An increasing number of Gynecologic malignancies arise in premenopausal childbearing age for many women delaying conception .Fertility-sparing procedures for cervical carcinoma patients are the excisional conization of the cervix and the Radical Trachelectomy (RT). Nearly 50% of women younger than 40 years of age, eligible for surgical management, may be candidate for those conservative procedures.
Cervical conization is an effective treatment modality for preinvasive intraepithelial neoplasia and for FIGO stage IA1 cervical cancers meaning a ≤ 3mm depth of invasion and horizontal spread ≤ 7mm with no vascular or lymphatic invasion and negative resection margins.For stromal invasion more than 3mm and < 5mm with spread ≤ 7mm, stage IA2, cervical conization can locally control the disease . In stage IA2 nodal metastasis is 5-8%, thus lymphadenectomy is mandatory.For FIGO stage IA1 with lymphovascular space involvement, IA2 and IB1 tumors ≤ 2 cm limited to the cervix without evidence of ymph node metastasis , radical trachelectomy and pelvic lymphadenectomy is the optimal approach .The procedure comprises the removal of the cervix on a radical approach along with the paracervical tissue and the upper vagina by using the same technique as in a Schauta vaginal or Wertheim abdominal radical hysterectomy. As the first part of the procedure a pelvic lymph-node dissection is performed laparoscopically or as open procedure. An upper cervical or isthmic cerclage by using no 1 nylon suture is placed after the trachelectomy to help prevent possible cervical incompetence.A preoperative assessment with Magnetic MRI is used preoperatively in order to assess tumor diameter, cervical stroma infiltration and parametrial invasion .
Lesion size is the most important risk factor for recurrence and tumors greater than 2 cm represent a significant increase in the risk of recurrenceThe parametrial resection performed with the usual radical vaginal trachelectomy correlates to a class II radical abdominal hysterectomy, thus the procedure seems to be safe in patients with small < 2cm tumors.Radical Abdominal Trachelectomy with pelvic lymphadenectomy represents an alternative fertility-sparing approach for treating women with stage IB1 lesions with tumor diameter of 2-4cmThe radical abdominal trachelectomy may result in wider parametrial resection (more than 50% greater) than in radical vaginal trachelectomies
Cervical conization and radical trachelectomy has similar oncologic outcomes to traditional radical approaches , and should be considered as alternative treatment options for young patients with early cervical cancer who wish to preserve their fertility.