The only constant in life, is change. Heraclitus

Vaginal radical trachelectomy with laparoscopic pelvic lymphadenectomy was first introduced by Daniel Dargent.1 This approach allowed select patients with early-stage cervical cancer to maintain fertility by preserving the uterine body while at the same time addressing the cancer. Vaginal radical trachelectomy has an acceptable oncologic outcome, in patients with tumors <2 cm and pelvic negative nodes, with a relapse and death rate of 4% and 2%, respectively.2 Of note, on my opinion, the procedure should have been originally called ‘modified vaginal radical trachelectomy’, as the uterine artery is ligated at its crossing with the ureter.

In this issue of International Journal of Gynecological Cancer, Köhler et al,3 report a retrospective evaluation on 471 patients who underwent radical vaginal trachelectomy spanning the time from 1995 to 2021. In their article, the authors reported on a young patient population (median age 33 years), with the majority of patients (83%) being nulliparous, and primarily (97%) with tumors <2 cm. Sentinel node detection was performed in 32% of patients, whereas 68% underwent systematic pelvic lymph node dissection. After a median follow-up of more than 13 years, the recurrence rate was 3.4%, and interestingly, more than 40% of these occurred after the fifth year of follow-up. The death rate was 2.1%.

The authors of the manuscript ought to be congratulated on publishing the largest series to date on radical vaginal trachelectomy with a very prolonged follow-up and an equally impressive low rate of loss to follow-up (n=3 patients). The authors should also be commended for their longstanding contributions to the field of gynecologic oncology and for the training of countless surgeons. With this article, our readership gains important information while at the same times it opens opportunities to reflect on gaps that should be further elaborated.

Given the retrospective nature of the study it is often difficult to capture the true denominator of patients who were considered, but ultimately did not have the procedure, and the reason for disqualifying such patients from this approach. Similarly, there was no stratification of outcomes by tumor size (<1 vs 1–2 cm) or by depth of stromal infiltration. In addition, there was no information provided as to the rate of previous conization or on the margin status. In the authors’ institution, frozen section evaluation is performed; however, many would call into question the accuracy of this routine practice, particularly in detecting isolated tumor cells or micrometastases. It is interesting that in the sentinel node group, a median of seven nodes was harvested (range 2–14). Some might argue that this is not consistent with the basic principles of sentinel lymph node mapping, where the sentinel lymph node is identified as the single lymph node closest to the organ of tumor origin. Some might argue that identifying 14 sentinel lymph nodes is practically a lymphadenectomy, thus how do the authors explain this finding? In addition, in this study, 31% of patients had stages IA2 or lower, thus suggesting that a vaginal radical trachelectomy was not necessary in such patients, thus an element of overtreatment. Lastly, as it pertains to oncologic outcomes, there is a gap, regarding information on location of recurrences and whether the recurrences were histologically confirmed or through imaging alone. One notable contribution in this manuscript is the fact that 40% of recurrences were documented after a very prolonged disease-free period. To the credit of this team, these findings might be explained by the extensive follow-up period (median 13 years) and high compliance rate with surveillance.

As it relates to the issues pertaining to fertility preservation, the authors report a very favorable fertility rate (73%). However, they report that fertility data were at times obtained by ‘phone calls’. This calls into question, the accuracy of the information as such approach lacks trackable documentation. Similarly, in a retrospective study it is always challenging to determine the number of patients who had assisted reproductive techniques.

The prospective ConCerv trial,4 demonstrated that a conization or simple hysterectomy in patients with low-risk (<2 cm) cervical cancer is associated with a low recurrence rate (2.4% after conization), and this paved the way for a more conservative approach in this patient population. Therefore, one cannot help but ask, what is the utility of radical vaginal trachelectomy in the future? Two reviews analyzing data on fertility and oncologic outcome in preservation techniques have been published by the same team within a 6-year period.2 5 These studies show a decrease in the reported number of patients undergoing vaginal radical trachelectomies and an increase in abdominal approach . This in turn has been followed by significant increase in publications and number of patients, receiving simple trachelectomy or conization in this same patient population (Table 1).

Comparison of two systematic literature reviews published by the same team in 2016 and 2022

The world is evolving, as well as our specialty, and we must prepare to embrace less aggressive treatments for patients with early-stage cervical cancer. We should continue to expand our knowledge and continue to explore options that will provide the least morbid surgical approaches to our patients while maintaining the best oncologic outcomes. In summary, for a procedure with decreasing numbers and indications, where the potential candidates are scant, and performed by few surgeons with a unique skill: are we to expect a continued decline in adoption of the procedure or a broader interest by the gynecologic oncology community? History thus far supports the former and not the latter.

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