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.