Radical TrachlectomyFertility-Sparing Op

present statusProf. Veena Agrawal

M.D., MICOG, WHO Fellow USA

Head of Dept of Obst. & Gynaec

G. R. Medical College,Gwalior, M.P.India

Faculty of human Genetics, Jiwaji University Gwalior

Past President Gwalior Obst & Gynae Society

In 1986, Prof Daniel Dargent 1st undertake fertility sparing surgery – lap pelvic lymphadenectomy & VRT also referred to as the “Dargent operation”.

RT can be done Vaginal (VRT) with lap pelvic lymphadenectomy

Abdominal (ART) 1997 by an international group.

Laparoscopy-assisted VRT

Total Laparoscopic (TLRT) 1st reported by Cibula et al in 2005

Robotically assisted TLRT 1st published by Person J et al. in 2008 ,

Parametria and vaginal cuff are also excised. Tanguay C et al 2004

Lymphadenectomy usually done, to assess for spread

Should save at least 1 cm of healthy stroma, lowers the risk for cervical incompetence,

ascending infection, and premature delivery.

Not yet considered standard of care; hysterectomy is standard of care.

Ramirez PT, Levenback C (2004).

Selection criteria & preoperative assessment

≤40 yrs with a desire to preserve fertility

FIGO stage IA1 with LVSI, IA2, and IB1.

appropriate if tumour ≤ 2 cm in largest dimension

No spread to lymph nodes.

Small-cell neuroendocrine carcinoma is not suitable RT

Pahisa J, Alonso I, Torné A 2008, Prof L Rob Mdet al 2011

Colposcopy assess the exocervical

diameter and spread to the vagina. Rob L et

al 2008, Plante M.2008

MRI volumetry

Important for determination of exact tumour size, amount of Cx stroma infiltration, involvement of paracervical tissues

infiltration >½ is the limit for a safe trachelectomy, Rob L,et al 2007, Milliken D. et al 2008,

MRI and CT scans are insufficient for evaluation of microscopic pelvic lymphnode infiltration. Sahdev A et al 2007, De Souza NM et al 206,

A new generation of PET–CT & MRI, feasible for preoperative assessment of lymph nodes. Wright JD, et al 2005, Rockall AG et al

2005, Vagor rectal USG is used for tumour

volumometry in some centres, with good results. Fischerova D et al 2008,

Benefits

Fertility-Sparing Op

Safe Lanowska, Malgorzata et al 2011

Quick recovery compared to hystrectomy

Risks Lymphoedema & lymphocysts – swelling of the legs

and genital area. Nerve damage - changed sensations in thighs &

genital areas & bladder morbidity. Cervical stenosis – dysmenorrhea. Fertility problems, pregnancy problems, Recurrence Need for further therapy - margins or lymph nodes

involved . Thrombosis, infection, excessive bleeding and

damage to other organs are rare side effects <5% of pts have immediate problems.

Follow up

four to six weeks avoid sexual intercourse, not place anything in the vagina, or take a bath or swim for

Every 3months

Close follow up for 2yrs & then 6monthly visits.

Compared to other treatments

Data on long-term outcomes is limited.

Recurrence & death are similar to radical hysterectomy & radiation. Dursun P, et al 2007.

Death and recurrence rates (app 3% and 5% respectively. trachelectomy.co.uk 2008

Preg post-trachelectomy

Wait 6-12 months

70% conceive. Dursun P et al 2007

Preg loss & preterm delivery is significantly higher, compared to healthy women. Jolley JA,et al 2007

Delivery is by CS.

Recent advances

Laparoscopy-assisted radical vaginal trachelectomy is an adequate Tx with its minimally invasive procedure and shorter recovery time

Robotic-assisted radical trachelectomy

Feasible safe, and easier to perform

Pt advantages similar or slightly improved Minimal blood loss, Shortened hospital stay, and Few operative complications

Multiple advantages for surgeons

Magrina JF, Zanagnolo VL.2008, Estape R et al 2009, Lowe MP et al 2009, Renato S et al 2011,

Continued research and clinical trials are needed to further elucidate the equivalence or superiority of robot-assisted surgery to conventional methods in terms of oncological outcome and patient's quality of life

Yim, Ga Won et al 2011

sentinel concept has a high potential for decreasing morbidity and for increasing oncologic safety.

SLN detection to predict pelvic lymph nodes status Blue dye method

Radiolabeled tracer

Combined isotope-dye

Preoperative SPECT/CT fusion images

Sensitivity, accuracy, -ve predictive value, and false -ve rate of SLN detection were Blue dye method - 85.7% Radiolabeled tracer - 96.3% Combined isotope-dye - 95.2% Preoperative SPECT/CT fusion images -14.3%

Ai Zheng. 2006

99mTc-labeled phytate injected at 3, 6, 9, & 12 o'clock, at a dose of 55-74 MBq in a volume of 0.8 ml) & intraoperative lymphatic mapping with handheld gamma probe sensitivity -82.3% (CI 95% = 56.6-96.2), -ve

predictive value 92.1% (CI 95% = 78.6-98.3).& accuracy 94.2%.Silva LB et al 2005

Sensitivity, accuracy, and false negative rates were 100%, 100%, and 0%,, Du XL,et al 2011

Sensitivity & -ve predictive value depend on tumor size:

Detection of circulating tumor cells in the sentinel node using HPVmRNA as marker may have a good prognostic value

Schneider A. 2007

Currently the sentinel concept should only be used in clinical studies before its validity has been proved.

Total laparoscopic nerve-sparing radical trachelectomy is consisted of reanastomosis of ut corpus & upper vagina & autonomic nerve-sparing dissection under magnified laparoscopic view.

Feasible No neurologic impairments such as bladder

hypotonia Without any increase of morbidity, Improve surgical outcomes, compared with

conventional.

David Cibula 2008, Zakashansky K et al 2009,Park NY,et al 2009

Ligation of ut artery permit adequate resection of paracervical tissues;

Ut remains viable via the ovarian vessels. Hence, fertility following RT adversely affected by ↓bl supply to the ut isthmus & corpus.

Modified abdominal radical trachelectomy (MART)

Ut Artery Preservation & Nerve-Sparing RT

↓ blood loss and feasible method

Wan XP, et al 2006, Hon g, Dae Gy et al 2011,WANG Yi-feng, e al 2011

Neoadjuvant chemotherapy

Downstaging tumours >2 cm by neoadjuvant chemotherapy followed by RT in “bulky” cervical cancers

Benedetti Panici PL et al 2007, meta-analysis.Eur J Cancer 2003; Maneo A 2008,

Conclusion

VRT with laparoscopic pelvic lymphadenectomy is currently the standard fertility preserving procedure.

Oncological results are similar in VRT & ART for tumours >2 cm

Downstaging by neoadjuvant chemotherapy is still an experimental

Pregnancy outcome depend on Removed cervix, Technique of re-anastomosis, Formation of neocervix, including cerclage Extent of resection of the paracervix Disruption of pelvic autonomic innervation Ut vascularisation