Vaginal Radical Trachelectomy
Over the past two decades, VRT with pelvic lymphadenectomy has been
accepted as an oncologically safe fertility-sparing alternative to RH in
carefully selected patients with early-stage disease. In accordance with
previous studies, we found that 4 patients (10.8%) were found to have
more extensive disease or LN metastases when attempting
fertility-sparing surgery 9, 19. In our cohort, no
VRTs were abandoned intraoperatively as all patients with LN metastases
were identified during separate SNP/PLND procedures. Fertility-sparing
surgery in cervical cancer warrants careful risk stratification. Apart
from routine preoperative MR-imaging and physical examination, we feel
that SN assessment prior to VRT contributes in proper patient selection
by detection of (micro) LN metastases. This two-step procedure prevents
not only for undertreatment but also for delay in starting
chemoradiotherapy due to surgical morbidity after VRT or RH.
No recurrences occurred after a median FU of 52 months, which is
favorable when compared with previous literature reporting rates of 2.7
– 7.1% 9, 19, 20. Given that our findings are based
on a limited number of cases, the results are encouraging but should be
interpreted with considerable caution.
Although many uncomplicated live-births have been reported after VRT,
well-known complications include infertility and prematurity. We report
a pregnancy rate of 62.5% and a live-birth rate of 75.0%, which is
comparable to previously reported rates ranging from 41 - 67% and 51 –
73% respectively9, 19, 21. Although 5 of the 12
(41.7%) patients experiencing difficulty conceiving ultimately
conceived through ART, we report a relatively high number of patients
experiencing fertility issues. As most of our patients were nulliparous,
it is difficult to establish whether fertility problems were related to
VRT or due to intrinsic factors. As reported by others, cervical
stenosis is a well-known cause of subfertility after VRT, presenting in
approximately 8.1% of the patients 22, 23. Cervical
stenosis may cause significant morbidity due to dysmenorrhea,
haematometra and difficulties when performing assisted reproduction
technologies. As all patients in our cohort required surgical dilatation
of the cervical ostium due to either haematometra or the inability of
performing ART, we feel that clinicians should make an effort to timely
recognize and treat cervical stenosis to improve fertility outcomes.
The rates for first- (19.0%) and second term miscarriages (4.8%) were
both in line with those reported in previous studies and not higher than
in the general population 9, 21. We report only 1
(5.0%) preterm delivery which is low when compared with the prematurity
rate of 25% as reported in a review concerning 200 pregnancies24. There were no severe obstetric or neonatal
complications in our study cohort. Our data confirm the earlier
described favorable obstetric and neonatal outcomes after VRT in most
patients.