Radical vaginal trachelectomy and laparoscopic bilateral pelvic lymph node dissection

You have been diagnosed with an early cervical cancer. Due to the size of the abnormal area already biopsied, it cannot be treated in outpatient colposcopy alone. This is because there would be a high risk of leaving some abnormal cells behind. Doctors refer to this as ‘inadequate treatment’ and it may result in return of the tumour.

Early (small volume) cervical cancers that are too large to be treated within the colposcopy clinic can be treated with a radical hysterectomy or radiotherapy. Both treatments are effective in removing cancer cells. However the treatment will unfortunately result in the loss of ability to have a baby.

Your doctor feels that, as an alternative to radical hysterectomy and radiotherapy, offering trachelectomy is an option for you to consider. This will give you the option of trying for a baby later on.

Below aims to provide you with:

• information about having a trachelectomy including the benefits and risks
• an explanation of the sequence of events to expect, what will happen during the operation (trachelectomy) and answers to some of the questions you may have
• information about the alternative treatment options (conventional surgery), including benefits and risks.

Radical trachelectomy

Trachelectomy is an operation performed for the treatment of cervical cancer which allows the option to get pregnant in the future, because the womb is left in place.

Benefits

• You will have the option to get pregnant in the future.
• You should recover quickly after the operation. The recovery normally takes about one month and is usually quicker than having a full hysterectomy.

Risks

• Lymphoedema and lymphocytes – swelling of the legs and genital area.
• Nerve damage leading to changed sensations in the thighs and genital areas.
• Cervical stenosis (narrowing of the cervix), leading to painful periods.
• Fertility problems, pregnancy problems, recurrence of cancer.
• Need for further therapy in the event of close margins or involved lymph nodes.
• Thrombosis, infection, excessive bleeding and damage to other organs are rare side effects which may happen in any operation.
• Fewer than 5% of patients have immediate problems.

What happens next?

Before proceeding with the surgery, you will have a MRI scan (magnetic resonance imaging). This will enable the doctor to assess:

• the size of tumour
• whether there is spread to surrounding tissues or lymph nodes

Some patients will also need to have an examination under anaesthetic (EUA) This will be explained to you by your doctor if it is thought we need more information about the tumour.

It is not usual practice to consider radical trachelectomy when your tumour is bigger than two centimetres (2cm) or there are areas where there is suspicious shadowing on the imaging.

The operation

• You will be admitted to hospital early on the morning of the operation.
• The procedure is performed with you asleep having a general anaesthetic.

Using laparoscopic (keyhole) techniques, lymph nodes (this is similar to lymph node removal in a standard hysterectomy operation) from selected areas in the pelvis are removed. This involves a long thin instrument (laparoscope) being passed through small cuts (one centimetre/1cm) in the abdomen. Carbon dioxide gas is used to inflate the abdomen so that more room is created for the doctor to work. At the end of the operation the gas is allowed to escape and the cuts are usually closed with dissolvable stitches.

The next part of the operation is performed through the vagina and will not involve any further cuts in the tummy area.

To ensure that all the tumour (cancer) is removed the cervical tumour is excised (cut) along with some of the supporting tissues in the vagina and surrounding area.

This means that some normal tissue near the cancer is removed as well. The vagina is then reconnected to the remains of the cervix in which we have inserted a support stitch (cerclage).

After the operation

• There are usually four little wounds on the tummy each less than one centimetre (1cm). A catheter (tube into the bladder) is often left in after the procedure until you have fully woken up.
• You should not experience much pain and any discomfort you do experience can be controlled with simple pain medication such as paracetamol or ibuprofen.
• Hospital stay is between one to two days after the operation.
• You will have a blood-stained discharge following the operation, this should not be a heavy bleed and will settle in a week or two.
• Your first period after the operation may be heavier than expected or cause you more pain than usual. Please contact the team if there are problems and we can help with those if they occur.
• Results are available about two weeks after the surgery and we shall contact you with these results. You can choose to come to the clinic to hear the results or speak to us on the phone in the comfort of your home.

Outline of discharge/follow-up

• You will be discharged from hospital approximately one to two days after surgery.
• You should attend your GP surgery five to seven days after the operation to have your abdominal wounds checked and stitches removed.
• Two weeks after surgery, you will receive the results either by phone or at a clinic appointment. It is your decision as to how you would like the results.
• You will be reviewed every three months in clinic. This involves discussion, enquiry into your general health, and pelvic examination with a cervical smear. This close follow up occurs for two years and then we move to six monthly visits.

We advise that you use contraception and avoid pregnancy until six months after the surgery to allow everything to heal and to see any early problems which may occur (this is unlikely).

During this initial recovery period, if you are considering becoming pregnant, we make arrangements for you to see one of the specialist obstetricians to discuss what will be required for monitoring during pregnancy. Delivery of your subsequent children will need to be by caesarean section

Results of the operation

The results over the last 13 years are very encouraging.

Surgical outcome

A good surgical outcome:

• recurrence less 3%
• death 2.3%

These results are similar to the outcomes seen in small tumours treated by conventional radical therapy.

Pregnancy outcome

• more than 30% pregnancy rate; the rate here at Addenbrooke's is ~45% for all women which includes some women not actively trying to conceive
• increased rate of premature delivery
• requirement for caesarean section

Please do not hesitate in contacting either Robin Crawford via his secretary on 01223 216251 or your specialist nurse if you have further questions.

Alternatives

Conventional treatment

Conventional treatment could be considered as an alternative to radical trachelectomy. These are outlined below:

• Radical surgery – hysterectomy (Wertheim’s type – removal of the womb) and either leaving the ovaries behind or removing them.

Or

• Radical radiotherapy – this is given as both external beam (from outside) and brachytherapy (a radiation source inserted into the vagina) usually given with chemotherapy.

Benefits

• There are good outcomes in the early stage of the disease. (Early disease treated with hysterectomy has high cure rates.)
• These treatments have been available for many years and there is evidence that they are effective.

Drawbacks

• Loss of fertility (being unable to get pregnant/have a baby) – for all patients.
• If ovaries are removed then this will cause the menopause (your periods will stop). You may suffer from hot flushes, sweats, upset sleep, dry skin and vagina as a result of the menopause.
• Lymphoedema (swelling of legs and genital area), or lymphocyst (collection of fluid).
• Thrombosis, infection, excessive blood loss and damage to other organs are rare side effects but may happen in any operation.
• Fistula (abnormal connection between ureter, bladder or bowel and vagina). This is rare.
• Late side effects of radiotherapy may be damage to the bowel and bladder leading to frequency of bowel motion and urination or blood loss.