YGYNO-975957; No.

of pages: 5; 4C:
Gynecologic Oncology xxx (2015) xxx–xxx

Contents lists available at ScienceDirect

Gynecologic Oncology

journal homepage: www.elsevier.com/locate/ygyno

Radical trachelectomy in early-stage cervical cancer: A comparison of

laparotomy and minimally invasive surgery
Marcelo A. Vieira a, Gabriel J. Rendón b, Mark Munsell c, Lina Echeverri b, Michael Frumovitz d,
Kathleen M. Schmeler d, Rene Pareja b, Pedro F. Escobar d, Ricardo dos Reis a, Pedro T. Ramirez d,⁎
a
Department of Gynecologic Oncology, Barretos Cancer Hospital, Barretos, Brazil
b
Department of Gynecologic Oncology, Instituto de Cancerología — Las Américas, Medellín, Colombia
c
Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
d
Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA

H I G H L I G H T S

• Radical trachelectomy via MIS results in less blood loss and a shorter hospital stay.
• Oncologic outcomes between open and MIS radical trachelectomy are similar.
• Pregnancy rate is higher for open radical trachelectomy.

a r t i c l e i n f o a b s t r a c t

Article history: Objectives. Radical trachelectomy is considered standard of care in patients with early-stage cervical cancer
Received 6 May 2015 interested in future fertility. The goal of this study was to compare operative, oncologic, and fertility outcomes
Received in revised form 15 June 2015 in patients with early-stage cervical cancer undergoing open vs. minimally invasive radical trachelectomy.
Accepted 17 June 2015 Methods. A retrospective review was performed of patients from four institutions who underwent radical
Available online xxxx
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 be-
tween 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. lapa-
rotomy (50 mL [range, 10–225 mL] vs. 300 mL [50–1100 mL]) (p b 0.0001). Nine patients required blood trans-
fusion, 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 b 0.0001). Three intraoperative complications occurred
(3%): 1 bladder injury, and 1 fallopian tube injury requiring unilateral salpingectomy in the MIS group and 1 vas-
cular 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 hos-
pital stay. Fertility rates appear higher in patients undergoing open radical trachelectomy.
© 2015 Elsevier Inc. All rights reserved.

1. Introduction
⁎ Corresponding author at: Department of Gynecologic Oncology & Reproductive
Medicine, Unit 1362, The University of Texas MD Anderson Cancer Center, 1515
Holcombe Blvd., Houston, TX 77030, USA. Radical trachelectomy is now considered a standard treatment for
E-mail address: [email protected] (P.T. Ramirez). women diagnosed with early-stage cervical cancer wishing to preserve

http://dx.doi.org/10.1016/j.ygyno.2015.06.023
0090-8258/© 2015 Elsevier Inc. All rights reserved.

Please cite this article as: M.A. Vieira, et al., Radical trachelectomy in early-stage cervical cancer: A comparison of laparotomy and minimally
invasive surgery, Gynecol Oncol (2015), http://dx.doi.org/10.1016/j.ygyno.2015.06.023
2 M.A. Vieira et al. / Gynecologic Oncology xxx (2015) xxx–xxx

fertility [1]. To date more than 1000 cases of vaginal radical trachelecto- arteries, device used to avoid cervical stenosis, use of cerclage, blood
my (VRT) have been published, with a global pregnancy rate (total transfusions, length of hospital stay, length of follow-up, and incidence
number of women who conceived of all who retained fertility) of 24% of intraoperative complications were recorded. Pathologic data included
[2], and a relapse and death rate of 4.2% and 2.9%; respectively [3]. The tumor histologic subtype and grade, residual tumor, surgical margin,
abdominal radical trachelectomy (ART) is an alternative approach to parametrial involvement, presence or absence of lymph vascular space
this procedure and offers an advantage to surgeons who are not profi- invasion, number of lymph nodes removed and nodal status. We also re-
cient in vaginal radical surgery. In a recent review that included 485 corded the need of adjuvant treatment. Serious morbidity was defined
abdominal radical trachelectomies, the reported pregnancy rate was as readmission, reoperation or need for second procedure, anemia ne-
16.2%, and relapse and death rates were 3.8% and 2.9%, respectively [2]. cessitating a blood transfusion, venous thromboembolism, ICU admis-
Radical trachelectomy can also be performed laparoscopically and, sion, death, or loss of fertility (need for postoperative radiotherapy).
to date, there have been 230 cases published in the literature, with a We also included the following as postoperative morbidities: urinary
pregnancy rate of 23.9% and a relapse and death rate of 6% and 1.7%; tract infections with symptoms such as dysuria and/or fever and posi-
respectively [4]. Another previously described minimally invasive ap- tive urine culture, voiding dysfunction with residual urine greater
proach is the robotic radical trachelectomy [5]. A total of 36 robotic rad- than 100 mL at the time of voiding trial, and lymphocyst associated
ical trachelectomies have been published in the literature thus far [6–9], with abdominal pain and/or fever diagnosed by radiological exam. All
with 4 reported pregnancies, and one relapse without death. postoperative morbidities were detailed and dichotomized as early (oc-
To date, there are limited data comparing the outcomes of patients curring less than 30 days) or late (occurring greater than 30 days but
undergoing radical trachelectomy based on the surgical approach. The within 1 year of surgery) morbidities. Postoperative pregnancy rates
goal of this study is to compare operative, oncologic, and fertility out- were also determined. In addition, patient status and disease status at
comes in patients with early-stage cervical cancer undergoing open vs. the time of the last follow-up were recorded.
minimally invasive radical trachelectomy. Statistical analyses were performed using SAS 9.3 for Windows
(Copyright © 2002–2010 by SAS Institute Inc., Cary, NC). Associations
2. Methods between categorical variables and modality of radical trachelectomy
(open vs. MIS) were determined using Fisher's exact test. Nonparamet-
Institutional Review Board approval was obtained from the Univer- ric continuous variables were summarized and compared using the
sity of Texas MD Anderson Cancer Center, Instituto de Cancerología — Wilcoxon rank sum test. All tests were two-sided, and a p-value b0.05
Las Americas in Colombia, Cleveland Clinic and the Barretos Cancer was considered statistically significant.
Hospital in Brazil. Data were collected retrospectively from all patients'
records that underwent open, laparoscopic or robotic radical trachelec- 3. Results
tomy for early-stage cervical cancer from June 2002 to July 2013. Open
radical trachelectomies were performed from June 2002 to February One hundred patients (fifty from MD Anderson Cancer Center
2013 and minimally invasive radical trachelectomies were performed [MIS = 23, open = 27]; thirty-three from Instituto de Cancerología
concurrently with open procedures from October 2008 to July 2013. In [MIS = 10, open = 23]; eight from Cleveland Clinic [open = 8] and
none of the institutions did patients undergo radical vaginal trachelec- nine from the Barretos Cancer Hospital [MIS = 9]) with early-stage cer-
tomy. All patients met the standard criteria for radical trachelectomy vical cancer were scheduled to undergo radical trachelectomy. The me-
(Table 1). dian age was 30 years (range, 21–40.6). The median body mass index
The surgical technique of open, robotic or laparoscopic radical trach- was 23.5 kg/m2 (range, 18–45). Sixty-one women were nulliparous.
electomy has been described elsewhere [5,10,11]. All trachelectomy The majority of patients were Hispanic (58%). Fifty-eight patients
specimens were submitted for frozen section. When the surgical margin underwent open radical trachelectomy and 42 patients underwent
was grossly positive or close (b 5 mm) for invasive cancer, the patient MIS (22 robotic and 20 laparoscopic). The most common stage was
underwent resection of additional tissue, and if this was not possible, IB1 (69%) and the most common histologic subtype was squamous
then immediate conversion to radical hysterectomy was performed. cell carcinoma (49%). Twenty-five (25%) patients had evidence of
The surgical approach was based on surgeon training and patient lymph vascular space invasion (LVSI) (Table 2).
preference. On preoperative pelvic examination 26 patients had a visible lesion
Patients who underwent conversion to radical hysterectomy were in the cervix, 9 patients in the MIS group and 17 patients in the open
excluded from the portion of the analysis pertaining to surgical and fer- surgery group (p = 0.49). The median tumor size in the 26 patients
tility outcomes, and the patients with hysterectomy during follow-up with a visible lesion was 2 cm (range, 0.5–3.5). Preoperative magnetic
subsequent to the radical trachelectomy were excluded from the fertil- resonance imaging (MRI) was obtained in 59 patients; ten patients
ity outcome analysis. Data extracted from the medical record included (17%) had visible tumor and 14 (24%) had suspicion of tumor in the cer-
patients' age at diagnosis, race/ethnicity, body mass index, pregnancy vix on preoperative MRI, none had suspicious nodes on MRI. Thirty-one
history, preoperative imaging, and preoperative pelvic examination patients underwent a CT scan and 2 of these were noted to have an en-
findings. Operative reports were reviewed and operative times, estimat- larged pelvic lymph node and underwent fine-needle aspiration (FNA).
ed blood loss, sentinel lymph node mapping, preservation of uterine These were negative for carcinoma in the biopsy, but one patient had a
positive lymph node in the lymphadenectomy specimen. Twenty-four
Table 1 patients had a PET/CT performed and none had evidence of metastatic
Radical trachelectomy recommended criteria. disease.
Patients undergoing MIS radical trachelectomy had significantly
Strong desire to preserve fertility
Histologic diagnosis of invasive squamous, adenocarcinoma or adenosquamous lower median blood loss than patients undergoing open surgery
cervical cancer (50 mL (range, 10–225) vs. 300 mL (range, 50–1100); respectively,
Stage IA1 with LVSI, IA2 or IB1 p b 0.0001). Nine patients required a blood transfusion, all in the open
Ideal tumor size less than 2cma
surgery group (p = 0.010). There was no difference in operative time
Pelvic MRI, ruling out upper endocervical involvement
Resolution of acute inflammation (4–6 weeks after conization) (MIS: 272 min [range, 130–441] vs. open: 270 min [range, 150–373],
No extracervical involvement p = 0.78) (Table 2). Twenty-two patients had uterine artery preserva-
Age less than 40 yearsa tion (MIS: 2 vs. open: 20, p = 0.0005).
No previous fertility impairmenta Excluding the patients that underwent radical hysterectomy, there
a
According to surgeons' and centers' experience and patient preferences. were three intraoperative complications (3%) and two of these were

Please cite this article as: M.A. Vieira, et al., Radical trachelectomy in early-stage cervical cancer: A comparison of laparotomy and minimally
invasive surgery, Gynecol Oncol (2015), http://dx.doi.org/10.1016/j.ygyno.2015.06.023
 M.A. Vieira et al. / Gynecologic Oncology xxx (2015) xxx–xxx 3

Table 2 infections (10/92 — 11%), voiding dysfunction (5/92 — 5.4%) and

Patient characteristics by surgical approach. lymphocyst formation (4/92 — 4%). Excluding another five patients
MIS (n = 42) Open (n = 58) p-Value who underwent hysterectomy during follow-up (after 30 days from
Agea 30.1 (25.4–40.6) 29.3 (21–40.3) 0.68
the surgery), the most common long-term (N 30 days) morbidities
Race 0.96 were cerclage erosion (11/63 — 17.5%) and cervical stenosis (8/87 —
White 15 (35.7%) 22 (37.9%) 9%) (Table 3).
Black 1 (2.4%) 2 (3.5%) A total of 5 patients in the MIS group experienced one or more serious
Hispanic 25 (59.5%) 33 (56.9%)
morbidities, 3 patients underwent hysterectomy, one because of uterine
Asian 1 (2.4%) 1 (1.7%)
BMIa 23.4 (18.8–45) 23.5 (18–33.4) 0.93 necrosis, another because of peritonitis and one because of chronic pelvic
History of previous pregnancy 0.84 pain. One patient developed a vesico-vaginal fistula 8 days after surgery
Yes 17 (40.5%) 22 (37.9%) and it was managed conservatively by placing a Foley catheter for 6
No 25 (59.5%) 36 (62.1%) weeks. Another patient developed a left uretero-vaginal fistula 13 days
Tumor stage 0.65
IA1 + LVSI 3 (7.1%) 3 (5.2%)
after surgery and it was managed with a Foley catheter for four months
IA2 12 (28.6%) 13 (22.4%) and then she underwent ureteral re-implantation.
IB1 27 (64.3%) 42 (72.4%) In the laparotomy group, eight patients experienced one or more
Tumor histology 0.58 serious morbidities, 2 patients underwent hysterectomy secondary to
Squamous 20 (47.6%) 29 (50%)
utero-vaginal anastomosis dehiscence with secondary uterine corpus
Adenocarcinoma 20 (47.6%) 22 (37.9%)
Adenosquamous 2 (4.8%) 5 (8.6%) necrosis. Another patient developed an utero-vaginal dehiscence
Mixed 0 2 (3.5%) following intercourse 3 months postoperatively. She was taken to the
Estimated blood loss (mL)a 50 (10–225) 300 (50–1100) b0.0001 operating room and noted to have disruption of the posterior vaginal
Rate of perioperative transfusion 0 (0%) 9 (15.5%) 0.010 to uterine anastomosis, which was revised. Three weeks following sec-
Operative time (min)a 272 (130–441) 270 (150–373) 0.78
ondary closure of the vaginal cuff, she developed a pelvic abscess and
Length of hospital stay (days) 1 (1–3) 4 (1–9) b0.0001
Nodal counts 17 (5–47) 22 (7–48) 0.03 was again readmitted, initiated on intravenous antibiotic therapy, and
Lymph vascular space invasion 11 (26.2%) 14 (24.1%) 0.99 underwent CT-guided drainage of the abscess without further compli-
Presence of residual disease 15 (35.7%) 27 (46.6%) 0.52 cation. Five patients developed anemia, necessitating blood transfusion
Rate of conversion to hysterectomy 5 (11.9%) 3 (5.2%) 0.27
in the immediate postoperative period.
Follow-up (months)a 25 (10–69) 66 (11–147) b0.0001
Recurrence 0 1 NA
Four patients underwent postoperative adjuvant therapy. Two
Death from disease 0 1 NA underwent radiation alone. One patient was treated because of disease
NA, not available.
at the margins and parametrium and another patient because of
a
Median (range). parametrial disease; a third patient had a positive lymph node, and
underwent concurrent chemotherapy and radiation. All of these pa-
tients were without evidence of disease at the last follow-up. The fourth
in the MIS group. One patient suffered from bladder injury that was patient had one right pelvic lymph node (1/29) positive for disease in
managed by the MIS approach and one patient suffered an injury to the final pathology and refused to undergo radiation due a strong desire
the fallopian tube because of grasper traction requiring unilateral to preserve fertility and underwent chemotherapy alone (4 cycles each
salpingectomy. There was one vascular injury in the left external iliac 21 days of cisplatin 75 mg/m2 and paclitaxel 175 mg/m2). At 23 months
artery during lymphadenectomy in the open group and this patient of follow-up, the patient was without evidence of disease and
lost 800 mL of blood and required a 2 unit blood transfusion. The medi- attempting to get pregnant.
an length of stay (LOS) was shorter in the MIS group than in the open In total, 17 (9 [21%] MIS vs. 8 [13.7%] open) patients were unable to
group (one day [range, 1–3] vs. 4 days [range, 1–9], respectively, p b maintain their fertility either secondary to a positive or close surgical
0.0001) (Table 2). margin necessitating conversion to hysterectomy (9/17), need for post-
The median number of lymph nodes retrieved was 20 (range, operative adjuvant therapy (4/17), a surgical complication (2/17), re-
5–48), and was lower in the MIS group compared to the open currence of disease (1/17) or ovarian dysfunction (1/17). Among the
group (17 [range, 5–47] vs. 22 [range, 7–48] respectively; p = patients that underwent trachelectomy excluding patients unable to
0.036). Fourteen patients (7 in the laparotomy cohort and 7 in the maintain their fertility, 34 (41%) of 83 patients had attempted to get
MIS cohort) underwent intraoperative lymphatic mapping, and all pregnant. Sixteen (47%) patients were able to do so (MIS: 2 vs. laparot-
had identification of sentinel lymph nodes and all sentinel nodes omy: 14, p = 0.01). Three women (18%) each had 2 pregnancies. A total
were negative for disease on final pathology. Two patients had posi- of 19 pregnancies have resulted in 4 (21%) first trimester losses, 1 (5.3%)
tive non-sentinel lymph nodes on final pathology, one for each second trimester loss, 9 (47.4%) pre-term deliveries, 1 (5.3%) term deliv-
group, and required adjuvant treatment. Eight patients were ery and 4 (21%) ongoing pregnancies (Table 4).
converted to radical hysterectomy secondary to a close (b5 mm) or Excluding patients that underwent hysterectomy (n = 13) and
involved surgical margin in frozen section (MIS: 5 vs. open: 3, p = the patients lost to the follow-up (n = 7), the median time of
0.27). Forty-two patients had residual disease in the cervical speci- follow-up was 51 months [range 10–147] for the entire cohort with
men, and this finding did not differ by type of technique. Sixty-
three patients (68%) had placement of cerclage at the time of
surgery. In order to prevent cervical stenosis, some surgeons chose Table 3
to use pediatric Foley catheters (57/92, 62%) versus others who Postoperative complications.
chose to use a Smit sleeve (Elekta AB, Stockholm, Sweden) (23/92,
MIS (n = 42) Open (n = 58) p-Value
25%) or none in 12 cases (13%). Of all the patients who had a pediat-
ric Foley for cannulation of the cervical os, six (10.5%) developed Morbidity b30 days from surgery
Urinary tract infection 4 (9.5%) 6 (10.3%) 0.99
cervical stenosis. Among patients who had a Smit sleeve placed to
Voiding dysfunction 1 (2.3%) 4 (6.8%) 0.64
maintain patency of the cervical os, one (4.3%) patient developed Lymphocyst 2 (4.7%) 2 (3.4%) 0.99
cervical stenosis and one (8.3%) patient with no catheter at all devel- Morbidity N30 days from surgery
oped cervical stenosis. Cerclage erosion 5 (11.9%) 6 (10.3%) 0.74
Excluding patients that underwent radical hysterectomy, the most Cervical stenosis 3 (7.1%) 5 (8.6%) 0.99

common morbidities within 30 days of surgery included urinary tract MIS, minimally invasive surgery.

Please cite this article as: M.A. Vieira, et al., Radical trachelectomy in early-stage cervical cancer: A comparison of laparotomy and minimally
invasive surgery, Gynecol Oncol (2015), http://dx.doi.org/10.1016/j.ygyno.2015.06.023
4 M.A. Vieira et al. / Gynecologic Oncology xxx (2015) xxx–xxx

Table 4 uterine arteries. Most studies published on radical trachelectomy do

Fertility outcomes comparing MIS versus open surgery. not advocate for uterine artery preservation [17,18]. Tang et al. showed
MIS (n = 42) Open (n = 58) by using computed tomography angiography that the benefit of pre-
Women with fertility preservation 33 (78.6%) 50 (86%)
serving the uterine artery is limited given the fact that 87.5% of
Women attempting pregnancy 7 (21.2%) 27 (54%) patients have occlusion of the uterine arteries after ART with uterine
Achieved pregnancy 2 (28.6%) 14 (51.8%) artery preservation [18].
Pregnancies 3 16 The strengths of our study lie in the fact that this is the largest
First trimester miscarriage 1 (33.3%) 3 (18.8%)
comparative series of open vs. MIS of radical trachelectomy. The
Second trimester deliveries 0 (0.0%) 1 (6.2%)
Third trimester deliveries 1 (33.3%) 9 (56.2%) study is composed of all patients who underwent radical trachelec-
Pre-term 1 (33.3%) 8 (50%) tomy at multiple institutions reflecting different levels of surgical ex-
Term 0 (0.0%) 1 (6.2%) pertise and different levels of a learning curve. We do recognize that
Ongoing 1 (33.3%) 3 (18.8%) our study also has the limitations of a retrospective study and it is
susceptible to limitations and biases inherent in such a design,
where criteria for surgical approach, surgeon expertise and skill,
a significantly shorter median time of follow-up for MIS vs. open and details of postoperative care may not have been clearly defined.
cases (25 months [range, 10–69] vs. 66 months [range, 11–147], The data presented in this article represents a composite of multiple
p b 0.0001) (Table 2). institutions and surgeons of varying degrees of surgical expertise
There has been one recurrence in the open surgery group. The performing radical trachelectomy. Although it would be ideal to pro-
patient had stage IB1 adenocarcinoma and at the time of her surgery vide an analysis of surgeons experienced in both open and minimally
her margins were negative. During her second year of follow-up, the pa- invasive radical trachelectomy, with surgeons involved with equal
tient had a pelvic relapse confirmed with biopsy and was not deemed a degrees of surgical expertise, this is not possible in the setting of a
surgical candidate and she received chemotherapy and radiation. Three procedure that is performed rarely and by select centers; and for
months after therapy she was noted to have peritoneal carcinomatosis which data is subsequently collected in a retrospective manner. We
and biopsies confirmed metastatic adenocarcinoma. She died 29 also did not have details regarding fertility potential and therapy in
months after her initial surgery (Table 2). those patients who underwent radical trachelectomy.
In summary, this study demonstrates the feasibility of radical trach-
4. Discussion electomy through a minimally invasive approach. As anticipated, the
MIS approach was associated with less blood loss and shorter length
Radical trachelectomy is feasible in appropriately selected patients of stay. However, we did note that the complication rates were not in-
in early-stage cervical cancer, and the MIS (robotic and laparoscopic) significant perhaps reflecting the impact of an initial learning curve.
approach offers a number of advantages such as improved visualization, We believe that a minimally invasive surgical approach should be con-
less blood loss, lower transfusion rates, and faster return to daily activi- sidered for women undergoing radical trachelectomy.
ties [4,7,9,12–16]. Nick et al. [7] have shown that robotic radical trache-
lectomy is safe and feasible. In their study, the authors showed that the
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Please cite this article as: M.A. Vieira, et al., Radical trachelectomy in early-stage cervical cancer: A comparison of laparotomy and minimally
invasive surgery, Gynecol Oncol (2015), http://dx.doi.org/10.1016/j.ygyno.2015.06.023
 M.A. Vieira et al. / Gynecologic Oncology xxx (2015) xxx–xxx 5

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Please cite this article as: M.A. Vieira, et al., Radical trachelectomy in early-stage cervical cancer: A comparison of laparotomy and minimally
invasive surgery, Gynecol Oncol (2015), http://dx.doi.org/10.1016/j.ygyno.2015.06.023