Type B Laparoscopic Radical Trachelectomy With Pelvic Lymphadenectomy for Early Cervical Cancer

Abstract

Study objective: To demonstrate the technique of laparoscopic radical trachelectomy (LRT) and laparoscopic pelvic lymphadenectomy for early cervical cancer.

Design: Case report (Canadian Task Force Classification Study design III).

Setting: Tertiary referral centre in Strasbourg, France.

Background: Over the past 15 years, gynecologic oncologists have sought ways to preserve female fertility when treating invasive cervical cancer. Many cases of cervical cancer have been diagnosed in young women with a desire to preserve their fertility. As more women are delaying childbearing, fertility preservation has become an important consideration. Radical hysterectomy and bilateral pelvic lymphadenectomy represent the standard surgical treatment for stage IA2-IB1 cervical cancer. In some women with small localized invasive cervical cancer, there is hope for a pregnancy after treatment. Vaginal radical trachelectomy (VRT) is a fertilitypreserving surgical procedure for early-stage cervical cancers. The National Comprehensive Cancer Network has published guidelines stating that radical trachelectomy is part of the standard of care for women desiring to preserve their future fertility. VRTwas introduced in 1987 with its first reported use in 1994, and since then more than 1000 cases of VRT have been reported involving more than 250 live births. The tumor recurrence rate is between 4.2% and 5.3%, and the mortality rate is between 2.5% and 3.2%. However, VRT has several limitations despite results demonstrating the safety of the procedure. One limitation is that it is an inadequate procedure for nulliparous patients and those with history of previous conization with adverse vaginal anatomy. In addition, it is difficult to learn the techniques involved in radical vaginal surgery.

Patients: A 26 year-old nulliparous women with a FIGO Stage IB1 squamous cell tumor of the cervix. A first conisation was performed with no safe resection margins.

Intervention: In this video we show a type B laparoscopic radical trachelectomy with round ligament and uterine artery preservation. A laparoscopic pelvic lymphadenectomy was also performed. Our institutional review board approved this study.

Measurements and main results: Operative time was 240 minutes. Intraoperative blood loss was less than 100 mL. The operation was performed successfully with no intraoperative complications. Pathological findings demonstrated the presence of a cervical intraepithelial neoplasia 2 on the anterior lips from an 11 o'clock to a 1 o'clock position. Resection margins were safe. The surgical specimen did not show any residual invasive carcinoma. Twenty one lymph nodes were removed, 7 on the right side, and 14 on the left side. No metastatic adenopathy was found. The patient was discharged on day 11. After 5 months, no late complications or recurrence was detected.

Conclusions: LRT appears to be a safe option for women who intend to maintain their desire for a future pregnancy.

Keywords: Cervix cancer; Fertility sparing surgery; Laparoscopic; Radical trachelectomy.