Total laparoscopic radical trachelectomy

What is a radical trachelectomy?

Radical trachelectomy is the surgical removal of the neck of the womb (cervix), some of its surrounding tissue, top of the vagina and the lymph glands from the pelvis.

It is a surgical technique that is carried out on women who wish to preserve their fertility following the diagnosis of early stage cervical cancer. The conventional treatment for early stage cancer of the cervix is a radical hysterectomy, where the cervix (neck of womb), uterus (womb), top of the vagina and the tissues around the cervix and pelvic lymph glands (nodes) are removed.

However, radical trachelectomy aims to preserve fertility for women with early stage cancer of the cervix and can be performed using one of the following three methods:

Radical abdominal trachelectomy (RAT)

This is an ‘open’ operation where a lower transverse or midline incision (cut) is made on 2 your tummy. The procedure involves the surgical removal of the cervix (neck of the womb), a small part of the vagina, the tissue surrounding the cervix (parametrium) and the pelvic lymph nodes (lymph glands in this area). This procedure can be offered to women who have early stage cancers of the cervix. The abdominal operation is similar to an ‘open’ radical hysterectomy, except that with a radical abdominal trachelectomy the uterus (womb) is preserved.

Radical vaginal trachelectomy (RVT)

This operation is done both laparoscopically (where three or four small incisions are made in the tummy) and through the vagina. It involves removing the whole of the cervix and a small part of the vagina, the pelvic lymph nodes (lymph glands in this area) and the tissue around the cervix. The vaginal component of the operation is usually cumbersome especially in women who have never had a vaginal delivery, as the vaginal is usually very tight.

Total laparoscopic radical trachelectomy (TLRT)

The entire operation is usually performed laparoscopically (key-hole) via 4 tiny cuts on your tummy. This allows removal of the cervix, surrounding tissue, top of the vagina and the lymph glands. The advantages of the key hole approach are: quicker recovery, less scarring, reduced pain, reduced amount of blood loss during surgery and quicker return to work. The keyhole approach also allows for better visualization of all the tissues to be removed because of increased magnification of the tissues on a high definition camera system.

All of the above methods of radical trachelectomy are done while you are asleep under a general anaesthetic

What is the aim of the treatment?

The aim of radical trachelectomy is to ensure complete removal of the cancer and to be sure that only normal tissue remains. However, the operation may be converted to a radical hysterectomy or abandoned in favour of chemotherapy/radiotherapy if during the operation we suspect that the cancer has spread. During the operation a sample of the lymph nodes and the cervix may be examined to detect whether the cancer has spread. If cancer cells are found, the operation may be converted to a radical hysterectomy or abandoned. All the tissue and lymph nodes removed during the operation are examined in the laboratory in the two to three weeks following surgery. After the operation, your hospital doctor will discuss with you these results to decide if you need either further surgery to remove the womb or radiotherapy treatment to destroy the remaining cancer cells.

Who is suitable for radical trachelectomy?

Not everyone will be suitable for this operation. A careful assessment will be carried out, as the cancer must be diagnosed at an early stage where it is confined to the cervix. The type of radical trachelectomy you are offered will usually depend on the experience of your surgeon on one or more of the above operative procedures. Please note we are unable to guarantee that your fertility will be preserved after this operation. If you do get pregnant after the operation, there is also a possibility of miscarriage. Usually during the operation, your surgeon will insert a large permanent suture (stitch) around the opening of the uterus, strong enough to reduce the risk of a miscarriage.

What happens before your operation?

MRI scan (special scan to locate the position and the size of the cancer as well as exclude the possibility of cancer spread). Review of all of your results, including the scans, findings of your examinations and any biopsies (tissue samples) taken.

Are there any risks associated with radical trachelectomy?

As with any operation, there are risks. Infections (usually minor wound or urine infection), bladder complications, including difficulty emptying the bladder, injury to the ureter, injury to the bowels, injury to nerves, deep vein thrombosis (DVT), pulmonary embolism, lymphoedema (swelling of the legs), haemorrhage (internal bleeding), which may require a second operation to control the bleeding, haematoma (bruising under the skin). Needing to convert the operation to a laparotomy, which is an ‘open’ operation where a larger cut is made across the lower abdomen (tummy). Please note that after a radical trachelectomy, the bladder and bowels may take a few days to start working properly again. In rare cases, a hole may develop in the bladder or ureter, which may result in urine leaking into the vagina. The hole may close on its own without surgery, but if it does not, a second operation may be needed to repair it.

We take many steps to keep the risks to a minimum. For example:

• We give you antibiotics to prevent infection and the procedure is carried out in sterile conditions
• We ask you to wear special support stockings and to take medication to thin the blood, as this helps to prevent the formation of blood clots
• Your anaesthetist will see you before the operation to check that you are fit for the anaesthetic.

Are there any long term effects with this procedure?

You may develop lymphoedema (swelling of the legs). This can vary in severity and is permanent, but can be managed. You may also experience numbness on the anterior aspect of your thighs. This is because the nerves that supply this part of your body can be damaged during removal of the lymph glands. This may eventually get better or could persist for several weeks or even months. It should however not disturb your mobility and you will eventually get used to it. If you become pregnant, you will need to be referred as soon as possible to a hospital with obstetric and neonatal facilities. The obstetrician will then contact the consultant who carried out your radical trachelectomy operation for details of your medical history and of the special care you will need for the safe delivery of your baby. When you are about 38 weeks pregnant, you will need to have an elective (planned) caesarean section to deliver your baby safely. This is because it will not be safe for you to have a vaginal birth, as you will no longer have a cervix. Also, delivering your baby vaginally may disturb the stitch at the base of your uterus (inserted during your trachelectomy to help prevent miscarriage).

Are there any alternatives to this procedure?

Radical hysterectomy is the standard procedure for cervical cancer but involves removal of the uterus (womb). Chemotherapy/radiotherapy is offered for larger tumours (cancers) and where there is evidence that lymph nodes are strongly suspected of or known to contain cancerous cells.