Conservative surgery for cervical cancer

Conservative surgery for cervical cancer: when is it used and what does it involve?

Cervical cancer surgery is based on two basic principles: preserving the fertility of women of reproductive age who wish to bear children in the future, and individualised treatment, depending on the stage of the disease, the extent of the cancer and ways of preventing recurrence.

Professor Elvira Bratila, MD, PhD, coordinates in Romania the team with the greatest expertise in oncological interventions in the gynaecological field and is the one who performed the first radical trachelectomy with pelvic lymphadenectomy in Romania by a minimally invasive route (laparoscopic or robotic surgery), being one of the few surgeons who perform this procedure in this way.

There are two categories of cervical cancer surgery: early cervical cancer surgery, stage 1A and 1B1, i.e. tumours under 2 cm, and advanced cervical cancer surgery, tumours measuring more than 2-4 cm, with the potential to expand and evolve.

Conservative treatments can be used in the early stages of cancer if the patient wants to have children, so that she can preserve her menstrual function and reproductive capacity. Usually the cervix is excised, along with the surrounding tissues, where the cancer frequently spreads, along with the lymph nodes. This allows us to preserve the uterus, which is essential for the implantation of a pregnancy.

When we talk about a conservative operation, the surgery is done in two stages:

  1. Identification of the sentinel nodes, by injecting a coloured substance, in order to identify the lymph nodes on the right and left, where the tumour drains most frequently. Robotic surgery has the advantage that a substance can be injected to better identify the sentinel node, the robot providing better visibility and has the benefit of injecting a substance – Indocyanin green – to guide the surgeon by highlighting the sentinel node and the entire lymph pathway.
  2. The lymph node is excised and then sent to pathology for a histological analysis, which reveals whether or not the tumour has infiltrated the tissue.

It is performed intraoperatively, so a decision can be made right during the surgery. If it is negative, you can do conservative surgery, pelvic lymphadenectomy, followed by radical trachelectomy (excision of the cervix with surrounding tissue).

If the cancer spreads, the tumour exceeds 2 cm, and the patient does not wish to preserve fertility, the treatment consists of radical hysterectomy with pelvic lymphadenectomy.

In advanced cancers, with tumours over 4 cm – when the tumour extends anteriorly to the bladder or posteriorly to the rectum, we have to do extensive exenteration surgery. When the tumour extends towards the bladder, anterior exenteration is performed – internal genital organs, surrounding tissues and the bladder are removed and an internal urinary diversion is performed to ensure urinary function. In case of cervical tumour extension to the rectum, posterior exenteration is performed – excision of internal genital organs, surrounding tissues, and the infiltrated segment of the digestive tract.

In the radical treatment of cervical cancer, radical hysterectomy with pelvic lymphadenectomy is performed, which can be performed classically, by incision, or minimally invasive, laparoscopically or robotically. One advantage of robotic surgery is the ability to perform sentinel lymph node, followed by pelvic lymphadenectomy and radical hysterectomy, with excision of the parametrium, depending on the stage of the disease.

Pelvic cancer surgery follows the trend of “tailoring surgery”, which means an individualized surgical approach, because each case is unique and requires a personalized medical decision, depending on the stage and extent of the cancer.