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ObjectiveRadical vaginal trachelectomy is a fertility-preserving treatment for patients with early cervical cancer. Despite encouraging oncologic and fertility outcomes, large studies on radical vaginal trachelectomy are lacking.MethodDemographic, histological, fertility, and follow-up data of consecutive patients who underwent radical vaginal trachelectomy between March 1995 and August 2021 were prospectively recorded and retrospectively analyzed.ResultsA total of 471 patients of median age 33 years (range 21–44) were included. 83% (n=390) were nulliparous women. Indications were International Federation of Gynecology and Oncology (FIGO, 2009) stages IA1 with lymphvascular space involvement (LVSI) in 43 (9%) patients, IA1 multifocal in 8 (2%), IA2 in 92 (20%), IB1 in 321 (68%), and IB2/IIA in 7 (1%) patients, respectively. LVSI was detected in 31% (n=146). Lymph node staging was performed in 151 patients (32%) by the sentinel node technique with a median of 7 (range 2–14) lymph nodes and in 320 (68%) by systematic lymphadenectomy with a median of 19 (range 10–59) lymph nodes harvested. Residual tumor was histologically confirmed in 29% (n=136). In total, 270 patients (62%) were seeking pregnancy of which 196 (73%) succeeded. There were 205 live births with a median fetal weight of 2345 g (range 680–4010 g). Pre-term delivery occurred in 94 pregnancies (46%). After a median follow-up of 159 months (range 2–312), recurrences were detected in 16 patients (3.4%) of which 43% occurred later than 5 years after radical vaginal trachelectomy. Ten patients (2.1%) died of disease (five more than 5 years after radical vaginal trachelectomy). Overall survival, disease-free survival, and cancer-specific survival were 97.5%, 96.2%, and 97.9%, respectively.ConclusionOur study confirms oncologic safety of radical vaginal trachelectomy associated with a high chance for childbearing. High rate of pre-term delivery may be due to cervical volume loss. Our long-term oncologic data can serve as a benchmark for future modifications of fertility-sparing surgery.

OBJECTIVESCervical cancer is one of the most frequently diagnosed cancers in pregnancy. Our aim was to evaluate the safety and efficacy of abdominal radical trachelectomy (ART) for pregnant women with early-stage cervical cancer who strongly desire to preserve their pregnancies. METHODS/MATERIALSA retrospective observational study was performed for stage IB1 cervical cancer patients who underwent ART or radical hysterectomy (RH) at our hospital between February 2013 and June 2017. We compared differences in perioperative findings and oncologic outcomes among ART during pregnancy (ART-DP), ART, and RH groups. RESULTSA total of 38 patients were included in this analysis. Six, 10, and 22 patients were assigned to the ART-DP, ART, and RH groups, respectively. There were no significant differences in the distribution of pathological TNM classifications, histology, tumor size, stromal invasion, and lymph-vascular space invasion among the 3 groups. The patients in the ART-DP group were younger than those in the RH group (P = 0.014). The ART-DP group was associated with more blood loss and prolonged surgery compared with the RH group (P = 0.017 and P = 0.014). The number of total lymph nodes in the ART-DP group was lower than that in the RH group (P = 0.036). However, there were no significant differences in age, surgical time, blood loss, or lymph node count between the ART-DP and ART groups. There were no significant differences in progression-free and overall survival times among the 3 groups, and no recurrence was observed in the ART-DP group. CONCLUSIONSAbdominal radical trachelectomy may be a tolerable treatment option for pregnant women with early-stage cervical cancer who strongly desire a baby.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

We aimed to provide a comparative analysis of the vaginal microbiota in pregnant women who underwent cervical conization (CZ) and radical trachelectomy (RT) for cervical intraepithelial neoplasia or early-stage cervical cancer. We included 114 pregnant Japanese women who underwent CZ group (n = 13), RT group (n = 20), or received no cervical treatments (CON group: n = 81) and cared at Keio University Hospital between 2019 and 2023. The differences in vaginal microbiota during the first, second, and third trimester using V1–V2 region of the 16S ribosomal RNA were investigated. Higher species diversity was observed in the CZ and RT groups than in the CON group; however, the abundance and composition of Lactobacillus were similar. The rate of preterm delivery in women who underwent cervical treatments was significantly higher than that in those who had full-term delivery; however, the species diversity and abundance or composition of Lactobacillus was not associated with preterm birth. Women who underwent CZ or RT had higher microbial species diversity than women who did not undergo a procedure; however, Lactobacillus abundance and composition remained the same. The cause of preterm delivery in women who received cervical treatment was not associated with Lactobacillus species diversity or abundance.

BackgroundRadical trachelectomy is considered a viable option for fertility preservation in patients with low-risk, early-stage cervical cancer. Standard approaches include laparotomy or minimally invasive surgery when performing radical trachelectomy.Primary ObjectiveTo compare disease-free survival between patients with FIGO (2009) stage IA2 or IB1 (≤2cm) cervical cancer who underwent open versus minimally invasive (laparoscopic or robotic) radical trachelectomy.Study HypothesisWe hypothesize that minimally invasive radical trachelectomy has similar oncologic outcomes to those of the open approach.Study DesignThis is a collaborative, multi-institutional, international, retrospective study. Patients who underwent a radical trachelectomy and lymphadenectomy between January 1, 2005 and December 31, 2017 will be included. Institutional review board approval will be required. Each institution will be provided access to a study-specific REDCap (Research Electronic Data Capture) database maintained by MD Anderson Cancer Center and will be responsible for entering patient data.Inclusion CriteriaPatients with squamous, adenocarcinoma, or adenosquamous cervical cancer FIGO (2009) stages IA2 and IB1 (≤2 cm) will be included. Surgery performed by the open approach or minimally invasive approach (laparoscopy or robotics). Tumor size ≤2 cm, by physical examination, ultrasound, MRI, CT, or positron emission tomography (at least one should confirm a tumor size ≤2 cm). Centers must contribute at least 15 cases of radical trachelectomy (open, minimally invasive, or both).Exclusion CriteriaPrior neoadjuvant chemotherapy or radiotherapy to the pelvis for cervical cancer at any time, prior lymphadenectomy, or pelvic retroperitoneal surgery, pregnant patients, aborted trachelectomy (intra-operative conversion to radical hysterectomy), or vaginal approach.Primary EndpointThe primary endpoint is disease-free survival measured as the time from surgery until recurrence or death due to disease. To evaluate the primary objective, we will compare disease-free survival among patients with FIGO (2009) stage IA2 or IB1 (≤2cm) cervical cancer who underwent open versus minimally invasive radical trachelectomy.Sample SizeAn estimated 535 patients will be included; 256 open and 279 minimally invasive radical trachelectomy. Previous studies have shown that recurrence rates in the open group range from 3.8% to 7.6%. Assuming that the 4.5-year disease-free survival rate for patients who underwent open surgery is 95.0%, we have 80% power to detect a 0.44 HR using α level 0.10. This corresponds to an 89.0% disease-free survival rate at 4.5 years in the minimally invasive group.

ObjectiveThere is a trend toward less radical surgery in women with small-volume disease who wish to preserve fertility. The objective of our study was to evaluate the oncologic and obstetrical outcome of simple vaginal trachelectomy and lymph node assessment in patients with low-risk early-stage cervical cancer (<2 cm).MethodsFrom May 2007 to January 2020, 50 patients underwent a simple vaginal trachelectomy/conization with laparoscopic sentinel lymph node mapping±complete pelvic node dissection. Patients underwent loop electrocautery excision (LEEP), cone/cervical biopsies, or simple trachelectomy. A preoperative pelvic MRI with gadolinium contrast was systematically performed in all cases. The size of the lesion was established by review of the LEEP, cone or trachelectomy specimen, MRI, and clinical examination. Data was collected prospectively in a computerized database. Descriptive statistics and the Kaplan–Meier estimate were used for analysis.ResultsThe median age was 29 years (range: 21–44) and 35 (70%) patients were nulliparous. As per FIGO 2009 classification, 11 patients had stage IA1 with lymphovascular space invasion (LVSI), 13 patients had stage IA2, and 26 patients had stage IB1. Twenty-six patients had squamous histology, 20 patients adenocarcinoma, and four patients other histologies. On final pathology, lymph nodes were negative in 46 patients (92%), three patients had isolated tumor cells, and one patient had micrometastasis. Thirty patients (60%) had either no residual disease in the trachelectomy specimen (22) or residual dysplasia only (eight). With a median follow-up of 76 months (range: 1–140), only one local recurrence occurred which was treated initially with chemoradiation. She recurred again locally and underwent a pelvic exenteration: the patient progressed again and died of disease. The 5-year progression-free survival and overall survival was 97.9% and 97.6%, respectively. There were 40 pregnancies: five (12.5%) ended in the first trimester, one (2.5%) in the second trimester, and three (7.5%) were late preterm: all the others (30 or 75%) delivered >36 weeks and one pregnancy is ongoing.ConclusionSimple trachelectomy/conization and lymph node assessment is an oncologically safe fertility-preserving surgery in well-selected patients with low-risk early-stage cervical cancer (<2 cm). Obstetrical outcomes are comparable to the general population.

Background In recent years fertility-sparing treatments are increasingly developing in patients with early stage cervical cancer. 1 , 2 Among these, trachelectomy represents a milestone with a wide range of surgical approaches, 3 evidence of oncological safety, and positive obstetric outcomes. 4 Patients and Methods A 26-year-old patient underwent conization for CIN3 with a subsequent diagnosis of squamous cervical cancer stage FIGO IB1. After a negative laparoscopic bilateral pelvic nodes sampling and the radiologic evidence [positron emission tomography–computed tomography (PET–CT) and magnetic resonance imaging (MRI)] of a disease limited to the cervix, the patient was a candidate for trachelectomy according to her fertility-sparing desire. Results The first laparoscopic time is dedicated to the safe opening of the vesicouterine and rectovaginal spaces until the medial pararectal fossa. Ureters are found and bilateral ureterolysis performed under vision. Colpotomy is then vaginally achieved, and the cervix is closed in a vaginal cuff to avoid tumor spread. Careful dissection of the anterior and posterior septa is carried out until reunification with laparoscopic dissection. Bilateral parametrectomy is performed. Vaginal trachelectomy is finalized with a negative deep margin at the frozen section. In the second laparoscopic time a monofilament polypropylene sling cerclage is bilaterally positioned from posterior to anterior through the broad ligaments and fixed anteriorly on the uterine isthmus to prevent an eventual preterm delivery. Conclusion Laparoscopic-assisted vaginal trachelectomy is a feasible procedure combining the conservative advantages of the vaginal approach and the oncological safety of laparoscopic spaces dissection with possible good obstetric outcomes.

Background Radical tracheletomy (RT) with pelvic lymphadenectomy has become an option for young patients with early invasive uterine cervical cancer who desire to maintain their fertility. However, this operative method entails a high risk for the following pregnancy due to its radicality. Methods We have performed vaginal RT for 71 patients and have experienced 28 pregnancies in 21 patients. They were followed up carefully according to the follow-up methods we reported previously. Their pregnancy courses and prognoses after the pregnancy were retrospectively reviewed. Results All the vaginal RTs were performed safely without serious complications, including 6 patients who underwent the operation during pregnancy. The median time to be pregnant after RT was 29.5 months. 13 patients (46%) became pregnant without artificial insemination by husband or assisted reproductive technology. Cesarean section was performed for all of them. The median time of pregnancy was 34 weeks, and emergent cesarean section was performed for 7 pregnancies (25%). The median birth weight was 2156 g. Four patients had trouble with cervical cerclage, and they suffered from sudden premature preterm rupture of the membrane (pPROM) during the second trimester of pregnancy. We underwent transabdominal cerclage (TAC) for all of them and careful management for the prevention of uterine infection was performed. One patient had a recurrence of cancer during pregnancy. Conclusions Both the obstetrical prognosis and oncological prognosis after vaginal RT have become favorable for pregnant patients after vaginal RT.

ObjectiveThe importance of minimally invasive fertility-sparing surgery for cervical cancer is gaining increasing interest, both to achieve a cure and for future fertility. Procedures for robotic radical trachelectomy involving uterine reconstruction are not fully established.MethodsThis study prospectively verified the feasibility and safety of robotic radical trachelectomy between February 2018 and May 2022. The criteria were almost identical to those for our standard abdominal radical trachelectomy. Larger tumors (> 2 cm in diameter) were acceptable for surgery, provided a secure ≥ 1 cm cancer-free space was identified between the tumor and internal os.ResultsEight patients (median age, 32 y) were registered; the median body mass index was 21.8, and the median tumor size was 11.5 mm (range 0–30 mm). Robotic radical trachelectomy could be achieved in all patients with hybrid sentinel lymph node navigation surgery, confirming the precise cervical amputation line with a newer small knob ultrasonography probe, adequate cervical cerclage with non-absorbable monofilament stitches, and avoiding looseness between vaginal–uterine anastomosis with uninterrupted barbed U-shaped sutures. None of the cases were converted to laparotomy or radical hysterectomy, and there were no major complications. The median follow-up period was 49.5 mo (range 21–58 mo) and no patient had disease recurrence.ConclusionRobotic radical trachelectomy is safe and feasible using newer technologies without reducing radicality; it is also less invasive. Procedures are consistently reproducible and have the potential to be generalized to minimally invasive approaches.

Objective To present reproductive and oncological outcomes of radical trachelectomy (RT) in patients with cervical adenocarcinomas (AC). Methods This retrospective study included 51 patients with cervical AC who underwent RT at Peking Union Medical Hospital from January 1, 2005 to June 1, 2023. Results Five patients (9.8%) experienced cervical stenosis following RT, which likely occurred in cases of abdominal RT (50%) and virginal prophylactic cerclage (33.33%) and those without copper T intrauterine devices during RT (20%). In total, 30 patients (58.82%) attempted to conceive, and 11 (36.67%) succeeded. Five patients (45.45%) achieved pregnancy with fertility assistance. The mean surgery–pregnancy interval was 27 months (range, 17–118). Two preterm and two full‐term births were achieved. With a median follow‐up of 50 months (range, 7–238), seven patients (13.73%) experienced recurrence and three (5.88%) died. Six of seven patients relapsed beyond the residual cervix. The cancer recurrence rate (CRR) was 5.88% for patients with pre‐cervical conization and 17.65% for those with biopsy (p = 0.250); 11.63% had human papillomavirus‐associated (HPVA) disease and 25% had non‐HPVA (NHPVA) (p = 0.313). The cancer death rate (CDR) was 4.65% with HPVA and 12.50% with NHPVA (p = 0.386); 13.63% had the endogenous type and 0 had the exogenous type (p = 0.04). Chemotherapy in patients with risk factors resulted in better CRR and CDR than in those without (5.88% vs. 17.65%, 0% vs. 8.82%). The cumulative 5‐year recurrence‐free survival (RFS) and overall survival rates were 82.03% and 94.39%, respectively. Conclusion RT in patients with AC led to an acceptable pregnancy rate but a higher CRR and lower 5‐year RFS. Careful patient selection for RT, combined with adjuvant chemotherapy when indicated, is crucial to optimize the balance between reproductive and oncological outcomes in AC.