• cervical cancer
• surgical procedures, operative
• ureter

Summary video vaginal approach in radical vaginal trachelectomy

Early-stage cervical cancer often affects young patients seeking parenthood. The combination of laparoscopic pelvic lymphadenectomy and radical vaginal trachelectomy was developed by D Dargent in 1994.1 Radical vaginal trachelectomy is oncologically as safe as radical hysterectomy if patient’s selection is done in accordance with internationally accepted guidelines. Patients undergoing radical trachelectomy should fulfill the following criteria: FIGO IA1 L1-IB1 (FIGO 2018), tumor-free pelvic lymph nodes, no rare histologic subtypes, and a strong desire to conceive.2

Four approaches for radical trachelectomy have been described: radical vaginal trachelectomy, abdominal radical trachelectomy, total laparoscopic radical trachelectomy, and robotic-assisted radical trachelectomy. All these fertility-sparing procedures have demonstrated excellent oncologic outcome. However, the largest collection of data is available for radical vaginal trachelectomy with long-term follow-up. While oncologically safe, adominal trachelectomy has a significantly lower pregnancy rate compared with other types of trachelectomy.3 After the publication of the LACC trial by Ramirez et al,4 total laparoscopic radical trachelectomy and robotic-assisted radical trachelectomy must be scrutinized due to their inherent use of uterine manipulators.

Radical vaginal trachelectomy is a standardized procedure comprising three steps: laparoscopic pelvic lymphadenectomy and preparation for the vaginal part (vaginal instruments are shown in Figure 1); transvaginal creation of the vaginal cuff and resection of distant part of the cervix and medial parametria; and laparoscopic control of hemostasis. However, radical vaginal trachelectomy did not become popular among gynecologic oncologists due to the long learning curve und possible difficulties with respect to ureteral dissection during the vaginal part. Thus, the distribution of knowledge and helpful techniques of this oncologically safe fertility-sparing operation is important. In this video 1, filmed under magnification of a videocolposcope, we want to show the vaginal part of radical vaginal trachelectomy following laparoscopic pelvic lymphadenectomy and dissection of the vesicovaginal and rectovaginal septum. It is the aim to demonstrate the advantages of this fertility-sparing technique: creation of a tumor-adapted vaginal cuff, meticulous dissection of the bladder pillar, parametrial resection according type B radicality, cervical resection under direct palpation, and exact placement of a permanent cerlage under direct viualization.

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Figure 1

Vaginal instruments for radical vaginal trachelectomy.