Dr. Pedro Ramirez on trachelectomy

While at the time I felt like I would end up having every procedure under the sun for cervical cancer, I did not have to have a radical trachelectomy.  To understand the procedure better, I asked Pedro Ramirez, MD, from MD Anderson Cancer Center to talk with me about the surgery.  He trained with the physician who developed it, Daniel D’Argent from Lyons, France.  He offered a lot of good news for women who may need a trachelectomy.

According to Dr. Ramirez, radical trachelectomy can be done for stages 1A1 with lymphvascular space invasion, 1A2 and 1B1 with certain tumor types.  Only squamous, adenocarcinoma or adenosquamous types are eligible because other tumor types recur at a higher rate.  Since preventing the cancer from coming back is the goal, doctors have to draw the line on the more aggressive tumor types. 

The good news is that the recurrence rates for trachelectomy versus radical hysterectomy in early stage disease are the same.  Approximately 800 trachelectomy cases worldwide have been followed, and the recurrence rate is around 4%.  These women have smaller tumors, and so whether they choose a radical hysterectomy or a trachelectomy, they have a good prognosis.

And the even better news is that 75% of women who try to get pregnant post-trachelectomy will get pregnant naturally!  They don’t usually need expensive procedures like IVF, and 65% of the pregnancies actually go full-term and have normal, healthy babies.  The rates of miscarriage in the 1st or 2nd trimester are the same as for any other normal woman.

When do you know if you can have a trachelectomy and not a radical hysterectomy?

Even though I had read a lot about trachelectomies, I was confused about how a woman would know if she can have just a trachelectomy--or if a radical hysterectomy would be required.  Dr. Ramirez explained to me that patients have imaging studies like MRI done before surgery to make sure that the cancer hasn’t spread further.  But it isn’t until the middle of surgery that doctors will know what has to be done.  

Patients are told before surgery that once they’re under anesthesia, the surgeons will cut out the majority of the cervix and nearby lymph nodes.  The cervical tissue will be examined immediately by the pathologist under microscope.  If the tumor is less than 2 cm with at least an additional 1 cm of normal tissue margin and all lymph nodes look uninvolved by visual inspection, they will wake up with a trachelectomy.  Otherwise, they will have a radical hysterectomy.

That made me pause.  

It would be scary to go into surgery not knowing what will happen, but at least with a surgeon like Dr. Ramirez, you know you have your best shot.  

Dr. Ramirez sews in a cerclage at the same time so the patients only need one surgery.  Then he puts in what’s called a “Smitt sleeve” through the canal he created so that it doesn’t heal shut.  After about a month, he just pulls the sleeve out during a vaginal exam, and that’s how a period can get out and sperm can get in.  

Interestingly, trachelectomy started as a vaginal procedure, but now places like MD Anderson do it abdominally with the help of robotics so that the incisions are small and recovery is usually just one hospital night.  

Some women have complications after surgery like stenosis, infection, blocked menstruation, or abnormal Pap smears, but these things have happened in only about 10% of women.     

After a trachelectomy, women need to go for followup Pap smears at least twice a year, and when they’re healed and ready, they can try to get pregnant--as early as 6 months after surgery.  20% of women go on to get pregnant more than once.  They can’t have normal, vaginal deliveries because of the cerclage, so they have planned C-sections, but who cares?  The goal is to preserve your ability to have children.

The reason more women don’t have radical trachelectomies instead of radical hysterectomies is largely that they don’t know about the procedure since so few surgeons and centers offer it—only about 10 centers worldwide have surgeons who know how to do it.  He estimates that 48% of women who have radical hysterectomies for early stage disease could have had a radical trachelectomy instead.

Dr. Ramirez said that women fear the risk of recurrence if they have a radical trachelectomy, and they think that pregnancy afterwards will be difficult.  He does about 10 trachelectomies a year, but he could be doing double that if more women knew about it and understood that the recurrence rates are the same as for a radical hysterectomy.  A radical trachelectomy is not a second-rate option.

So if your doctor tells you that you have stage 1A1, 1A2 or 1B1 cervical cancer and need a radical hysterectomy, contact one of the doctors who do radical trachelectomies and get another opinion.  You have time to investigate your options, and if you want to get pregnant some day and have children, take the time.