, which was manifested by regular but decreased menstrual flow and newly-developed dysmenorrhea. These patients underwent cervical cannulation and dilatation. Eighteen patients (32.7%) attempted to conceive, with six out of 18 patients receiving fertility treatments. Fourteen pregnancies (i.e., four missed abortions, six preterm births and four full-term births) occurred in 10 patients after LRT. Nine out of 10 patients gave birth to 10 healthy babies. The pregnancy rate after LRT was 55.6% (10/18). The spontaneous abortion rate and live birth rate were 28.6% (4/14) and 71.4% (10/14), respectively. The preterm birth rate was 60% (6/10). Pregnancy and live birth rates after LRT were promising; however, the preterm birth rate was relatively high. Cervical stenosis also occurred in a small percentage of patients.
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    ABSTRACT: To guarantee a better perfusion, the preservation of the uterine arteries during ART has sometimes been performed but has seldom been tested. We share the results of our tests to provoke a potentially different point of view on such uses of ART. Using computed tomography angiography (CTA), we identified the uterine blood supply in patients who underwent ART with uterine artery preserved and sacrificed. We included 26 consecutive post-ART patients from the outpatient service. The uterine arteries were preserved in 16 patients (61.5%) and ligated in 10 patients (38.5%). Out of the 26 patients studied, 17 (65.4%) were supplied by only the ovarian arteries; seven (26.9%) by one uterine artery and the contralateral ovarian artery; and only 2 (7.6%) by the uterine artery supply alone. No recanalization of the ligated uterine artery or other newly formed compensatory circulation was observed. Among the 16 patients who had preserved uterine arteries, only two (12.5%) showed identifiable bilateral uterine arteries, whereas seven (43.6%) had unilateral uterine artery occlusion and another seven (43.6%), bilateral occlusion. We had three obstetric outcomes, two of which came from the ovarian artery supplying group and one from the hybrid supplying group. The ovarian artery became the dominant supplying vessel after ART. The anatomically preserved uterine artery had a 87.5% chance of occlusion after the procedure. Moreover, the contributing uterine artery did not show any functional superiority. Thus, the benefit of preserving the uterine arteries during ART is probably very limited.
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