1. Radical Trachlectomy
Fertility-Sparing Op
present status
Prof. 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

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

3. 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 ,

4.  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.

5. Not yet considered
standard of care;
hysterectomy is standard
of care.
Ramirez PT, Levenback C (2004).

6. Selection criteria &
preoperative
assessment

7.  ≤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

8.  Colposcopy assess the exocervical
diameter and spread to the vagina. Rob L et
al 2008, Plante M.2008

9. 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,

10.  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,

11. Benefits
 Fertility-Sparing Op
 Safe Lanowska, Malgorzata et al 2011
 Quick recovery compared to
hystrectomy

12. 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.

13. 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.

14. 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

15. 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.

16. Recent advances

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

18.  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,

19.  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

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

21. SLN detection to predict pelvic
lymph nodes status
 Blue dye method
 Radiolabeled tracer
 Combined isotope-dye
 Preoperative SPECT/CT fusion images

22.  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

23.  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

24.  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

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

26.  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

27.  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.

28. 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

29. 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,

30. Conclusion

31.  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