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Radical TrachlectomyFertility-Sparing Op
present statusProf. Veena Agrawal
M.D., MICOG, WHO Fellow USA
Head of Dept of Obst. & Gynaec
G. R. Medical College,Gwalior, M.P.India
Faculty of human Genetics, Jiwaji University Gwalior
Past President Gwalior Obst & Gynae Society
In 1986, Prof Daniel Dargent 1st undertake fertility sparing surgery – lap pelvic lymphadenectomy & VRT also referred to as the “Dargent operation”.
RT can be done Vaginal (VRT) with lap pelvic lymphadenectomy
Abdominal (ART) 1997 by an international group.
Laparoscopy-assisted VRT
Total Laparoscopic (TLRT) 1st reported by Cibula et al in 2005
Robotically assisted TLRT 1st published by Person J et al. in 2008 ,
Parametria and vaginal cuff are also excised. Tanguay C et al 2004
Lymphadenectomy usually done, to assess for spread
Should save at least 1 cm of healthy stroma, lowers the risk for cervical incompetence,
ascending infection, and premature delivery.
Not yet considered standard of care; hysterectomy is standard of care.
Ramirez PT, Levenback C (2004).
Selection criteria & preoperative assessment
≤40 yrs with a desire to preserve fertility
FIGO stage IA1 with LVSI, IA2, and IB1.
appropriate if tumour ≤ 2 cm in largest dimension
No spread to lymph nodes.
Small-cell neuroendocrine carcinoma is not suitable RT
Pahisa J, Alonso I, Torné A 2008, Prof L Rob Mdet al 2011
Colposcopy assess the exocervical
diameter and spread to the vagina. Rob L et
al 2008, Plante M.2008
MRI volumetry
Important for determination of exact tumour size, amount of Cx stroma infiltration, involvement of paracervical tissues
infiltration >½ is the limit for a safe trachelectomy, Rob L,et al 2007, Milliken D. et al 2008,
MRI and CT scans are insufficient for evaluation of microscopic pelvic lymphnode infiltration. Sahdev A et al 2007, De Souza NM et al 206,
A new generation of PET–CT & MRI, feasible for preoperative assessment of lymph nodes. Wright JD, et al 2005, Rockall AG et al
2005, Vagor rectal USG is used for tumour
volumometry in some centres, with good results. Fischerova D et al 2008,
Benefits
Fertility-Sparing Op
Safe Lanowska, Malgorzata et al 2011
Quick recovery compared to hystrectomy
Risks Lymphoedema & lymphocysts – swelling of the legs
and genital area. Nerve damage - changed sensations in thighs &
genital areas & bladder morbidity. Cervical stenosis – dysmenorrhea. Fertility problems, pregnancy problems, Recurrence Need for further therapy - margins or lymph nodes
involved . Thrombosis, infection, excessive bleeding and
damage to other organs are rare side effects <5% of pts have immediate problems.
Follow up
four to six weeks avoid sexual intercourse, not place anything in the vagina, or take a bath or swim for
Every 3months
Close follow up for 2yrs & then 6monthly visits.
Compared to other treatments
Data on long-term outcomes is limited.
Recurrence & death are similar to radical hysterectomy & radiation. Dursun P, et al 2007.
Death and recurrence rates (app 3% and 5% respectively. trachelectomy.co.uk 2008
Preg post-trachelectomy
Wait 6-12 months
70% conceive. Dursun P et al 2007
Preg loss & preterm delivery is significantly higher, compared to healthy women. Jolley JA,et al 2007
Delivery is by CS.
Recent advances
Laparoscopy-assisted radical vaginal trachelectomy is an adequate Tx with its minimally invasive procedure and shorter recovery time
Robotic-assisted radical trachelectomy
Feasible safe, and easier to perform
Pt advantages similar or slightly improved Minimal blood loss, Shortened hospital stay, and Few operative complications
Multiple advantages for surgeons
Magrina JF, Zanagnolo VL.2008, Estape R et al 2009, Lowe MP et al 2009, Renato S et al 2011,
Continued research and clinical trials are needed to further elucidate the equivalence or superiority of robot-assisted surgery to conventional methods in terms of oncological outcome and patient's quality of life
Yim, Ga Won et al 2011
sentinel concept has a high potential for decreasing morbidity and for increasing oncologic safety.
SLN detection to predict pelvic lymph nodes status Blue dye method
Radiolabeled tracer
Combined isotope-dye
Preoperative SPECT/CT fusion images
Sensitivity, accuracy, -ve predictive value, and false -ve rate of SLN detection were Blue dye method - 85.7% Radiolabeled tracer - 96.3% Combined isotope-dye - 95.2% Preoperative SPECT/CT fusion images -14.3%
Ai Zheng. 2006
99mTc-labeled phytate injected at 3, 6, 9, & 12 o'clock, at a dose of 55-74 MBq in a volume of 0.8 ml) & intraoperative lymphatic mapping with handheld gamma probe sensitivity -82.3% (CI 95% = 56.6-96.2), -ve
predictive value 92.1% (CI 95% = 78.6-98.3).& accuracy 94.2%.Silva LB et al 2005
Sensitivity, accuracy, and false negative rates were 100%, 100%, and 0%,, Du XL,et al 2011
Sensitivity & -ve predictive value depend on tumor size:
Detection of circulating tumor cells in the sentinel node using HPVmRNA as marker may have a good prognostic value
Schneider A. 2007
Currently the sentinel concept should only be used in clinical studies before its validity has been proved.
Total laparoscopic nerve-sparing radical trachelectomy is consisted of reanastomosis of ut corpus & upper vagina & autonomic nerve-sparing dissection under magnified laparoscopic view.
Feasible No neurologic impairments such as bladder
hypotonia Without any increase of morbidity, Improve surgical outcomes, compared with
conventional.
David Cibula 2008, Zakashansky K et al 2009,Park NY,et al 2009
Ligation of ut artery permit adequate resection of paracervical tissues;
Ut remains viable via the ovarian vessels. Hence, fertility following RT adversely affected by ↓bl supply to the ut isthmus & corpus.
Modified abdominal radical trachelectomy (MART)
Ut Artery Preservation & Nerve-Sparing RT
↓ blood loss and feasible method
Wan XP, et al 2006, Hon g, Dae Gy et al 2011,WANG Yi-feng, e al 2011
Neoadjuvant chemotherapy
Downstaging tumours >2 cm by neoadjuvant chemotherapy followed by RT in “bulky” cervical cancers
Benedetti Panici PL et al 2007, meta-analysis.Eur J Cancer 2003; Maneo A 2008,
Conclusion
VRT with laparoscopic pelvic lymphadenectomy is currently the standard fertility preserving procedure.
Oncological results are similar in VRT & ART for tumours >2 cm
Downstaging by neoadjuvant chemotherapy is still an experimental
Pregnancy outcome depend on Removed cervix, Technique of re-anastomosis, Formation of neocervix, including cerclage Extent of resection of the paracervix Disruption of pelvic autonomic innervation Ut vascularisation