Gynecologic malignancies are most often diagnosed in postmenopausal women, and can also arise in premenopausal women who have fertility as top of mind. The increasing number of women delaying childbearing has led to a significant increase in the number of women diagnosed with a gynecologic malignancy before desired completion of childbearing. Many of the standard treatments for these malignancies result in permanent sterility; however, there are now options for select young women who wish to preserve their fertility.
The standard treatments for cervical cancer—hysterectomy (simple or radical) and pelvic radiation—result in permanent sterility. Select patients with early stage cancer could qualify for fertility sparing options, which include radical fertility sparing trachelectomy, where the cervix is removed but the uterus is spared.
It is estimated that approximately one-third of patients with cervical cancer may meet the criteria for this procedure. Due to the rarity of this procedure, many referring physicians are not aware that this is an option for their patients.
Who is a candidate for radical trachelectomy?
It is first and foremost important to have a patient that desires future fertility. Otherwise, more conventional methods for treating cervical cancer are typically preferred, primarily due to the fact that the surgery itself can be more complicated when compared to a standard hysterectomy. The patient would need to meet with a gynecologic oncologist who performs the procedure, because not all gynecologic oncologists are adequately trained to perform fertility sparing trachelectomies.
At a patient’s initial consultation, important information would be obtained to assess if it is an appropriate option. Some of these criteria include tumor size, lack of any spread of disease on imaging and the specific pathologic type of cancer, among others.
How is the procedure performed?
There are many surgical approaches to performing a trachelectomy, including vaginal or abdominal, and robotic or minimally invasive. Most surgeons utilize either an incision on the belly or multiple smaller incisions, and perform the surgery in a minimally invasive fashion. The surgery requires very careful dissection due to the steps involved to keep the uterus viable while eliminating the cervical cancer. Here are the general steps:
- The uterus is carefully dissected and the blood supply to the uterus is spared.
- The uterus is separated from the cervix, and a stitch, also known as a cerclage, is placed around the base of the uterus to secure it in the event that the patient becomes pregnant in the future.
- The uterus is reconstructed to the top of the vagina.
Can women still become pregnant naturally after a trachelectomy?
Yes. Pregnancy rates are very encouraging after a trachelectomy, with close to 70 percent of women achieving pregnancy afterward. Some patients may require some reproductive assistance, for instance, intrauterine insemination or in vitro. It is important to involve a reproductive specialty physician in these cases to offer guidance along the way. Patients will need to deliver via cesarean section because of the permanent cerclage placed at the base of the uterus to prevent premature delivery.
Dr. Jessica Stine is a gynecologic oncologist who is trained to perform trachelectomies on young women. Schedule a consultation with Dr. Stine by calling her office at 813-530-4950.
What are the differences between robotic surgery and laparoscopic surgery?
In a traditional laparoscopic surgery, the surgeon places small incisions on the patient’s belly, and a camera and small instruments go inside those incisions to perform the procedure while the surgeon manipulates the instruments at the bedside. These are called straight-stick instruments, because the tips of the instruments only move in the up or down directions.
Robotic surgery starts in the very same way where small incisions are made; however, the instruments are placed and held by a robotic platform as opposed to having the surgeon hold the instruments at the bedside. The surgeon stands near a console and manipulates the instruments completely with hand controls. One huge advantage to robotic surgery is that the instruments move in all directions. This allows the surgeon to operate much like they would with their human hand. Surgeons can perform more complex procedures with better precision, which is a huge advantage, especially for cancer procedures. In addition, the camera has three-dimensional visualization, which allows the surgeon to see more clearly.
Does the robot or the surgeon perform the surgery?
Patients imagine that the robot is acting independently, which could not be further from the truth. No single movement of the instrument is made without the surgeon controlling it from the console. Think of the robotic platform as a stationary assistant during surgery, holding the instruments and directly communicating the movements of the surgeon’s hands.
What types of procedures can you perform robotically?
There are many different procedures that can be performed robotically, from simple hysterectomies to more complex pelvic surgery for patients with large uterine fibroids or very severe endometriosis, which can cause scarring and inflammation in the pelvis. Procedures can be performed for endometrial, cervical and ovarian cancers where lymph nodes and multiple biopsies are removed. Robotic surgery can also be performed for very complex ovarian or endometrial cancer operations where metastatic tumors are removed from multiple locations in the pelvis and abdomen. In the past, these surgeries were commonly performed using an “open approach” or a very large incision in the belly.
What are the benefits of having a robotic procedure versus a traditional open procedure?
There are many proven benefits to robotic surgery as compared to open surgery. Patients who have minimally invasive surgery will experience much less pain, less blood loss overall, less hospitalization time and lower infection rates. Around 90% of my patients go home the same day as their procedures, including complex cancer procedures. The movement toward same-day discharge has been increasing steadily and has been studied extensively at major surgical and cancer centers. It has been found to be safe and very satisfying for patients who can spend more recovery time with their families in the comfort of their homes versus the hospital.
Recovery time from robotic procedures is typically cut in half when compared to open approaches, which allows patients to get back to their normal routines much sooner and relieves financial burden for patients who need to get back to work. In the long-term, we see much less formation of adhesions and scar tissue after minimally invasive surgeries when compared to open procedures.
Who are candidates for robotic surgery and what are some important questions to ask your doctor?
Any patient who is considering a gynecological surgery should have a consultation with their trusted surgeon to discuss the possible options for performing the surgery. It is important for patients to have a detailed conversation with their provider about the appropriateness of a robotic procedure in their condition. As an example, there are many women who may be told they are not candidates for robotic surgery due a history of multiple previous surgeries, when they actually may be able to very safely have minimally invasive surgery. It is important to ask about your doctor’s experience with minimally invasive approaches and ask what to expect after surgery, specifically regarding restrictions and timing of returning to work. These questions will help prepare patients for the recovery period.