Abstract
Keywords
Patients with early cervical cancer (Federation Internationale de Gynecolgie et d'Obstetrique [FIGO] stage 1–2A) are conventionally considered to be suitable candidates for surgical treatment while those with more advanced disease are treated by chemoradiation. Surgical treatment usually involves a radical hysterectomy with pelvic lymphadenectomy, except for those with early microscopic disease (FIGO stage 1A) where conization or extrafascial hysterectomy ± lymphadenectomy would suffice. With the good implementation of the cervical screening program in most developed countries, it is expected that more women would present with early disease. For these women, the long-term prognosis is good, with survival over 90%; with this the preservation of fertility potential and quality of life become more important issues and have been the focus of surgical advances in the treatment of cervical cancer in recent years.
Fertility-sparing surgery
Radical vaginal trachelectomy was originally pioneered by Dargent in the late 1980s. This involved radical resection of the primary cervical tumor with an adequate clear margin of surrounding paracervical and vaginal tissues, with a pelvic node dissection performed laparoscopically. To date, more than 500 cases have been reported [1–6]. From the combined data of all published series, the overall average operating time was 215 min, the median blood loss was 275 ml and the overall intraoperative complication rate was 4% [7]. Bladder injury during the trachelectomy procedure was the most common complication followed by vascular injury during lymphadenectomy. Bladder dysfunction, the most common postoperative complication, was found in approximately 12%, which is similar to that seen after radical hysterectomy. Alexander-Sefre compared the surgical morbidities in radical trachelectomy with that in radical hysterectomy and found that radical trachelectomy was associated with significantly less operative morbidity, including shorter operating time, less blood loss and less analgesic requirements. Postoperative bladder dystonia was also found to be less frequent in the trachelectomy group [8]. However, there were significantly more deep dyspareunia, excessive vaginal discharge and recurrent candidiasis, which may be related to the cervical suture rather than the trachelectomy itself. A recent report compared 118 cases of radical vaginal trachelectomy with 139 cases of radical vaginal hysterectomy and found that the intra- and post-operative complications were similar [9].
The oncological outcome was good, with an overall recurrence rate of 5%, which is comparable to that of radical hysterectomy. However, for a tumor size greater than 2 cm, the recurrence rate was up to 17% [7]. Nearly 40% of recurrences were in the parametrium (19%) or pelvic side wall (19%), which might suggest inadequate parametrial resection with this technique for large tumors. Good reproductive outcome had also been reported recently. Although approximately half of the women did not try to conceive [10,11], up to 70% of those who attempted to conceive were successful, resulting in 49% term deliveries [10]. First trimester miscarriage rate was similar to the general population, but 10% had second trimester loss compared with the 4% in the general population, and the preterm delivery rate (20%) was also higher [10].
The original operation was via the vaginal approach, however, the abdominal approach, with the advantage of a shorter learning curve with no additional vaginal surgical skills required, has subsequently been reported, but the abdominal approach was associated with more blood loss and longer hospital stay compared with the vaginal approach [12–17].
In order to achieve a good outcome, careful selection criteria are essential. As only approximately half of the women in the reported series eventually attempted to conceive and the subfertility rates are higher after the operation, women should be carefully counseled on their desire for preserving fertility and their realistic chance of conceiving before choosing this option. Women over 40 years of age or those with existing subfertility would not be good candidates. As tumors greater than 2 cm were found to have nearly 20% recurrence, this procedure should be limited to small tumors of less than 2 cm. There is general agreement among authors that conservative surgery should not be performed in patients who have upper endocervical canal involvement, positive lymph node, or in patients with a poor prognosis histological subtype (neuroendocrine or anaplastic tumor).
Laparoscopic approach
Laparoscopic-assisted radical vaginal hysterectomy
With the recognition of importance of lymphadenectomy, the original radical vaginal hysterectomy alone (Schauta operation) had lost popularity compared with radical abdominal hysterectomy with pelvic lymphadenectomy. However, with the recent development of laparoscopic equipments and technique, there is a resurgence of interest in radical vaginal hysterectomy with laparoscopic pelvic lymphadenectomy as an alternative to the open abdominal approach. Subsequently, as more experience is gained in dissection of the uterine vessels, the ureters and the parametria, laparoscopic-assisted radical vaginal hysterectomy (LARVH) was described where opening of the pararectal and vesical spaces, parametrectomy and division of the uterine arteries and infundibulopelvic ligaments as well as pelvic lymphadenectomy were performed laparoscopically and the remaining procedures done vaginally [18]. More than 700 cases had been published so far, thus demonstrating the feasibility of this procedure [19–24]. A number of studies had compared this procedure with the traditional abdominal approach (Table 1) [25–30]. In general, blood loss was significantly lower in LARVH compared with the abdominal approach while the operating time was longer. Intra- and post-operative complication rates appeared similar, except for the possibility of higher ureteric and bladder injury in the LARVH group, although this did not reach any statistical significance. Postoperative bladder dysfunction appeared to be less in the laparoscopic group. Jackson et al. found that 89% of women in the LARVH group could void normally after catheter removal compared with 55% in the abdominal group [28], and Sharma et al. reported that the number of days that women required catheterization was significantly lower in the LARVH group (4.4 days) compared with the open group (8.8 days) [29], however Morgan et al. found no difference between the two groups [30]. It was suggested that better bladder function in the LARVH group may be a result of less radicality of the operation, although there was no difference in the completeness of surgical margins or in the nodal yield [28,29]. The overall recurrence rate was similar [27–30]. However, there was a direct correlation between tumor size and positive tumor margin and risk of recurrence [26,28]. All five patients with positive margin in the LARVH group had a tumor size greater than 2 cm in Jackson's series, while Nam et al. found a fourfold increase in recurrence (8.5 vs 2.1%) that was attributable to tumor size and he concluded that the laparoscopic approach should be limited to tumors less than 2 cm in size [26,28].
Comparisons between laparoscopic-assisted radical vaginal hysterectomy and open radical hysterectomy.
Denotes significant difference (p < 0.05).
Hb: Hemoglobin; LARVH: Laparoscopic-assisted radical vaginal hysterectomy; NA: Not applicable; RAH: Radical adominal hysterectomy.
Despite these initial favorable reports, long-term oncological outcome data are still lacking. Ideally, the true benefit of the procedure, particularly for long-term morbidity and failure rates, should be tested in a prospective randomized trial. However, as pointed out by Steed et al., a randomized study would require 14,000 women to demonstrate the equivalence of the two procedures with regard to recurrence rates and it is questionable whether such a trial would ever be carried out [27]. Meanwhile, this procedure appeared to be best suited to women with low-volume tumor (<2 cm) after careful discussion regarding better cosmetic results and the known short-term benefit of shorter hospital stay and less blood loss versus the lack of sufficient evidence for recurrence and survival.
Total laparoscopic radical hysterectomy
With better experience in laparoscopic surgery and development of instruments, total laparoscopic radical hysterectomy (TLRH) becomes an alternative option to LARVH. Since the first introduction more than a decade ago, more than 400 patients have been reported on demonstrating its feasibility. Similar to LARVH, this procedure was limited to small-volume early disease. Recently, series comparing TLRH with the abdominal procedure became available [31–36]. The majority of the studies demonstrated a longer operating time [31,32,34], less blood loss [32–35] and shorter hospital stay with the laparoscopic approach [32–34]. The most common intraoperative complication was ureteric or bladder injury for the TLRH group, although the overall intra- and post-operative complication rates were not significantly different from the radical abdominal hysterectomy (RAH) group. Negative margin rates were the same for both approaches, but lymph node yield appeared to be less in the laparoscopic group (14 in TLRH vs 19 in RAH) from Frumovitz series comparing 35 TLRH with 54 RAH [32]. However, other series have reported the same nodal yield with these techniques [31,33]. Li et al. reported a similar recurrence rate in both groups with a median follow-up of 26 months [31]. For other series, the follow-up time was too short and all patients were free of disease at publication. Ghezzi et al. performed a detailed analysis of the surgico-pathological outcome of their series of 50 TLRH versus 48 RAH in an attempt to provide some indirect evidence for oncological safety of the procedure [33]. They demonstrated that the same parametrial width was achieved, as well as the same lymph node yield and negative margins in both groups, suggesting that the laparoscopic approach is as safe as the traditional abdominal approach. Overall, TLRH appeared to be a possible option for selected patients, with better short-term outcome, such as blood loss and hospital stay, and similar intra- and post-operative complication rates. However, data on oncological safety remains sparse. It is expected that longer term follow-up data would become available in the near future. However, similar to the situation with LARVH, strong evidence requires prospective randomized trials that may not be feasible to carry out.
Laparoscopic staging in advanced disease
The FIGO staging for cervical cancer is based on clinical rather than surgical findings, without taking into account lymph nodes status. This allows a common staging system to be used throughout the world, including developing countries who have the highest incidence of cervical cancer and where advanced facilities and equipment required for lymph node assessment are limited. However, in developed countries with sufficient resources, surgical staging and assessment of lymph node status have been advocated since lymph node involvement is one of the most important prognostic factors. For advanced disease (stage Ilb–IVA), para-aortic lymph node involvement can be up to 24.8% [37]. If para-aortic lymph nodes are involved, extended field chemoirradiation appears beneficial. Currently, the most common methods for lymph node assessment are various imaging techniques, such as CT, MRI or PET scans, the sensitivities of which are highly variable. Surgical staging would offer a more definitive assessment. Traditionally, surgical staging was done with an open abdominal approach, but this often led to bowel adhesions and increased postradiation morbidity. In recent years, there has been a move towards laparoscopic staging where such complications were much reduced. Series reporting transperitoneal laparoscopic surgical staging involving intra-abdominal exploration for tumor spread and pelvic and para-aortic lymphadenectomy [38,39] demonstrated a median operation time of 172–202 min with minimal significant intra- and post-operative complications and a nodal yield comparable to the open approach. The most common complication was formation of large lymphocoele in up to 15% of patients. An extraperitoneal approach to lymphadenectomy may further reduce the adhesions that results in enteric radiation damage. A recent large series involving 184 patients reported a combined approach of intra-abdominal exploration and extraperitoneal lymphadenectomy where the enteric radiation complication was seen in only 2.6% and intraoperative complication rate was 2.2% and there was minimal postoperative complication. Similar to the transperitoneal approach, there was a high rate of symptomatic lymphocysts up to 13.4% [37]. It appears that laparoscopic staging is a feasible and safe technique that offers an accurate assessment of lymph node status for tailored chemoirradiation as well as an opportunity to debulk enlarged nodes. However, controversy remains a to whether this translates into any survival benefit. Although a 10-month survival advantage was seen in patients who had surgical staging in one series [40], the only randomized trial comparing patients with clinical staging versus laparoscopic or extraperitoneal surgical staging showed a significantly worse survival in those who underwent surgical staging [41]. The issue of survival benefit needs to be further investigated before laparoscopic surgical staging can form part of the routine care.
Transposition of the ovaries
In order to preserve ovarian function and therefore improve the quality of life in young women with cervical cancer who may require pelvic irradiation, the ovaries can be transposed into the paracolic gutters by pediculization of the ovarian vessels either during laparotomy or laparoscopically. Ovarian function has been shown to be well preserved in 65% of women with ovarian transposition who underwent postoperative radiotherapy [42].
Reducing radicality
Sentinel lymph node assessment
Radical hysterectomy with systematic pelvic lymphadenectomy has been the standard treatment of early stage cervical cancer. Lymph node metastasis has been found in approximately 4% of microinvasive disease [43], but this increases to 20% in Stage 1b disease [44]. Although lymph node involvement does not contribute to the FIGO staging, it is one of the most important prognostic factors. A systematic lymphadenectomy would give a good assessment of the lymph node status, although it is also associated with potential morbidities, such as formation of lymphocysts and lymphedema, where the incidence can be up to 21 and 20%, respectively [45,46]. Considering the low incidence of lymph node involvement, the majority of women, particularly those with very early disease, would have undergone a systematic lymphadenectomy with its associated risks unnecessarily. Furthermore, in situations where lymph nodes are involved, chemoirradiation would be offered. In these patients, a systematic lymphadenectomy would not give any additional benefits. The concept of the sentinel lymph node has developed as a method to detect lymph node metastasis and, thus, avoid the complications associated with complete nodal dissection. The sentinel lymph node is the first lymph node that the tumor cells would spread to via the lymphatics. Histological status of the sentinel node would be representative of all other lymph nodes draining at the same anatomical site, in other words, if this sentinel node is negative histologically, the remaining lymph nodes draining the same region would also be negative. This concept has been used successfully in breast cancer and melanoma. In the past 5 years, the role of sentinel lymph nodes has been studied in cervical cancer. The exact technique varies in the reported series. In general, it involves subepithelial application of a radioactive tracer substance, for example, 99m technetium (Tc) labeled colloid, at four quadrants around the cervical tumor the day before the operation. The total radioactive dose varies between 10 and 111MBq, depending on the time interval between injection and surgery [47,48]. Lymphoscintography may be performed after injection of the radioactive tracer to map any positive lymph nodes, especially those at extrapelvic sites [49,50]. At the beginning of surgery, blue dye (e.g., Patent Blue or methylene blue) is applied around the tumor. Intraoperatively, blue-dye stained lymph nodes can be visualized after opening the retroperitoneum and nodes with radioactive uptake can be detected with a gamma camera. The blue or the radioactive nodes are then removed as sentinel lymph nodes [51]. In current practice, since the false-negative rates of this procedure had not been firmly established, a complete lymphadenectomy would be performed in cases where no sentinel nodes or negative sentinel nodes were found.
Recently, a systematic review of the diagnostic performance of sentinel lymph node detection for assessment of nodal status in early cervical cancer has been published [52]. A total of 23 studies involving 842 patients were included in the review. The sentinel lymph node detection rate was highest (97%) using the combined technique of technetium and blue dye compared with Tc colloid (88%) or blue dye (84%) alone. The sensitivity was the same for the combined technique and Tc colloid alone (92%). The use of blue dye alone was inferior, with sensitivity of only 81%. This was better than the use of CT or MRI, which give a sensitivity of 43 and 60%, respectively [53]. However, the detection of sentinel lymph node appeared to be lower in tumors bigger than 2 cm [54,55].
Covens et al. argued that the true false-negative rates for sentinel lymph node detection may be even lower than reported [56]. Although the overall detection rate is up to 97%, many studies reported detection of sentinel nodes only unilaterally. Bilateral detection rates are lower [56]. Satisfactory sentinel lymph node detection should include successful detection bilaterally [57] since status of sentinel nodes on one side cannot accurately reflect the status of the nodes on the other side. In some reports, sentinel nodes were found to be negative on one side and no sentinel nodes could be identified on the other side. Systematic dissection then revealed positive nodes on the side where sentinel nodes could not be identified. These situations had been reported as ‘false-negatives’ for sentinel node detection [54,58]. These cases should be classified as ‘unsatisfactory detection’ rather than false-negatives. Other false-negatives were caused by positive lymph nodes found in the parametrium from the final pathology specimen [59–61]. Theoretically, these should not be classified as false-negatives since the purpose of the sentinel node detection concept in cervical cancer was to determine the need for systematic pelvic lymphadenectomy. Parametrial lymph nodes would be removed in the radical hysterectomy and dissection of these is not part of the pelvic lymphadenectomy procedure. After exclusion of these, the actual false-negative rates can be less than 2% [56].
So far, the sentinel lymph node concept appeared to be feasible, and encouraging data on its accuracy in determining pelvic nodal status are emerging. A correct technique is important in achieving the high sensitivity reported. Variations in the details can affect the detection rate, including the amount of dye, the timing and site of injection as well as the detection methods, such as the wrong angle of probe intraoperatively. Refining the technique, such as the use of single-photon emission computed tomography/high-resolution CT for better localization or better timing for dye injections, may give even better results [62]. A learning curve of approximately 30 cases had been suggested [57]. So far, the use of sentinel lymph nodes has been confined to clinical trials. A large multicenter trial by the Gynecologic Oncology Group is underway. With further confirmation of safety and accuracy, it is possible that sentinel lymph node detection can be part of the standard surgical treatment instead of systematic pelvic node dissection in early cervical cancers in the future.
Apart from the role of determining the need for a complete pelvic lymphadenectomy, detection of sentinel lymph nodes has additional advantages. Sentinel lymph nodes had been detected in sites beyond the standard pelvic dissection fields in up to 20% of cases [62,63]. These nodes would be missed during standard pelvic lymphadenectomy and these cases may account for the recurrence seen in node-negative cases. Furthermore, ultrastaging with the use of immunohistochemistry and serial section can increase the detection of metastasis by 10–15% [64,65]. Such labor-intensive histological examination is not practical when applied to a large number of lymph nodes as obtained in the systematic dissection, but has proved to be feasible when examining a small number of sentinel lymph nodes. However, the exact significance of these micrometastases in terms of overall prognosis is still unknown.
Reducing parametrectomy
Radical hysterectomy involves resection of the parametrium where autonomic innervations to the pelvic floor run. These autonomic pathways are important for normal bladder, bowel and sexual functions. The hypogastric nerves originating from the superior hypogastric plexus contain sympathetic fibers for bladder compliance and urinary continence. The pelvic splanchnic nerves originating from the sacral nerve roots (S2–S4) contain parasympathetic fibers involved in detrusor contractility, rectal function and vaginal lubrication. The hypogastric and pelvic splanchnic nerves form the pelvic plexus, which stretches from an area anterolateral to the rectum to the lateral vaginal wall and bladder base [66]. These nerves may be injured or divided at various stages of a classical radical hysterectomy, such as injury to the hypogastric nerves during resection of the uterosacral ligaments, division of the pelvic plexus at the resection of the uterosacral and rectovaginal ligaments and damage to the vesical branches of the pelvic plexus at resection of the vesicouterine ligaments [67]. This leads to voiding difficulties, constipation and vaginal dryness, which affect long-term quality of life [68,69].
The extent of pelvic floor dysfunction appears to be associated with the radicality of the hysterectomy [70]. A randomized trial of type II versus type III radical hysterectomy demonstrated that voiding dysfunction was reduced while the pattern of recurrence and disease-free survival remained similar [71]. However, in this study, approximately half the patients in both arms received pelvic radiation therapy. Reducing the radicality has been advocated, particularly in patients with early disease with good prognostic factors [72–74], considering the situation where 70–80% of stage 1A2 to 1B1 disease has no parametrial or nodal involvement. In patients with small-volume disease (<2 cm), no lymphovascular space or pelvic nodal involvement, the incidence of parametrial was only 0.4% [75]. Recently, a series of women with small-volume (16–640 mm3) stage 1B1 disease treated with loop cone or simple hysterectomy ± pelvic node dissection was published, demonstrating a good oncological outcome [76]. With implementation of cervical screening programs in most developed countries, women are more likely to present with early disease. Therefore, tailoring radicality will become an increasingly important issue, particularly in young women who would like to preserve fertility. For women with good prognostic factors as above, a prospective clinical trial to evaluate laparoscopic pelvic lymphadenectomy followed by therapeutic cervical conisation if pelvic nodes are negative should be considered.
Although reducing radicality may be an option for early small volume disease, there are still women with poor prognostic factors with significant risk of parametrial involvement who may still require the standard radical hysterectomy. Nerve-sparing techniques during conventional hysterectomy had been advocated in Japan since the 1920s and had been successfully adopted by European countries in recent years [77,78]. There are variations in the exact technique, but the overall principle is to minimize the damage to the autonomic innervation during resection of the uterine-supporting ligaments without compromising radicality. Good postoperative bladder functions were reported in the published series [67,77]. When comparing type III standard radical hysterectomy, early bladder functions for type III nerve-sparing radical hysterectomy were found to be superior and were comparable to standard type II radical hysterectomy, while other complications were similar [79]. Results from detailed urodynamics studies after nerve-sparing techniques have recently emerged supporting favorable outcomes [80]. Nonetheless, published data so far are mainly small series demonstrating the feasibility of the different techniques proposed. Results from prospective randomized studies are still awaited to demonstrate the exact role of nerve-sparing techniques in improving the quality of life while preserving oncological safety.
Management of recurrence
Pelvic exenteration (PE) with removal of tumor en bloc with bladder (anterior PE), rectum (posterior PE) or both (total PE) is a salvage treatment for patients with locally advanced disease or with pelvic recurrences with previous irradiation. In well-selected cases, palliative PE can be offered to those whose symptoms cannot be controlled by any other means. With improvement of perioperative care and surgical techniques, the surgical mortality has reduced from 23% in Brunschwig's first case series in 1948 to less than 2% [81]. However, it remains one of the most mutilating abdominal procedures, with formation of two separate stomas for urinary and bowel diversions. In recent years, much attention has been focused on the reconstruction of pelvic organs after PE to improve the quality of life. Low bowel anastomosis avoids the need for a permanent colostomy, and the use of stapling devices in recent years reduces the operative time and blood loss. Good results have been achieved, particularly in nonir-radiated patients [82]. Development of a continent pouch using an intussuscepted nipple valve system for continence avoids the need of an external urine collection bag. The initial pouch (Koch's pouch) had a high failure rate of 10–20%. Alternative approaches have been developed, such as the Miami pouch, Mainz pouch, Indiana pouch and Florida pouch, with the Miami pouch being one of the most popular methods used in recent years. This technique uses a low pressure detubularized colonic reservoir with a tapered ileum and sutures to reinforce the ileocecal valve as its continent mechanism. The low pressure reservoir is formed by an isolated intestinal segment incised along the tenia and the opened ascending and transverse portions of the colon anastomosed in a U-shape fashion. A recent report of 15 years of experience with this technique demonstrated that continence was achieved in 93% of women but the complication rate was 53%. The most common reservoir-related complications included urinary infection (40%), ureteric stricture (20%) and difficulty with self catheterization (18%) [83]. Most complications could be treated conservatively without relaparotomy. Recently, a report on a simplified technique, the Rome pouch, was published. With the Rome pouch, multiple teniamyotomies, instead of detubularization of the colon, were made to increase reservoir volume. This resulted in fewer operative steps, shorter operative time and less blood loss [84].
With recent enthusiasm in the laparoscopic approach, case reports of laparoscopic or laparoscopic-assisted transvaginal exenterations with or without reconstructions had been reported [85–87] demonstrating its feasibility, but the true advantages and oncological outcomes are still unclear.
PE is generally considered to be suitable for centrally located tumors with no pelvic side wall or distal involvement and negative para-aortic lymph nodes. Many would not proceed with a PE if there was positive pelvic nodes owing to the overall poor prognosis [79]. Despite full preoperative investigation, aborted exenteration at the time of laparotomy is approximately 40–63%. In order to reduce the chance of aborted procedure, laparoscopic assessment in patients prior to PE, including those who had previous irradiation, has been reported [88,89]. In a series of 41 patients undergoing laparoscopic assessment, 20 were found to have unresectable disease. For all 21 patients who were deemed suitable for PE, laparoscopic evaluation was found to be accurate at laparotomy. Only one patient had extension of disease missed at both laparoscopy and laparotomy and only discovered at an advanced phase of the exenteration. This suggests that laparoscopy is effective for pre-exenteration assessment and would avoid unnecessary laparotomy in approximately 50% of the cases.
For patients with recurrences involving the pelvic side wall, who are generally considered not suitable for PE, Hockel developed a technique of laterally extended endopelvic resection (LEER) where the viscera was resected en bloc with the side wall muscles and major vessels in the lesser pelvis. He achieved a microscopic complete resection in 34 of 36 patients with a survival rate of 49% [90]. To further improve local control, afterloading catheters were inserted into the tumor bed at the side walls intraoperatively to deliver brachytherapy starting on the second week postoperation [91]. Further data from larger series are awaited to evaluate the overall outcomes for these techniques.
Conclusion
In recent years, there is a general trend towards tailoring surgical radicality for the individual, in order to maximize the quality of life while maintaining a good oncological outcome. For early disease, radical trachelectomy and laparoscopic techniques, such as LARVH or TLRH and laparoscopic lymphadenectomy in selected cases, have been well supported by evidence from large series, while evidence is emerging for adopting a less radical approach, such as cone biopsy with pelvic lymphadenectomy, for small-volume disease. The oncological safety in reducing radicality by reducing parametrectomy should be continuously addressed in clinical trials and audits. Lymph node assessment can help to determine the suitability of surgical management in women with apparently early disease. Current data suggests that sentinel lymph node assessment may be superior to imaging techniques. Further data are required to ascertain its sensitivity and specificity in assessing lymph node status before it can be routinely adopted in clinical practice. For advanced disease, laparoscopic staging for tailored chemoirradiation is feasible, but its benefit in terms of survival remains controversial. For those with locally advanced disease where pelvic exenteration is an option, development of new reconstructive techniques can potentially improve quality of life.
Future perspective
The effect of reduction of cervical cancers with the introduction of the human papillomavirus vaccine may not be seen within the next 10 years, so management of cervical cancer will remain an important area for gynecological oncologists in the near future. Meanwhile, with implementation of cervical screening programs in more developing countries, we anticipate a continuous trend towards earlier presentation with small-volume disease. These women would be ideally enrolled into clinical trials evaluating the newer techniques described above. The effectiveness of sentinel lymph nodes assessment is likely to be improved with further improvement of technique and imaging technology and may become a part of the standard assessment for women with Stage 1A2–1B tumors. With better assessment of prognostic factors, the surgical radicality will be better tailored for the individual. The role for radical trachelectomy may be reduced in the future as more data will emerge confirming the small risk of parametrial involvement in small volume disease without lymph nodes involvement. Instead, women with small-volume disease may be offered conization alone with sentinel lymph node assessment to exclude lymph node involvement. Similarly, the standard radical hysterectomy may also be replaced by less radical hysterectomies, done via the laparoscopic approach. The use of robotics, such as the Da Vinci system, may become more popular if it proves to be a cost-effective option.
Although the majority of women will be treated early and will have excellent long-term prognosis, there will still be women with recurrences. Currently, surgical option in the form of pelvic exenteration would only be offered for those with central recurrences. The remaining patients would only be suitable for palliative treatment. The role of surgery in recurrence should be further explored in the near future. As the incidence of cervical cancers in the developed world continues to fall, future clinical trials are likely to be multicenter. On the other hand, multicenter trials on specific surgical techniques are particularly difficult to run and interpret since there would be a large variation in the individual surgeon's operative style and experience. Meanwhile, large amounts of data would become available from developing countries where new technologies and surgical techniques are more quickly implemented than a population-wide health program for the reduction of cervical cancer.
Executive summary
This is a feasible option for young women with small tumors who wish to preserve their fertility potential.
Morbidity associated with radical trachelectomy is comparable to radical abdominal or radical vaginal hysterectomy.
Recurrence rate is comparable to radical hysterectomy for tumors less than 2 cm.
Second trimester loss and preterm delivery after trachelectomy are more common than in the general population.
Blood loss was lower but operating time was longer for laparoscopic-assisted radical vaginal hyterectomy/total laparoscopic radical hysterectomy compared with open approach, but surgical morbidity was similar.
Negative margins and nodal yields were similar to the open procedure.
Overall recurrence rate was similar to the abdominal approach for tumors less than 2 cm.
Laparoscopy staging and para-aortic node dissection is a feasible option to tailor the extent of radiation field and debulk enlarged nodes.
Sentinel lymph node (SLN) status may be used to guide the need for systematic pelvic lymphadenectomy.
SLN detection rate was highest using combined injection of technetium and blue dye.
A satisfactory SLN detection should include successful detection bilaterally.
The false-negative rate can be less than 2% in experienced hands.
The incidence of parametrial involvement in patients with small volume disease, no lymph nodes or lymphovascular space involvement is low.
Reducing the radicality of parametrectomy would reduce postoperative bladder, bowel and sexual dysfunction.
Laparoscopic assessment for suitability for pelvic exenteration is a feasible option.
Continence pouches and low rectal anastomosis can improve quality of life postpelvic exenteration.
A laterally extended endopelvic resection technique may be able to remove pelvic side wall disease.
Intraoperative insertion of afterloading catheters for brachytherapy at pelvic side walls may improve local control.
Footnotes
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.