Fertility-preserving surgery
Total Laparoscopic Radical Trachelectomy
Keyhole surgery that removes early cervical cancer while preserving the womb, for carefully selected patients.
A total laparoscopic radical trachelectomy is a specialist fertility-sparing operation for carefully selected women with early-stage cervical cancer who wish to preserve the possibility of becoming pregnant in the future.
The procedure removes the cervix and surrounding tissues affected by, or at risk from, cancer while preserving the main body of the womb (uterus). The operation is performed using keyhole surgery through several small abdominal incisions.
For appropriately selected patients, preserving the womb can provide an alternative to radical hysterectomy, allowing the possibility of a future pregnancy.
However, fertility-sparing surgery is not suitable for every cervical cancer. Careful assessment of the tumour, lymph nodes, imaging, histology and other factors is essential before this approach can be recommended. Current European guidance recommends that fertility-sparing treatment is undertaken in specialist gynaecological oncology centres with comprehensive expertise.
What is a radical trachelectomy?
A trachelectomy is an operation to remove the cervix while leaving the body of the womb in place.
A radical trachelectomy is more extensive. As well as removing the cervix, it removes surrounding tissues called the parametrium and part of the upper vagina.
The aim is to remove the cervical cancer with an adequate margin of healthy tissue while preserving the upper part of the womb.
A permanent stitch called a cerclage is usually placed at the junction between the remaining cervix and womb to provide additional support during a future pregnancy. Current ESGO guidance recommends placement of a permanent cerclage during simple or radical trachelectomy.
What does “total laparoscopic” mean?
The term total laparoscopic means that the abdominal part of the operation is performed entirely through keyhole surgery.
Rather than making a large abdominal incision, the surgeon uses several small incisions to introduce:
- A laparoscope with a camera
- Specialised surgical instruments
- Equipment used to assess and remove lymph nodes where required
The surgeon views the pelvic organs on a high-definition monitor while carrying out the operation.
This approach can avoid the larger abdominal incision associated with traditional open abdominal surgery.
Why might I need a radical trachelectomy?
A radical trachelectomy may be considered when a woman has an early-stage cervical cancer and wishes to preserve her fertility.
For appropriately selected patients, fertility-sparing surgery can provide an alternative to radical hysterectomy.
The decision is highly individual and takes into account:
- The stage of the cancer
- The size of the tumour
- The type of cervical cancer
- The tumour's location
- How deeply the cancer has invaded the cervix
- Whether there is lymphovascular space invasion (LVSI)
- The distance between the tumour and the internal opening of the cervix
- Whether lymph nodes are free from cancer
- The results of MRI or expert ultrasound
- Your desire to preserve fertility
Current guidance considers fertility-sparing treatment an oncologically valid alternative to radical hysterectomy for carefully selected patients, particularly those with tumours smaller than 2 cm.
Who may be suitable?
Suitability is assessed very carefully.
Fertility-sparing surgery is generally considered for selected patients with early cervical cancer where there is a high likelihood that the cancer can be completely removed while preserving the womb.
For some small, early tumours, a less extensive procedure such as a cone biopsy or simple trachelectomy may be sufficient.
A radical trachelectomy may be considered when a more extensive removal of the cervix and surrounding tissue is required.
Current ESGO guidance describes radical trachelectomy as an option for selected T1b1 disease and recommends it for certain patients with T1b1 tumours and lymphovascular space invasion.
The exact criteria depend on the individual cancer and should be discussed by a specialist gynaecological oncology team.
Why is tumour size important?
Tumour size is one of the important factors when considering fertility-sparing treatment.
For appropriately selected patients with cervical cancer measuring less than 2 cm, fertility-sparing treatment can be an oncologically valid option.
For tumours larger than 2 cm, fertility-sparing treatment is more complex and is associated with a higher risk of recurrence. It is therefore not considered standard treatment for these patients, although selected cases may be discussed within specialist centres.
This is why detailed imaging and specialist assessment are so important before deciding whether radical trachelectomy is appropriate.
Why are lymph nodes assessed?
Checking the lymph nodes is a crucial part of assessing whether fertility-sparing surgery is safe.
If cervical cancer has spread to the pelvic lymph nodes, fertility-sparing surgery would generally no longer be appropriate because the cancer requires a different treatment strategy.
For this reason, lymph node staging is an important part of fertility-sparing treatment.
Current ESGO guidance recommends pelvic lymph node staging, with sentinel lymph node assessment playing an important role in appropriately selected patients.
If cancer is found in the lymph nodes during surgery, the planned fertility-sparing procedure may need to be abandoned and another treatment approach recommended.
What is sentinel lymph node surgery?
A sentinel lymph node biopsy identifies the first lymph nodes to which cancer cells are most likely to travel from the cervix.
A tracer, often including indocyanine green, is used to identify these lymph nodes.
The sentinel nodes are removed and examined by a specialist pathologist.
If the sentinel lymph nodes are clear of cancer, this can provide important information about the likelihood that the cancer has spread to other pelvic lymph nodes.
If a suspicious lymph node is identified, it may also be removed.
For fertility-sparing cervical cancer surgery, ESGO recommends lymph node staging as the first step and highly recommends sentinel lymph node identification and ultrastaging where appropriate.
What happens before surgery?
Before deciding on a radical trachelectomy, you will undergo detailed assessment to determine whether fertility-sparing surgery is safe and appropriate.
This may include:
- Colposcopy
- Cervical biopsy or cone biopsy
- MRI of the pelvis
- Expert transvaginal ultrasound
- CT or PET-CT in selected circumstances
- Assessment of the pelvic lymph nodes
- Blood tests
- General health assessment
- Discussion with a specialist multidisciplinary team
MRI or expert ultrasound is particularly important because your specialist needs to understand the size and exact position of the tumour, its depth of invasion and the amount of healthy cervix that can be preserved.
Why is multidisciplinary assessment important?
Fertility-sparing treatment requires careful consideration of both cancer control and future pregnancy.
Your case should be discussed by specialists in gynaecological oncology and, where appropriate, fertility and reproductive medicine.
The team will consider whether preserving the womb is oncologically safe and whether another treatment would provide better cancer control.
Current international guidance recommends multidisciplinary planning and specialist-centre management for fertility-sparing cervical cancer treatment.
What happens during a total laparoscopic radical trachelectomy?
The procedure is performed under a general anaesthetic.
Several small incisions are made in the abdomen.
The abdomen is gently inflated with carbon dioxide gas to create space for the operation.
A laparoscope provides a magnified view of the pelvis while specialised instruments are used through the other small incisions.
The surgeon carefully identifies and protects important structures, including the bladder, bowel, ureters, blood vessels and nerves.
The pelvic lymph nodes are assessed or removed as required.
The cervix and surrounding tissues are then carefully removed, together with the upper part of the vagina and the parametrial tissue required for radical surgery.
The main body of the womb is preserved.
A permanent cerclage is placed to support the remaining cervical opening and help reduce the risk of cervical insufficiency during a future pregnancy.
What happens to the remaining womb?
The body of the womb remains in place.
This is what makes pregnancy potentially possible following a trachelectomy.
The remaining uterine cavity continues to be available for implantation of an embryo.
However, fertility following trachelectomy cannot be guaranteed. There can be several factors affecting fertility, including the original cancer, the surgery itself and changes to the cervical anatomy.
Can I become pregnant after radical trachelectomy?
One of the main reasons women choose fertility-sparing surgery is to preserve the possibility of future pregnancy.
Pregnancy is possible following a successful radical trachelectomy, but it is important to understand that this is not guaranteed.
Some women may conceive naturally, while others may require assistance from fertility specialists.
Your fertility team can discuss your individual circumstances and whether any additional fertility treatment may be appropriate.
Is pregnancy after trachelectomy considered high risk?
Yes.
Pregnancy following fertility-sparing cervical cancer surgery is considered a high-risk pregnancy because the cervix has been substantially shortened or removed.
There is an increased risk of complications including:
- Miscarriage
- Premature rupture of the membranes
- Preterm birth
- Infection
- Cervical insufficiency
Pregnancy should therefore be managed with appropriate specialist obstetric care.
Current ESGO guidance recommends that pregnancies following fertility-sparing treatment are considered high risk. It also states that following simple or radical trachelectomy with a permanent cerclage, delivery should be by caesarean section.
Will I need a caesarean section?
Following a radical trachelectomy with a permanent cerclage, delivery is generally by caesarean section.
The permanent cerclage remains in place and provides support where the cervix would normally be.
Your obstetric team will monitor your pregnancy carefully and advise you about the safest timing and method of delivery.
What are the benefits of a laparoscopic approach?
For appropriately selected patients, laparoscopic surgery can provide the advantages associated with minimally invasive surgery.
These can include:
- Smaller abdominal incisions
- Less visible abdominal scarring
- Less abdominal wall trauma
- Reduced postoperative discomfort for some patients
- Earlier mobilisation
- Shorter hospital stay in many patients
- Potentially faster recovery than an equivalent open operation
However, the most important consideration is safe and effective cancer treatment.
The fact that an operation can be performed through keyhole surgery does not automatically mean that it is the best approach for every patient.
Is laparoscopic radical trachelectomy suitable for everyone?
No.
The approach must be considered very carefully.
For cervical cancer, the choice of surgical approach depends on factors including tumour size, stage, lymph-node status and the expertise of the specialist centre.
Current European guidance has become more cautious about minimally invasive surgery for cervical cancer because of concerns about oncological outcomes with minimally invasive radical surgery in certain settings. For appropriately selected low-risk tumours, minimally invasive approaches may be considered in highly experienced centres following detailed discussion with the patient.
This means that the decision to perform a total laparoscopic radical trachelectomy should be made by an experienced gynaecological oncology team rather than simply on the basis of the availability of keyhole surgery.
What are the risks of radical trachelectomy?
As with any major operation, radical trachelectomy carries risks.
These can include:
- Bleeding
- Infection
- Blood clots
- Anaesthetic complications
- Injury to the bladder
- Injury to the bowel
- Injury to the ureters
- Injury to blood vessels
- Urinary problems
- Formation of adhesions
- Lymphatic complications
- Lymphoedema
- Need for additional surgery
- Conversion to open surgery
There are also specific risks associated with preserving fertility.
These include:
- Difficulty becoming pregnant
- Miscarriage
- Preterm birth
- Premature rupture of membranes
- Pregnancy complications
- The possibility that fertility-sparing surgery may ultimately need to be abandoned if cancer is found in the lymph nodes or adequate margins cannot be achieved
These risks should be discussed fully before surgery.
What if cancer is found in the lymph nodes?
If cancer is identified in the pelvic lymph nodes during surgery, fertility-sparing treatment may no longer be considered safe.
The planned trachelectomy may therefore be abandoned, and your treatment plan changed.
Depending on the findings, you may be advised to have chemoradiotherapy or another form of cancer treatment.
This possibility is discussed before surgery so that you understand why the operation may need to change.
Current ESGO guidance specifically recommends abandoning fertility-sparing surgery when pelvic lymph node involvement is confirmed during surgery and referring the patient for appropriate chemoradiotherapy.
What if the cancer cannot be completely removed?
The aim of radical trachelectomy is to remove the cancer with clear margins while preserving the womb.
If the surgeon discovers that this cannot safely be achieved, a different surgical approach may be necessary.
This may include conversion to a more extensive operation, including hysterectomy, depending on the circumstances.
The priority is always complete and safe cancer treatment.
Preserving fertility can only be considered when it does not compromise the chance of curing the cancer.
What happens after surgery?
Following the operation, you will be monitored while you recover from the anaesthetic and surgery.
You may temporarily have:
- A urinary catheter
- Surgical drains
- Pain relief
- Medication to reduce the risk of blood clots
You will normally be encouraged to get up and move around as soon as it is safe.
Your hospital stay and recovery will depend on the complexity of the surgery and your individual recovery.
What is recovery like?
It is normal to feel tired following surgery.
You may experience:
- Abdominal discomfort
- Bloating
- Bruising around the small incisions
- Temporary changes in bowel or bladder function
- Vaginal discharge or light bleeding
- Tiredness
You should gradually return to normal activities rather than trying to do too much too quickly.
Your surgical team will advise you about driving, work, exercise and sexual activity.
Because this is specialist cancer surgery, your recovery plan will be individualised.
What happens to the tissue removed?
The cervix, surrounding tissues and any lymph nodes removed during the operation are sent to a specialist pathology laboratory.
The pathologist examines the specimens carefully to determine:
- The type of cervical cancer
- The size of the tumour
- How deeply it has invaded
- Whether the surgical margins are clear
- Whether lymph nodes contain cancer cells
- Other features that may influence your prognosis and further treatment
These results are essential in confirming whether the cancer has been completely removed and whether additional treatment is required.
Will I need further treatment?
Not necessarily.
If the cancer has been completely removed, the lymph nodes are clear and there are no features requiring additional treatment, surgery may be all that is needed.
If cancer is found at a surgical margin, in lymph nodes or other concerning features are identified, additional treatment may be recommended.
Your results will be discussed by your specialist multidisciplinary team.
What about follow-up after surgery?
Close follow-up is particularly important following fertility-sparing treatment.
Your follow-up may include:
- Clinical examinations
- Cervical or vaginal assessment where appropriate
- Imaging when clinically indicated
- Monitoring for recurrence
- Discussion of fertility and pregnancy planning
Your specialist will provide an individual follow-up programme based on your cancer and treatment.
Will I still have periods?
Because the body of the womb and ovaries are generally preserved, menstrual periods can continue after radical trachelectomy.
However, your periods may change following surgery.
Your individual experience will depend on the exact procedure and any additional treatment you receive.
Will my ovaries be preserved?
Usually, the ovaries can be preserved during fertility-sparing cervical cancer surgery when there is no medical reason to remove them.
Preserving the ovaries allows them to continue producing reproductive hormones.
In some circumstances, additional fertility preservation strategies may be discussed, particularly if other cancer treatment is required.
Why specialist experience matters
Radical trachelectomy is a highly specialised procedure.
It requires expertise in:
- Gynaecological oncology
- Fertility-sparing cancer surgery
- Complex pelvic anatomy
- Laparoscopic surgery
- Lymph node assessment
- Cervical cancer staging
- Management of the potential obstetric consequences of treatment
Current ESGO guidance recommends that fertility-sparing surgery is performed exclusively in gynaecological oncology centres with comprehensive expertise in these procedures.
Mr Jafaru Abu has a specialist interest in gynaecological oncology and minimally invasive surgery, including fertility-sparing procedures.
His approach combines careful cancer assessment with consideration of your future fertility goals, where fertility preservation is medically appropriate.
A treatment plan built around you
Being diagnosed with cervical cancer can be particularly difficult when you are hoping to have children in the future.
A radical trachelectomy may offer selected women the possibility of treating early cervical cancer while preserving the womb.
However, fertility preservation can only be considered when it is oncologically safe.
Your specialist team will carefully assess your cancer and discuss the potential benefits, limitations and risks of each option with you.
You should have the time and information you need to make a decision that is right for you.
Book a specialist consultation
If you have been diagnosed with early cervical cancer and would like to know whether fertility-sparing surgery could be an option, a specialist consultation can provide a detailed assessment of your diagnosis and treatment choices.
At Gynae Solution, Mr Abu can discuss whether a total laparoscopic radical trachelectomy or another fertility-sparing approach may be appropriate, including the potential impact on future fertility, pregnancy and cancer treatment.
The priority is always to provide effective cancer treatment while preserving fertility wherever this can be achieved safely.
Patient leaflets
Written for patients, relatives and hospital personnel, to read before your operation and to keep afterwards.
Common questions
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