Surgery Insight: Radical Vaginal Trachelectomy as a Method of Fertility Preservation for Cervical Cancer

Mario E Beiner; Allan Covens*

Disclosures

Nat Clin Pract Oncol. 2007;4(6):353-361. 

In This Article

Summary and Introduction

Over the past decade, the treatment of cervical cancer has evolved with an increased emphasis on preservation of fertility. There has been a gradual abandonment of radical surgical procedures in favor of more conservative techniques in an effort to decrease morbidity and preserve fertility without compromising overall survival. Radical vaginal trachelectomy (RVT) with laparoscopic pelvic lymphadenectomy is a fertility-preserving procedure that has recently gained worldwide acceptance as a method of surgically treating small invasive cancers of the cervix. Since the original description of RVT by Daniel Dargent in 1994, over 500 cases of utilization of this technique have been reported in the literature, with over 100 live births reported following this procedure. The morbidity associated with RVT is low, with a tumor recurrence rate of 5% and a mortality rate of 3%. The current literature indicates no difference in the rate of recurrence with this technique compared with radical hysterectomy when proper selection criteria are used. Combining RVT with laparoscopic sentinel lymph-node biopsy can further reduce the duration, extent, and complications of surgery.

Over the past decade, the treatment of cervical cancer has evolved with an increased emphasis on preservation of fertility. There has been a gradual abandonment of radical surgical procedures in favor of more conservative techniques in an effort to decrease morbidity and preserve fertility without compromising overall survival. As more women are delaying child-bearing, preservation of fertility and reproductive function is a major concern when these young women are counseled with regard to the effects of treatment for cervical cancer. Approximately 15% of all cervical cancers and 45% of surgically treated stage IB cancers occur in women under 40 years of age.[1] These women represent the subset of patients who are candidates for fertility preservation if they are identified as having a low risk of recurrence and a low risk of lymph-node involvement.

Radical vaginal trachelectomy (RVT) with laparoscopic pelvic lymphadenectomy is a fertility-preserving procedure that has recently gained worldwide acceptance as a method of surgically treating small invasive cancers of the cervix. RVT was first described by Daniel Dargent in 1994 and involves the removal of most, if not all, of the cervix, its contiguous parametrium, and vaginal cuff, in addition to a laparoscopic pelvic lymphadenectomy. Since RVT's original description, over 500 cases of utilization of this technique have been reported in the literature, with over 100 live births reported following this procedure.[2,3,4,5] An understanding of how cervical cancer spreads is helpful so that the uterus might be spared for future childbearing. Cervical cancer tends to spread laterally from the cervix into the parametrium and inferiorly to the upper vagina.[6] This cancer very seldom has a propensity to spread superiorly into the uterus in small stage IB cervical cancers. Consequently, in women with small stage IB tumors the removal of the cervix, contiguous parametrium and vagina (similar to removal in a radical hysterectomy) should be equally efficacious as a radical hysterectomy. This less invasive surgical approach, however, leaves the fundus of the uterus intact to allow conception and the carrying of a pregnancy to term.

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