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Fertility-sparing surgery for cervical cancer


Medical editor Gunnar B. Kristensen MD
Gynecological Oncologist
Oslo University Hospital

General

Ten to fifteen percent of cervical cancer cases are diagnosed in fertile women. Loss of fertility is considered a serious problem for younger women treated for cervical cancer. For patients with cervical cancer in stage Ia and Ib less than 2 cm , it is now possible to offer surgery that will spare the cervix to allow for future pregnancy. The risk for recurrence is the same as for radical surgery. The number of such operations is low. To maintain expertise, it is important this surgery is centralized to a regional hospital.  

Operative techniques

  • Patients with tumors in stage Ia1 can be treated with cervical conization.  
  • For stage Ia2, the cone must be large enough that a distance of at least 5 mm is achieved from the tumor to the resection border.
  • For stage Ib tumor less than 2 cm, a radical trachelectomy can be performed. 
  • After trachelectomy, a cerclage is placed, which is a non-absorbable suture, around the uterine isthmus (transition between the uterus and cervix). The cerclage is located hidden under the mucosa. We therefore recommend that later births are by cesarean section. Since the cervix is shortened considerably after a trachelectomy, there is a risk for premature birth at later pregnancy. About 10% of these births occur in week 28-32. About 15% deliver in week 33-36 and about 75% deliver > 36 weeks (18).
  • For stage 1a2 and 1b, in addition a pelvic lymph node dissection is performed.

Indications

  • Cervical cancer Ia1
  • Cervical cancer Ia2
  • Cervical cancer Ib1

Goal

  • Preserve fertility after surgery for early cervical cancer.

Preparation

  • Bowel emptying (enema)
  • Thrombosis prophylaxis
  • Antibiotic prophylaxis

Implementation

  • The patient lies in the lithotomy position.
  • The leg holders should be well padded. 
  • Insert a self-retaining speculum.
  • Pinch the vaginal mucosa where the resection border will be.
  • Inject 20 ml of xylocain 0.5% with adrenaline into the cervix. This will make the layers easier to separate and the adrenaline will reduce bleeding.
  • Incise the vaginal mucosa around the entire cervix.
  • Dissect the mucosa and invert it over the cervix. Forceps are placed on the edges of the mucosa to keep the cervix covered. If the vaginal cuff is small, forceps can be placed directly on the cervix for maneuvering.  
  • The space between the bladder and the cervix is opened.
  • The bladder is liften up with an anterior speculum.
  • Open up to the paravesical space.
  • The ureter is dissected on both sides.
  • Open up to the Douglas pouch by an incision at the posterior side of the cervix.
  • The cardinal ligaments can now be separated for an adequate distance from the cervix. 
  • The cardinal ligaments are divided at an adequate distance from the cervix after placement of forceps.
  • Suture and ligate.
  • Repeat the procedure on the other side of the cervix.
  • The cervix may now be amputated with diathermy.
  • Place a cerclage around the uterine isthmus . Place this medial to the vessels.
  • Place a Hegar 5 in the cervical canal while the cerclage is tied to ensure the cervix is not closed completely. It is usual to place the knot on the anterior side of the cervix.
  • Suture the vaginal mucosa to the edge of the cervix. The cerclage is thereby layered submucosally.
  • Insert a Foley catheter.

Follow-up

  • The Foley catheter is removed the day after the surgery.
  • Light bleeding for 1–2 weeks after the surgery may occur. 
  • The patient should not have sexual intercourse during the first 3 weeks after the surgery.

Further follow-up

  • Every 3 months for the first 2 years.
  • Thereafter every 6 months.
  • After 5 years, once yearly.

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