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Modification of Dargent’s radical vaginal trachelectomy to facilitate ureteral dissection: description of technique
  1. Andrea Plaikner1,
  2. Anna Jacob1,
  3. Kathrin Siegler1,
  4. Achim Schneider2,
  5. Volker Ragosch3,
  6. Jana Barinoff4 and
  7. Christhardt Kohler1,5
  1. 1 Department of Special Operative and Oncologic Gynecology, Asklepios Klinik Altona, Hamburg, Hamburg, Germany
  2. 2 Center for Dysplasia and Cytology, MVZ Fürstenbergkarree Berlin, Berlin, Germany
  3. 3 Department of Obstetrics and Gynecology, Asklepios-Clinic Hamburg-Altona, Asklepios Hospital Group, Hamburg, Germany
  4. 4 Department of Gynecology and Obstetrics, Sankt Gertrauden Krankenhaus GmbH, Berlin, Berlin, Germany
  5. 5 Department of Gynecology, University of Cologne, Koln, Germany
  1. Correspondence to Dr Andrea Plaikner, Department of Special Operative and Oncologic Gynecology, Asklepios Klinik Altona, 22763 Hamburg, Germany; an.plaikner{at}gmail.com

Abstract

Objective Radical vaginal trachelectomy is the fertility-preserving surgery for patients with early stage cervical cancer. However, it has not gained widespread approval by gynecologic oncologists because of difficulties in the dissection of the bladder pillars and identification of the ureter during the vaginal portion of the surgery.

Method We describe a modification of radical vaginal trachelectomy for easier dissection of the bladder pillar. Following pelvic lymphadenectomy, the vesicovaginal space is widely opened laparoscopically. After identification of the uterine arteries, one should proceed along the course of the arteries laterally and, thus, visualize the overcrossing of the artery with the ureter. The medial aspect of the supraureteric bladder pillar is transected and the ureter marked with vessel loops on both sides close to its entry into the bladder. The lateral portion of the supraureteric bladder pillar remains intact. During the vaginal part of radical vaginal trachelectomy, the ureter may be easily found by grasping the formerly placed vessel loop and dissection of the infraureteric bladder pillar may be done without risk of ureteral injury.

Results Between October 2018 and August 2019 our group has performed radical vaginal trachelectomy using this modified ureteral dissection in 12 patients. Median operation time was 239 min (range 127–290) and median blood loss was 25 mL (range 10–100). No intra- or post-operative urologic complication occurred. Median time to normal bladder function was 4 days (range 3–13).

Conclusion The vaginal portion of radical vaginal trachelectomy may be simplified using this technique, especially when difficult circumstances such as endometriosis, prior operations, or unusual anatomy in nulliparous women are encountered.

  • cervical cancer
  • gynecologic surgical procedures

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HIGHLIGHTS

  • Radical vaginal trachelectomy is a fertility-sparing surgery for early stage cervical cancer with favorable oncologic outcomes.

  • Dissection of the bladder pillar can be difficult during the vaginal part of the surgery; the ureter can be dissected during laparoscopy marked with a vessel loop.

  • During the vaginal part of the surgery the ureter may be found by grasping the vessel loop and dissection of the infraureteric bladder pillar may be done without risk of ureteral injury.

Introduction

In contrast to other gynecologic malignancies, cervical cancer is often diagnosed in women younger than 40 years who are interested in future fertility.1 2 Therefore, fertility-preserving therapy is an issue of concern for these patients, especially for nulliparous women. With the ability to perform laparoscopic pelvic lymph node dissection safely,3 the combination of laparoscopic lymphadenectomy and radical vaginal trachelectomy (radical vaginal trachelectomy) was developed by Daniel Dargent at the end of the last century.4 In strict accordance with globally accepted indications, radical vaginal trachelectomy as fertility-sparing surgery has been shown to be oncologically as safe as radical hysterectomy for women diagnosed with early cervical cancer.5–9 Today, radical vaginal trachelectomy is a standardized procedure comprising three steps: (1) laparoscopic pelvic lymphadenectomy and preparation of the vaginal part of the procedure; (2) radical transvaginal resection of a portion of the cervix and parametria; and (3) laparoscopic control of hemostasis. However, radical vaginal trachelectomy has not gained popularity among gynecologic oncologists due to its prolonged learning curve and difficulties with respect to ureteral dissection during the vaginal part of the procedure. Other approaches for radical trachelectomy with dissection of the ureters under direct visualization have been described, such as abdominal radical trachelectomy, total laparoscopic radical trachelectomy, and robotic-assisted radical trachelectomy.10 However, abdominal radical trachelectomy is associated with a lower pregnancy rate compared with radical vaginal trachelectomy.11 Moreover, following the results of the Laparoscopic Approach to Cervical Cancer (LACC) trial by Ramirez et al, any fertility-sparing surgery using uterine manipulators such as total laparoscopic radical trachelectomy or robotic-assisted radical trachelectomy must be potentially associated with higher recurrence rates.12 We describe a modification of radical vaginal trachelectomy to facilitate ureteral dissection, especially when non-cancer-related conditions such as synchronous endometriosis, prior operations, or narrow vagina in nulliparous women are encountered.

Description of technique

The technique of radical vaginal trachelectomy has already been described in detail elsewhere.13 Following laparoscopic pelvic lymphadenectomy or sentinel-laparoscopic lymphadenectomy and while waiting for histologic results of lymph nodes at the time of frozen section, the vaginal portion of the radical vaginal trachelectomy is prepared. Paravesical spaces on both sides are dissected to the level of the levator ani muscle to facilitate insertion of a Breisky speculum transvaginally. The uterus is then elevated and the peritoneum of the cul-de-sac incised. Thus, the rectovaginal space is opened and the rectum can be pushed away from the posterior parametria. Then, under moderate filling of the bladder, the vesicouterine peritoneum is incised and the bladder is dissected away from the uterine cervix to the upper vagina. During this procedure both uterine arteries are freed and become visible at their entry to the uterine side wall (Figure 1). In the original technique (with vaginal identification of the ureter using click maneuver) one would now move to the transvaginal part of radical vaginal trachelectomy and place the patient in the lithotomy position.

Figure 1

Laparoscopic situs following opening of the vesicocervical and vesicovaginal septum (vagina, yellow arrow). Both uterine arteries are visible at their entry to the uterine wall (red arrows). The medial aspect of the bladder pillar is visible but not dissected (green arrows).

Our modification is related to the dissection of the ureter. After emptying the bladder, we continue via laparoscopy and dissect the bladder pillar under direct visualization. We follow along the already visible uterine artery from the uterine side wall laterally to its overcrossing with the ureter. By transection of the medial supraureteric bladder pillar, the ureter can be freed over a distance of 1 cm just before its entry into the bladder. The ureter is carefully mobilized using an Overholt clamp and a silicone vessel loop is placed around the ureter and knotted several times (Figures 2 and 3). After placing the vessel loops on both sides (we recommend using different colors) and confirmation of tumor-free lymph nodes on frozen section, the patient is placed in the lithotomy position for the vaginal portion of the tumor specimen resection.

Figure 2

Schematic diagram of laparoscopic transection of bladder pillar. The medial supraureteric bladder pillar is transected (green) and the lateral bladder pillar is visible (light blue). The moderately filled bladder is grasped with an atraumatic grasper. A silicon (black) loop is placed around the ureters close to their entry into the bladder.

Figure 3

Intra-operative situs of identical view to that in Figure 2. The left ureter is marked with a red vessel loop and the right ureter with a yellow loop.

The vaginal part of the radical vaginal trachelectomy is exactly according to the previously described technique. After creation the tumor-adapted vaginal cuff, the rectovaginal space, and vesicovaginal spaces are opened. Following transection of the infraureteric bladder pillar, the vessel loops can now be grasped (different colors of the loops are helpful for the identification of the correct side) and the ureters are identified under complete visualization vaginally (Figures 4 and 5). The remaining steps are identical to the classic radical vaginal trachelectomy technique. The loops may be removed either at the end of the vaginal part or during final laparoscopic evaluation.

Figure 4

Schematic diagram during the vaginal part of radical vaginal trachelectomy. After opening of the vesicovaginal and lateral paravesical spaces, the bladder pillar is visible between the Breisky specula. The run of the ureters can easily be identified by grasping the vessel loop, after which the infraureteric bladder pillar (purple) can be dissected.

Figure 5

Intra-operative picture during the vaginal part of the surgery. Both ureters are visibly marked with the vessel loops and show good visibility after dissecting the bladder pillar. The modified Chrobak clamps are placed on the vaginal cuff and a Breisky speculum is placed in the vesicovaginal space.

Results

Between October 2018 and August 2019 our team used the modified technique of radical vaginal trachelectomy in 12 patients (Table 1). The reasons for applying this new technique were additional endometriosis (n=2), two-step trachelectomy following previously performed laparoscopic lymphadenectomy (n=1), extensive adhesions in the vesicovaginal space after cesarean section (n=2), narrow and/or long vagina in nulliparous women (n=3), short remaining cervix following large cone excision (n=2), or a combination of these factors (n=2). During the same period, a radical vaginal trachelectomy was performed in 19 other patients by transvaginal (click maneuver) dissection of the bladder pillar.

Table 1

Demographic, histologic, and operative data

The median age was 32 years (range 28–38); seven (58%) of the 12 patients were nulliparous. The diagnosis of cervical cancer was confirmed in nine (75%) of the 12 patients by conization and in three (25%) patients by biopsy. Histologically, five (42%) of the 12 patients were diagnosed with squamous cell carcinoma, six (50%) with adenocarcinoma, and one (8%) with villoglandular adenocarcinoma. Eleven (92%) of the 12 patients underwent complete pelvic lymph node dissection and one patient underwent sentinel lymph node detection followed by radical vaginal trachelectomy. No ureteral or bladder injury or complication occurred in any patient. One patient had post-operative fever and a lower urinary tract infection. No patient had post-operative hydronephrosis. The suprapubic catheter was removed in all patients after bladder training after a median of 4 days (range 3–13) and there was no ongoing micturition disturbance. The median blood loss during trachelectomy was 25 mL (range 10–100) and the median operative time was 239 min (range 127–290).

Discussion

Radical vaginal trachelectomy is an established fertility-sparing procedure with an excellent oncologic outcome and high pregnancy rates for women with early stage cervical cancer.6 9–11 14 Interestingly, there are limited data with respect to intra- and post-operative complications, especially urologic complications, and on the learning curve. The radical vaginal trachelectomy procedure was derived from the laparoscopic-assisted radical vaginal hysterectomy introduced by Daniel Dargent. While it is known that ureteral dissection during the procedure may be difficult,15 resulting in an unacceptably high urologic complication rate of up to 22%,16 17 this issue has not been addressed in most studies on radical vaginal trachelectomy.

Possible intra- and post-operative urologic complications of radical vaginal trachelectomy are direct injury to the bladder and ureter as well as a secondary fistula from the urinary tract, urinary retention, or urinary incontinence.18 19 Morbidity specifically for this surgical procedure may be secondary dysmenorrhea (~24%), irregular bleeding (~17%), issues with permanent cerclage (~14%), excessive vaginal discharge (~14%), cervical stenosis (~7%), and deep dyspareunia (~5%).18

Alexander-Sefre et al described one cystotomy in 27 patients (4%) and post-operative bladder hypotonia in 4% of patients.18 In their series of 49 patients Balaya et al reported post-operative hydronephrosis 7 weeks after surgery in one patient (2%), while dysuria (8.2%) and lower urinary tract infection (16%) were more frequent.20 In the first 100 radical vaginal trachelectomy procedures Hertel and co-workers did not report any intra-operative urologic complications.21 In a study by Marchiole et al,14 the authors reported one injury to the bladder, one to the ureter, and one vascular complication in 118 trachelectomies, but no post-operative fistulas or hydronephrosis. Fleming et al 22 reported a ureter laceration and a post-operative ureter fistula after radical trachelectomy. Rizzuto et al 23 reported a vesico-vaginal fistula in 19 patients. In a large cohort of 208 radical vaginal trachelectomies, Shepherd reported three ureteral fistulas and one intra-operative bladder perforation. He highlighted that all injuries occurred in the early development period of the procedure.9

Ureteral identification and dissection (click maneuver) during the vaginal portion of the radical vaginal trachelectomy is likely the most challenging step of the procedure. Although no analysis of the learning curve for radical vaginal trachelectomy exists, this difficult part may be the reason for the low acceptance of this technique among gynecologic oncologists. Radical vaginal trachelectomy may be impacted after the publication of the LACC trial.12 Alternative trachelectomy approaches, such as total laparoscopic radical trachelectomy or robotic-assisted radical trachelectomy may also be impacted, as there is increasing concern regarding the use of uterine manipulators. Recently, Matsuo et al 24 have pointed out that there is no difference in the oncologic outcomes when comparing open versus minimally invasive radical trachelectomy. However, that study did not have the objective of evaluating oncologic outcomes and its primary objective was to determine trends in the procedure. Similarly, the results of the ongoing IRTA study,25 which have been presented in abstract form only, suggest no worse outcome regarding recurrence rate or survival of minimally invasive trachelectomy approaches.

One of the strengths of our study is that the current modification of radical vaginal trachelectomy has not been described before. However, the small number of patients in our study requires further evaluation.

In conclusion, our modified technique of the ureteral dissection during radical vaginal trachelectomy may potentially overcome barriers to this fertility-sparing surgery, especially when additional diseases or specific anatomical features are encountered.

References

Footnotes

  • Contributors All authors have contributed substantially to the development of the technique, the design and writing of the manuscript, and data collection.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article.