Elsevier

Gynecologic Oncology

Volume 138, Issue 3, September 2015, Pages 585-589
Gynecologic Oncology

Radical trachelectomy in early-stage cervical cancer: A comparison of laparotomy and minimally invasive surgery

https://doi.org/10.1016/j.ygyno.2015.06.023Get rights and content

Highlights

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    Radical trachelectomy via MIS results in less blood loss and a shorter hospital stay.

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    Oncologic outcomes between open and MIS radical trachelectomy are similar.

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    Pregnancy rate is higher for open radical trachelectomy.

Abstract

Objectives

Radical trachelectomy is considered standard of care in patients with early-stage cervical cancer interested in future fertility. The goal of this study was to compare operative, oncologic, and fertility outcomes in patients with early-stage cervical cancer undergoing open vs. minimally invasive radical trachelectomy.

Methods

A retrospective review was performed of patients from four institutions who underwent radical trachelectomy for early-stage cervical cancer from June 2002 to July 2013. Perioperative, oncologic, and fertility outcomes were compared between patients undergoing open vs. minimally invasive surgery.

Results

A total of 100 patients were included in the analysis. Fifty-eight patients underwent open radical trachelectomy and 42 patients underwent minimally invasive surgery (MIS = laparoscopic or robotic). There were no differences in patient age, body mass index, race, histology, lymph vascular space invasion, or stage between the two groups. The median surgical time for MIS was 272 min [range, 130–441 min] compared with 270 min [range, 150–373 min] for open surgery (p = 0.78). Blood loss was significantly lower for MIS vs. laparotomy (50 mL [range, 10–225 mL] vs. 300 mL [50–1100 mL]) (p < 0.0001). Nine patients required blood transfusion, all in the open surgery group (p = 0.010). Length of hospitalization was shorter for MIS than for laparotomy (1 day [1–3 days] vs. 4 days [1–9 days]) (p < 0.0001). Three intraoperative complications occurred (3%): 1 bladder injury, and 1 fallopian tube injury requiring unilateral salpingectomy in the MIS group and 1 vascular injury in the open surgery group. The median lymph node count was 17 (range, 5–47) for MIS vs. 22 (range, 7–48) for open surgery (p = 0.03). There were no differences in the rate of postoperative complications (30% MIS vs. 31% open surgery). Among 83 patients who preserved their fertility (33 MIS vs. 50 open surgery), 34 (41%) patients attempted to get pregnant. Sixteen (47%) patients were able to do so (MIS: 2 vs. laparotomy: 14, p = 0.01). The pregnancy rate was higher in the open surgery group when compared to the MIS group (51% vs. 28%, p = 0.018). However, median follow-up was shorter is the MIS group compared with the open surgery group (25 months [range, 10–69] vs. 66 months [range, 11–147]). To date, there has been one recurrence in the laparotomy group and none in the MIS group.

Conclusions

Our results suggest that radical trachelectomy via MIS results in less blood loss and a shorter hospital stay. Fertility rates appear higher in patients undergoing open radical trachelectomy.

Introduction

Radical trachelectomy is now considered a standard treatment for women diagnosed with early-stage cervical cancer wishing to preserve fertility [1]. To date more than 1000 cases of vaginal radical trachelectomy (VRT) have been published, with a global pregnancy rate (total number of women who conceived of all who retained fertility) of 24% [2], and a relapse and death rate of 4.2% and 2.9%; respectively [3]. The abdominal radical trachelectomy (ART) is an alternative approach to this procedure and offers an advantage to surgeons who are not proficient in vaginal radical surgery. In a recent review that included 485 abdominal radical trachelectomies, the reported pregnancy rate was 16.2%, and relapse and death rates were 3.8% and 2.9%, respectively [2].

Radical trachelectomy can also be performed laparoscopically and, to date, there have been 230 cases published in the literature, with a pregnancy rate of 23.9% and a relapse and death rate of 6% and 1.7%; respectively [4]. Another previously described minimally invasive approach is the robotic radical trachelectomy [5]. A total of 36 robotic radical trachelectomies have been published in the literature thus far [6], [7], [8], [9], with 4 reported pregnancies, and one relapse without death.

To date, there are limited data comparing the outcomes of patients undergoing radical trachelectomy based on the surgical approach. The goal of this study is to compare operative, oncologic, and fertility outcomes in patients with early-stage cervical cancer undergoing open vs. minimally invasive radical trachelectomy.

Section snippets

Methods

Institutional Review Board approval was obtained from the University of Texas MD Anderson Cancer Center, Instituto de Cancerología — Las Americas in Colombia, Cleveland Clinic and the Barretos Cancer Hospital in Brazil. Data were collected retrospectively from all patients' records that underwent open, laparoscopic or robotic radical trachelectomy for early-stage cervical cancer from June 2002 to July 2013. Open radical trachelectomies were performed from June 2002 to February 2013 and

Results

One hundred patients (fifty from MD Anderson Cancer Center [MIS = 23, open = 27]; thirty-three from Instituto de Cancerología [MIS = 10, open = 23]; eight from Cleveland Clinic [open = 8] and nine from the Barretos Cancer Hospital [MIS = 9]) with early-stage cervical cancer were scheduled to undergo radical trachelectomy. The median age was 30 years (range, 21–40.6). The median body mass index was 23.5 kg/m2 (range, 18–45). Sixty-one women were nulliparous. The majority of patients were Hispanic (58%).

Discussion

Radical trachelectomy is feasible in appropriately selected patients in early-stage cervical cancer, and the MIS (robotic and laparoscopic) approach offers a number of advantages such as improved visualization, less blood loss, lower transfusion rates, and faster return to daily activities [4], [7], [9], [12], [13], [14], [15], [16]. Nick et al. [7] have shown that robotic radical trachelectomy is safe and feasible. In their study, the authors showed that the robotic approach was associated

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