Radical vaginal trachelectomy

Marie Plante Michel Roy

Introduction

Radical vaginal trachelectomy (RVT) is a new conservative surgical procedure for the treatment of selected cases of early-stage cervical cancer. It has the advantage of preserving the uterine body, which in turns allows the preservation of childbearing potential. This procedure has been described by Professor Daniel Dargent from Lyon, France. Among the group of more than a hundred women who have undergone this operation, more than 20 healthy babies have been born so far, the majority by elective cesarean section at term.

Indications

The indications for RVT are not definitely established at this point. The eligibility criteria currently used by the authors are as follows:

1. Desire to preserve fertility

2. No clinical evidence of impaired fertility

3. Lesion size less than 2.0 cm

4. FIGO stage IA2-IB1

5. Squamous cell carcinoma or adenocarcinoma

6. No involvement of the upper endocervical canal as determined by colposcopy

7. No metastasis to regional lymph nodes.

As data accumulate, these criteria may change in the future.

Anatomical considerations

Vascular supply

The blood supply to the cervix is assured by the cervical (or descending) branch, of the uterine artery, and by the vaginal artery which originates from the hypogastric, the uterine or the superior vesical artery. At the level of the upper endocervix, these two arteries form a network of anastomoses and a rich vascular plexus. At the isthmus, the uterine artery also forms a loop, often referred to as the cross of the uterine artery. This

Uterine Artery

Figure 1

Cervical vascular supply is an important landmark because all efforts should be made to preserve the uterine artery in order to assure a good vascular supply to the uterine body, particularly in the event of a pregnancy. The venous supply follows the arterial one (Figure 1).

Uterovaginal endopelvic fascia

The endopelvic fascia consists of the reflections of the superior fascia of the pelvic diaphragm upon the pelvic viscera. This thin layer thus encases the urethra and bladder (urethrovesical fascia), the vagina and lower uterus (uterovaginal fascia) and the rectum (rectal fascia). The uterovaginal endopelvic fascia is of particular importance as it lies in close proximity to the pelvic peritoneum. The fascial plane is an avascular space that should be defined when mobilizing the bladder base at the time of RVT, but the anterior pelvic peritoneum itself should not be entered (Figure 2).

Cardinal (Mackenrodt) ligament

The cardinal ligament is composed of condensed fibrous tissue and some smooth muscle fibers. It extends from the lateral aspect of the uterine isthmus toward the pelvic wall. This fibrous sheath contains the ureter, the uterine vessels and associated nerves, the lymphatic channels and lymph nodes draining the cervix and some fatty tissue. It is commonly referred to as the parametrium. The cardinal ligament is in continuity anteriorly with the uterovaginal endopelvic fascia, and posteriorly its fibers are integrated with the uterosacral ligament. Since RVT is performed in patients with small lesions, only the medial part (i.e. approximately 2 cm) of the cardinal ligaments is usually taken (Figure 3).

Mackenrodt Ligament
3 J 2 t

Figure 2

1 Rectal fascia

2 Uterovaginal fascia

3 Pelvic peritoneum

4 Urethrovesical fascia

Uterosacral ligaments

The uterosacral ligaments are true ligaments of musculofascial consistency which run from the upper part of cervix to the sides of the sacrum. They contribute to the uterine support together with the cardinal ligaments. Only the proximal parts of the uterosacral ligaments are taken at the time of RVT to leave adequate uterine support.

Operative procedure

Anatomical relationship

It is of paramount importance to understand the relationship between the ureter, the uterine artery and the cardinal ligament (parametrium), and to picture the relationship between the bladder base and the lower uterine segment when performing radical vaginal surgery. When a radical hysterectomy is done abdominally, the uterus is pulled upwards bringing with it the parametrium and the uterine vessels, while the bladder base is mobilized downwards. Therefore, the uterine vessels lie above the concavity of the ureters as the ureters run into the parametrial tunnel to enter the bladder base; after mobilization, the ureters end up lateral to and below the parametrium (Figure 4A). When the radical hysterectomy is done vaginally, the relationship between the structures is completely the opposite. The uterus is pulled downwards and the bladder base along with the ureter is mobilized upwards. As a result, the uterine vessels end up below the concavity or the 'knee' of the ureter, and after mobilization the ureter courses above the parametrium (Figure 4B) (see also Chapter 8).

Viginal Cuff

Figure 3

1 Cardinal ligament

2 Uterine artery

3 Ureter

Vaginal cuff preparation

A rim of vaginal mucosa is delineated circumferentially clockwise using 8-10 straight Kocher clamps (Lawton, Montreal, Canada) placed at regular intervals. For small lesions, 1-2 cm of vaginal mucosa is sufficient. To reduce bleeding from the edges of the vaginal mucosa, 20-30 ml of lidocaine 1% solution mixed with adrenaline (epinephrine) 1:100000 is used to inject the vaginal mucosa between each Kocher clamp. A circumferential incision is then made with a scalpel just above the Kocher clamps (Figure 5). Finally, the edges of the vaginal mucosa are grasped with 5 or 6 Chrobak clamps (Groupe Lepine, Lyon, France) in order to cover the exocervix completely and allow a good traction on the specimen (Figure 6).

Identification of the vesicouterine space

The vesicouterine space is opened by directing Metzenbaum scissors (Lawton, Montreal, Canada) perpendicular to the cervix. Care is taken not to enter the peritoneum as in a simple vaginal hysterectomy. The space should be avascular, allowing the surgeon easily to palpate the anterior surface of- the endocervix and isthmus and see the whitish body of the uterus. When the space is stretched with a narrow retractor, the anterior bladder pillars lie on each side of the space as vertical strands of tissue (Figure 7).

Opening the paravesical space

The opening of the paravesical space is described here for the patient's left side. The Chrobak clamps are pulled towards the patient's right side. Straight Kocher clamps are placed onto the vaginal mucosa at the 1

Hysterectomy After

Figure 4

Comparison of (A) abdominal and (B) vaginal approaches to radical hysterectomy (after Dr Hélène Roy). The arrows indicate the direction of traction; the dotted line indicates the level of excision of the parametrium

1 Uterine artery

2 Ureter

3 Parametrium

4 Uterus

5 Bladder o'clock and 3 o'clock positions and stretched out. An areolar plane is seen just medial and slightly anterior to the 3 o'clock clamp. The paravesical space is blindly entered using Metzenbaum scissors, with the tips pointing upwards and outwards. The space is widened by rotating the scissors under the pubic bone in a semicircular rotating motion to the patient's right side (Figure 8).

Identification and mobilization of the ureter

A small retractor is placed in the left paravesical space and rotated under the symphysis pubis, pulling the bladder pillars and the bladder medially. The 'knee' of the ureter is seen on the lateral aspect of the bladder pillars, which act as pseudoligaments (Figure 9). With the Chrobak clamps held between the palms of both hands, the surgeon's right index finger is placed in the left paravesical space and the left index finger in the

Viginal Cuff

Figure 5

Vaginal cuff preparation: incision (after Dr Hélène Roy)

1 Straight Kocher clamps

2 Vaginal mucosa

3 Cervix vesicouterine space. The surgeon's fingers are then pulled down gently until the 'click' is heard and the ureter is felt rolling under the fingers. To avoid damage, the ureter must be seen and palpated unequivocally (Figure 10). With Metzenbaum scissors, the ureter is freed laterally from its posterior attachment to allow its mobilization upwards. Medial dissection of the ureter should be avoided because of the risk of injury to the bladder base.

Section of the bladder pillars

Once the ureter has been safely mobilized upwards, the bladder pillars can be excised midway between the bladder base and the anterior aspect of the specimen. This maneuver allows the bladder base to be mobilized upwards as well (Figure 11).

Section of the cardinal ligament (proximal parametrium)

After opening the posterior cul-de-sac, the proximal aspect of the uterosacral ligament is excised. After careful identification of the ureter and the cross of the uterine artery, two curved Heaney clamps (Lawton, Montreal, Canada) are used to secure the cardinal ligament or proximal parametrium. The first Heaney clamp is placed medially and with gentle traction the second is placed more distally to obtain wider parametrium, with the ureter safely mobilized upwards (Figure 12). The cervicovaginal branch of the uterine artery is then

Vaginal Radical Trachlectomy

Figure 6

Vaginal cuff preparation: placing the clamps (after Dr Hélène Roy)

1 Anterior and posterior vaginal mucosa covering cervix

2 Chrobak clamps identified at the level of the isthmus, clamped, incised and ligated. Care should be taken to identify and preserve the cross of the uterine artery (Figure 13).

Excision of the specimen

The preceding steps are then repeated on the patient's right side. The cervix is amputated, using a scalpel held perpendicularly to the specimen at about 1 cm from the isthmus (Figure 14). This is followed by endocervical curettage of the residual endocervical canal. The trachelectomy specimen is sent for immediate frozen section examination to assess the level of the tumor in relation to the endocervical resection margin. At least 8-10 mm of free endocervical canal should be obtained, otherwise additional endocervical tissue should be removed, or the trachelectomy should be aborted and a radical vaginal hysterectomy (Schauta procedure) completed instead (see Chapter 8).

Prophylactic cervical cerclage and closure of the vaginal mucosa

The posterior cul-de-sac is first closed with a pursestring suture of chromic 2-0 suture. A permanent cerclage is then placed using a nonresorbable polypropylene 0 suture, starting at the 6 o'clock position to

Figure 7

Opening the vesicouterine space (after Dr Hélène Roy)

1 Exocervix

2 Uterine isthmus have the knot lying posteriorly. Sutures are placed at the level of the internal os and not too deeply within the cervical stroma. When the knot is being tied a uterine probe can be left in the cervical os to avoid overtightening of the knot, which could cause cervical stenosis (Figure 15). The edges of the vaginal mucosa are sutured to the residual ectocervical stroma (and not to the endocervical tissue) with interrupted figure-of-eight stitches. Sometimes, excess vaginal mucosa has to be excised to facilitate the closure. Sutures should not be placed too close to the new cervical os to avoid burying the cervix, making follow-up examinations more difficult (Figure 16).

Trachelectomy specimen

Ideally, the cervical specimen should be at least 1 cm long, with 1 cm of vaginal mucosa and 1-2 cm of parametrium. Figure 17A shows a cervix with a small exophytic lesion; Figure 17B shows a lateral view of the trachelectomy specimen demonstrating the endocervical cut margin, proximal parametria (stretched by the Debaky instruments) and vaginal cuff (suture) covering the cervical lesion; Figure 17C shows the appearance of the cervix after suturing of the vaginal mucosa to the residual exocervix.

Cervical appearance after trachelectomy

With time, the new cervix gradually resumes an almost normal appearance except for its shorter length. It therefore remains accessible for monitoring with colposcopic examination, cytology and curettage.

Colposcopy Instruments

Figure 8

Opening the paravesical space (after Dr Hélène Roy)

1 Paravesical space

2 Ureter

3 Bladder pillars

4 Vesicouterine space

Figure 18A shows the appearance of the cervix 6 months after trachelectomy; Figure 18B shows it in the first trimester in a patient who became pregnant after the procedure.

Saling procedure

Second trimester abortion and prematurity can be a major problem after RVT (Roy and Plante 1999). The inevitable shortening of the cervix after this procedure seems to prevent the formation of an efficacious mucus plug: the mucus plug is thought to be a physiological barrier between the vaginal flora and the membranes to prevent ascending infections. In order to avoid chorioamnionitis, which is most likely responsible for premature rupture of membranes and premature labor following RVT, Dargent (1999) has proposed a complete cervical closure of the cervix during pregnancy, a technique described by Saling in 1981 for patients with habitual abortions.

The Saling technique of cervical closure is simple. The procedure is ideally performed at around 14 weeks of pregnancy under general anesthesia. The vaginal tissue just around the external os is superficially injected with a saline solution in order to separate the mucosa from the underlying mucosal layers. A 1.5 cm-wide area of cervicovaginal mucosa is then removed 360° around the external os. The defect is closed with a monofilament resorbable suture in two layers: the deep layer includes the cervical stroma, taking care not to go too deep in order to avoid rupturing the membranes; and the second layer includes the vaginal

Virginal Layer Ovary

Figure 9

The 'knee' of the ureter is exposed on the lateral aspect of the bladder pillars (after Dr Hélène Roy)

1 Bladder pillars

2 Paravesical space

3 Knee of ureter

4 Vesicouterine space mucosa. Restoration of the permeability of the cervix is accomplished at the time of the planned caesarean section (at approximately 38 weeks) by digital perforation of this reversible vaginal closure. Only one of the six patients operated on by Dargent with this technique had premature labor, compared to 6 of 21 before the routine use of the Saling procedure (personal communication). Thus this technique warrants further evaluation, since it appears promising to prevent premature labor and delivery in patients with shortened cervices following RVT.

Results

The authors retrospectively reviewed their first 30 patients treated by laparoscopic pelvic lymphadenectomy followed by RVT. The median age of the patients was 32 years (range 22-42 years); 15 were nulligravid and 19 nulliparous. Twenty cancers were at stage IB, 1 was at stage IA1, 7 were at stage IA2, and 2 were at stage IIA. The majority of cases (18) were squamous: 2 lesions were >2 cm in size and only 4 had vascular space invasion. The median operative time was 285 minutes (range 155-455 minutes), median blood loss 200 mL (range 50-1200 mL), and median hospital stay 4 days (range 2-9 days). There were 4 intraoperative complications—2 attributed to the RVT and 2 resulting from the lymphadenectomy.

The median follow-up time at review was 25 months (range 1-79 months). One patient had a recurrence in the left parametrium 18 months after RVT and died of metastatic disease. The only six patients attempting pregnancy have succeeded.

Palpating Pubic Symphysis

Figure 10

To avoid damage to the ureter, it must be clearly seen and palpated (after Dr Hélène Roy)

1 Right index in paravesical space

2 Ureter

3 Left index in vesicouterine space

In conclusion, RVT appears to be a valuable procedure in well-selected patients with early-stage cervical cancer. Successful pregnancies are definitely possible after this procedure. This new surgical technique warrants further careful evaluation to determine precise indications.

Bibliography

Dargent D (1999) The story of Mme M (videocassette). In: Proceedings of the 30th Annual Meeting of the Society of Gynecologic Oncologists. San Francisco.

Dargent D, Brun J-L, Roy M, Mathevet P, Remy I (1994) La trachélectomie élargie (TE). Une alternative à l'hystérectomie radicale dans le traitement des cancers infiltrants développés sur la face externe du col utérin. J Obstet Gynecol 2:285-92.

Plante M, Roy M (1997) Radical trachelectomy surgical technique. In: Gershenson D, editor. Operative techniques in gynecologic surgery. Philadelphia: WB Saunders; vol. 2, pp. 187-99.

Roy M, Plante M (1999) (Reply to a letter to the Editor). Am J Obstet Gynecol 181:230.

Roy M, Plante M (1998) Pregnancies after radical vaginal trachelectomy for the treatment of early-stage cervical cancer. Am J Obstet Gynecol 179:1491-6.

Saling E (1981) Der frühe totale Muttermundverschlufl zur Vermeidung habitueller Aborte und Frühgeburten. Z Geburtshilfe Perinatol. 185:259-61.

Figure 11

Excision of the bladder pillars (after Dr Hélène Roy)

1 Bladder pillars

2 Paravesical space

3 Vesicouterine space

4 Ureter

5 Bladder base

Figure 12

Excision of the parametrium (after Dr Hélène Roy)

1 Parametrium

2 Ureter

3 Uterine artery

4 Isthmus with cross of uterine artery

5 Descending branch of uterine artery

Figure 13

Care is needed to preserve the cross of the uterine artery (after Dr Hélène Roy)

1 Excised parametrium

2 Cross of the uterine artery

3 Ureter

4 Uterine artery

5 Descending branch of uterine artery

Figure 14

Excision of the cervix (after Dr Hélène Roy)

1 Trachelectomy specimen

2 Residual endocervix

Cerclage Sical

Figure 15

Placing the cervical cerclage (after Dr Hélène Roy)

1 Suture

2 New exocervix

Trachelectomie Met Cerclage

Figure 16

Closure of vaginal mucosa (after Dr Hélène Roy)

1 New external os

2 New exocervix

Ectocervical Mucosa

Figure 17

Example of trachelectomy specimen. (A) Exophytic cervical lesion. (B) Lateral view. (C) After closure

Exophytic Cervical Cancer
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