Laparoscopic Vaginal-Assisted Nerve-Sparing Radical Trachelectomy

Abstract

Study objective: To demonstrate a laparoscopic vaginal-assisted nerve-sparing radical trachelectomy.

Design: An edited educational video, including a step-by-step description of the procedure.

Setting: Radical trachelectomy is the main surgical indication for selected cases of initial cervical cancer with a fertility-sparing approach. Although transvaginal access is the most traditional route, this technique has not gained widespread acceptance because of the complexity of the ureteral dissection and the limited amount of resected parametrial tissue. This video describes a laparoscopic technique including an adequate parametrial resection with autonomic preservation (C1 level) and a standard laparoscopic ureteric dissection under direct visualization. All parametrial dissections were performed by laparoscopy using a nerve-sparing technique. The uterine vessels were well dissected and transected at their origin. The colpotomy was performed by laparoscopy with a 1-cm vaginal margin using a monopolar energy hook. To achieve an adequate endocervical margin and to avoid thermal injury to the endocervix, the cervical section was performed transvaginally with a cold knife. The specimen was then retrieved, and a segment of the remaining cervix was removed for frozen section analysis. If the margin was free of tumor, the cervical-vaginal anastomosis was performed transvaginally. An endocervical device was placed to avoid postoperative cervical stenosis.

Interventions: Laparoscopic vaginal-assisted nerve-sparing radical trachelectomy.

Conclusion: This video demonstrates a reproducible laparoscopic technique for radical trachelectomy with a nerve-sparing technique. The vaginal route was used at the moment of sectioning the cervix/isthmus to permit adequate margin evaluation.

Keywords: Cervical cancer; Cervix; Laparoscopy; Nerve sparing; Pelvic lymphadenectomy; Radical trachelectomy; Vaginal assisted.