Trachelectomy, also known as a cervicectomy, refers to surgical resection of the uterine cervix. It may be considered as a fertility-sparing treatment for low-stage cervical cancer.
Although radical hysterectomy is routine for treatment of endometrial and more advanced cervical cancer, uterine-sparing surgery is performed for low-stage cervical malignancy 2,3. It may be performed by vaginal, abdominal, laparoscopic, or robotic approaches. The extent of tissue resection varies:
-
excisional cone biopsy
- sometimes considered a form of trachelectomy, it involves removal of the lower portion of the cervix
- simple trachelectomy
- resection of the majority of cervix except the internal os
- cerclage may be placed to prevent uterine incompetence 5
- may be considered for intraepithelial neoplasia or superficial carcinomas 5
- radical trachelectomy
- resection of the majority of cervix sparing the internal os, as well as a portion of upper vagina, paravaginal (paracolpos) and parametrial tissue
- cerclage may be placed to prevent uterine incompetence 5
- may be preferred for stage IB1 cervical cancer (controversial) 5
Formal trachelectomies are usually preceded by diagnostic pelvic lymphadenectomy to assess for disease beyond the cervix that would preclude a fertility sparing approach.
Suggested eligibility criteria for a radical trachelectomy include 4,5:
- childbearing age and desire to preserve fertility, without clinical evidence of impaired fertility
- cancer limited to the cervix, stage IB1 or lower
- by definition, T1b1 tumors must be <2 cm
- absence of deep stromal invasion
- tumor located ≥1 cm from cervical internal os 5
- absence of lymphovascular invasion (LVSI+)
- absence of metastatic (pelvic nodal or distant) disease
Certain histologies are considered more aggressive and are generally excluded:
Radiographic assessment
MRI
MRI is the modality of choice for assessing anatomy and disease recurrence in patients prior to and following trachelectomy 1,4.
General imaging assessment includes 1:
- with the resection of the cervix, the expected surgical appearance is that of an end-to-end anastomosis between the corpus uteri and the vaginal vault
- appearance of the anastomosis at the neofornix of the vagina can vary. In about half of cases, there can be a posterior extension of the vaginal wall appearing as a neo-posterior vaginal fornix 1
- artifacts: suture artifacts arise from two sources
- anastomotic sutures
- cerclage sutures, which are placed around the corpus uteri to preserve competence during pregnancy
- these artifacts are most pronounced with fast spin-echo T2-weighted sequences
- vaginal appearances
- there can be diffuse wall thickening since a trachelectomy requires the dissection of paravaginal and parametrial tissue in order to mobilize the proximal vagina and cervix prior to resection. This is reported to occur in ~7% of cases and peaking between 3 and 6 months post surgery 1.
Post-procedural advice and imaging follow-up recommendations
- patients are asked not to become pregnant until 1 year after trachelectomy 4
- recommendations for follow up imaging are variable
- some perform 1-year follow up to assess the status of the cervical remnant and the cerclage 4
- other recommendations do not suggest reimaging in the absence of symptoms of recurrence 5
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