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Obstet Gynecol Sci > Epub ahead of print
Lee, Mun, Park, Lee, Lee, and Kim: Vaginal delivery after robot-assisted uterine artery-preserving radical trachelectomy for early-stage cervical cancer

Abstract

Radical trachelectomy is conducted in women with early-stage cervical cancer who strongly desire fertility preservation. For improving fertility outcomes, the preservation of the uterine artery has been suggested, which can be feasible by minimally invasive surgery using laparoscopy or robot. Although cesarean delivery is required for maternal and fetal health, we sometimes worry about vaginal delivery because of fast delivery process or preterm labor. We report a case of a 32-year-old nulliparous woman with stage IB1 cervical cancer who underwent robot-assisted uterine artery-preserving radical trachelectomy for improving fertility. This case is meaningful because she delivered by vaginal delivery after incising of the fibrotic ring at the level of uterovaginal anastomosis because delivery proceeded too quickly before the preparation of the cesarean delivery.

Introduction

Since radical vaginal trachelectomy using the Dargent approach was introduced to preserve fertility in 1994 [1], radical trachelectomy has become an alternative option of radical hysterectomy for young women with early-stage cervical cancer who strongly wish to preserve fertility, which has been performed via vaginal or abdominal approach traditionally. In spite of a minimally invasive procedure, vaginal radical trachelectomy has the difficulty in surgical approach by the narrow field of view through the vagina, whereas abdominal radical trachelectomy has some advantages such as wide view for resection and relatively short learning curve. However, the uterine arteries have been sacrificed in both procedures up to now in spite of the increasing expectation for better functionality of the remaining uterus [2,3].
Recently, laparoscopic or robot-assisted radical trachelectomy has been activated with the development of minimally invasive surgery, and thereby the delicate surgery preserving the pelvic autonomic nerves or uterine arteries has been more feasible [4]. Recurrence rates appear to be the same irrespective of whether the trachelectomy is performed by the vaginal, abdominal, laparoscopic or robotic approach.
However, obstetrics limitations including preterm birth and cesarean delivery are still unresolved in women treated with radical trachelectomy [5]. Women were advised to deliver by caesarean section for permanent isthmus preservation. However, in women who have undergone trachelectomy, it may be difficult to assess preterm birth because mid-trimester miscarriages and preterm labor can be painless progressive dilatation of the neo-cervix. Thus, we introduce a case of vaginal delivery due to fast fetal decent after robot-assisted uterine artery-preserving radical trachelectomy for early-stage cervical cancer.

Case report

Patients information-diagnosis and surgery

A 32-year-old nulliparous woman visited due to atypical squamous cells-cannot exclude high-grade squamous intraepithelial lesion on cervical cytology. Since cervical biopsy showed cervical intraepithelial neoplasia III, we conducted loop electrical excision procedure, and the pathologic finding demonstrated microinvasive squamous cell carcinoma with a vertical invasion of 1 mm/3 mm in total thickness and horizontal spread of 4 mm without lymphovascular space invasion. For preserving her fertility, we performed cold knife conization again because of positive resection margin showing high-grade dysplasia. However, the pathologic finding showed invasive squamous cell carcinoma with a vertical invasion of 4.5 mm/10 mm in total thickness and horizontal spread of 8 mm with negative surgical margin on the 12 to 3 o’clock specimen. For defining clinical stage of cervical cancer, we performed computed tomography (CT) and magnetic resonance imaging of thge pelvis, which demonstrated no evidence of local tumor invasion or lymph node metastasis. Positron emission tomography-CT showed no definite malignant lesion, and sigmoidoscopy and cystoscopy showed no abnormal findings. Finally, she was diagnosed with stage IB1 cervical cancer, and we determined robot-assisted uterine artery-preserving radical trachelectomy, considering her strong desire to preserve fertility.
For this surgery, a four-arm da Vinci Si system (Intuitive Surgical, Inc., Sunnyvale, CA, USA) with a standard port placement and a set of robotic instruments for the pelvic surgery were used for the procedure [6]. In the pelvic cavity, we identified one enlarged lymph node in the left external iliac artery area, which was negative on the frozen section. Then, we performed systematic pelvic lymphadenectomy and para-aortic lymph node sampling till the level of the inferior mesenteric artery. Thereafter, radical trachelectomy preserving the uterine arteries was performed (Fig. 1), and a cerclage was placed with a transvaginal MERSILENE® polyester fiber suture. Uterovaginal reanastomosis was made through the vaginal approach and 6fr 2-way Foley catheter was placed in the uterine cavity to maintain patency.
The operation time was 330 minutes, and blood loss was about 200 mL. The final pathological examination showed no residual tumor in 3.5 cm sized specimen of the cervix and vagina, and no lymph node metastasis among 17 resected lymph nodes. After six months after surgery, no abnormal findings were observed (Fig. 2), and we recommend the attempt of her pregnancy through assisted reproductive technology.

Fertility care

She received clomiphene citrate for five days from the second day of her menstrual cycle and human menopausal gonadotropin for seven days followed by successful implantation with intrauterine insemination 14 months after surgery. Progesterone intramuscular injection and vaginal tablets were used for implantation support.

Obstetric care

As with other mothers, nuchal translucency measurements and pregnancy-associated plasma protein-A levels were checked at 12 weeks of gestation, and performed Quad test at 16 weeks of gestation. The intergrated test showed low risk. She had no specificities except for antibiotic treatment with repeated acute pyelonephritis during pregnancy.
Abdominal pain occurred at 21 weeks and three days of gestation, and 2 cm bag bulging was observed at ultrasonography and speculum exam. Thereafter, she was hospitalized and treated with prophylactic antibiotics due to incompetent internal os of cervix. At 22 weeks and one day of gestation, the rupture of membrane occurred. At 24 weeks and three days of gestation occured uterine contraction and started the tocolytics. Although she had received tocolytics for suppressing her uterine contraction, the regular contraction and fetal descent proceeded abruptly at 26 weeks and 3 days of gestation. Since the fetus was already in stage 3 and there is no fetal heart rate deceleration, we decided to try vaginal delivery instead of preparing for cesarean section. Since the fibrotic ring at the level of uterovaginal anastomosis interfered with the abrupt descent, we removed the cerclage knot and incised the ring by scissors at 2,10 o’clock for facilitating vagina delivery instead of cesarean delivery.
As a result, she immediately delivered a preterm male baby with no anomalies, weighing 830 g, who showed the Apgar score of 1 and 4 at 1 and 5 minutes, respectively. Umbilical cord PH 7.334 showd no fetal hypoxia. After delivery, the incision wound was healed without suture as with the lacerated cervix. Although the baby had been treated to the neonatal intensive care unit, she shows no recurrence, and her child is healthy five years after delivery.

Discussion

A radical trachelectomy is a treatment option for women with early-stage cervical cancer who want to preserve their fertility. Up to now, more than 900 cases about radical trachelectomy have been reported so far, resulting in 300 pregnancies and 196 live births, suggesting the pregnancy rate of 15-30% [7,8]. In spite of no evidence that the preservation of the uterine arteries during trachelectomy may improve fertility in women with early-stage cervical cancer, the importance of preservation of the uterine artery for improved fertility has been reported in several studies, where womens treated with the uterine artery embolization showed higher rates of preterm delivery and malpresentation (odds ratios, 6.2 and 4.3) than those treated with myomectomy [9]. This suggests that the preservation of the uterine arteries may be beneficial in subsequent pregnancies. Although the preserved uterine arteries have been reported to have about 88% of chance of occlusion after surgery [10], the preservation of them is still of value if more delicate surgery is performed in a larger field of view by laparoscopy or robot.
However, obstetrical complications including preterm labor and premature rupture of membrane are major obstacles that women with early-stage cervical cancer are reluctant to radical trachelectomy. Recent studies has reported that the rate of preterm delivery (24-37 weeks) was 25-28%, which is a four-fold increased risk compared with the normal population [11,12]. Moreover, premature delivery commonly appears to arise following premature rupture of membranes, the mechanism of which is due to cervical incompetence or ascending infection [13,14]. Although cerclage can provide a strong support because decreased mechanical support for the fetus by resecting the cervix is expected to be a significant risk to preterm labor, the extremely short cervix, and relevant risk of vulnerable infection are still major limitations for term delivery in women treated with radical trachelectomy. Thus, close monitoring of pregnancy and care of the fetus in a neonatal intensive care unit should be supported for them.
Furthermore, cesarean delivery is required for maternal and fetal health after radical trachelectomy because vaginal delivery can lead to uterine rupture and subsequent massive hemorrhage [15]. To the best of our knowledge, this is the first case report about vaginal delivery after radical trachelectomy. However, we tried vaginal delivery after incision of the fibrotic ring at the level of uterovaginal anastomosis because delivery proceeded too quickly before the preparation of the cesarean delivery, and fetal deceleration developed too much with compression of the fetal head to the fibrotic ring. Thus, we think that the vaginal delivery is a lucky success, and cesarean delivery is still the principle of delivery for women treated with radical trachelectomy.
In conclusion, robot-assisted radical trachelectomy can be considered for women with early-stage cervical cancer who strongly want their fertility, and the preservation of the uterine arteries may be feasible by laparoscopy or robot for improving fertility. Moreover, vaginal delivery can be attempted by incising the fibrotic ring at the level of uterovaginal anastomosis interfering fetal descent if delivery proceed too quickly before the preparation of cesarean delivery.

Notes

Conflict of interest

No conflict of interest relevant to this article was reported.

Ethical approval

Ethical Committee approval was received for this study from the Ethics Committee of Seoul national University School of Medicine, dated 06.11.2019 and numbered H-1906-022-1038.

Patient consent

Written informed consent and the use of images from patients are not required for the publication.

Funding information

None.

Fig. 1
Procedures for preserving the uterine artery in robot-assisted radical trachelectomy: (A) tunneling of left ureter with preservation of left uterine artery; (B) division of left vesicouterine ligament; (C) ligation of left deep uterine vein; (D) division of left anterior parametrium; (E) anterior colpotomy; (F) division of paracolpos; (G) division of cervical branch of left uterine artery; (H) amputation of the cervix at the level of the isthmus.
ogs-19127f1.jpg
Fig. 2
Postoperative view of the vaginouterine reanastomosis site at six months after surgery.
ogs-19127f2.jpg

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