Background/Objectives: Fertility-sparing surgery (FSS) is a standard practice for managing early stage cervical cancer, yet significant variation exists in clinical approaches worldwide. Our objective was to ascertain current practices and preferences for cerclage use among expert centers globally regarding FSS in patients with early stage cervical cancer. Methods: We conducted a cross-sectional survey from May to July 2023 involving expert centers identified through their scientific contributions and participation in international workgroups and conferences.. The survey, comprising 27 questions, evaluated existing practices in FSS. Results: Out of the centers surveyed, 21 (36.2%) gynecologic oncologists responded. For tumors <2 cm, 86% of centers preferred radical trachelectomy, primarily via the vaginal approach, while 13.6% favored a simple trachelectomy. Three experts preferred simple trachelectomy (13.6%). For tumors >2 cm, 47.6% utilized neoadjuvant chemotherapy before trachelectomy. Others did not offer FSS or performed an abdominal radical trachelectomy. Over time, there has been a shift towards less radical surgeries for tumors <2 cm and increased use of neoadjuvant chemotherapy for larger tumors. Some abandoned the minimally invasive surgical approach. Nearly all experts (90.5%) placed a cerclage immediately following trachelectomy. Conclusions: The majority of experts opt for radical trachelectomy in early stage cervical cancer, with immediate cerclage placement being a common practice. However, considerable international variations highlight the urgent need for standardized guidelines and further research to optimize treatment strategies, balancing oncological safety with fertility outcomes.

Cervical cancer has been and still is a major global health problem and a major treatment challenge for which surgical interventions have played a key role throughout the past century. In early stages (I/A2-II/B), where high-risk factors are not present, the efficacy of surgical and radiotherapy treatment has been considered equivalent with different (treatment modality specific) complications and quality of life consequences. Negative prognostic factors in early stages of the disease (pelvic lymph-node positivity) and in more advanced stages (parametrial and/or surgical margins’ tumor involvement) forecast the deterioration of outlooks for good life expectancy. In these high-risk cases, when radio- or chemoradiotherapy is contraindicated, we investigated the potential role of a more radical surgical approach than the traditional radical hysterectomy. Twenty-five years ago, a hyperradical surgical procedure for the treatment of high-risk cervical cancer patients was introduced in Budapest. The procedure was named as laterally extended parametrectomy (LEP) in Budapest Hungary. The surgical intention was the complete removal of the fibro-fatty tissue content of the pelvis, which contains the lymphatic vessels, lymph nodes, and tumor-affected pelvic side wall structures. We initiated observational studies on the primary treatment in parametrium and/or lymph-node tumor-positive early-stage cases and on second-line surgical therapy of pelvic side wall recurrent tumors following radiotherapy. Promising results of our observational studies propose that prospective randomized trials are worth to be initiated to clarify the potential of this treatment modality in this poor prognosis cohort of patients.

In the choice of a planned fertility preservation procedure for stage IA1 and IB1 cervical cancer, optimal oncological safety is the main focus of virtually all protocols. The surgeon should remove the appropriate proportion of the cervix for oncological safety, ensuring an adequate tumour-free surgical margin. However, some of the literature on fertility preservation, referring to histological parameters, still considers conisation with excellent fertility results to be optimal for the treatment of tumours with a diameter of 2 cm. With regard to fertility preservation in the case of radical trachelectomy versus simple conisation, we are aware of several ongoing studies, the results of which may provide an answer as to whether a more conservative surgical therapy for smaller tumours (less than 2 cm in diameter) represents an acceptable oncological safety.

Objective To describe the laterally extended parametrectomy (LEP) surgical technique, emphasizing the main challenges of the procedure. Methods LEP was designed as a more radical surgical procedure aiming to remove the entire parametrial tissue from the pelvic sidewall. Its initial indications were for lymph node positive Stage Ib (current International Federation of Gynecology and Obstetrics 2018 Stage IIIc) and Stage IIb cervical cancer. Currently, with most guidelines recommending definitive radiochemotherapy for these cases, initial LEP indications have become debatable. LEP is now mainly indicated for removing tumors involving the soft structures of the pelvic sidewall during a pelvic exenteration, aiming to obtain lateral free margins. This expands the lateral borders of the dissection to not only the medial surface of internal iliac vessels, but also to the true limits of the pelvic sidewall. Results During LEP, the parietal and visceral branches of the hypogastric vessels are divided at the entry and exit level of the pelvis. Consequently, the entire internal iliac system is excised, and no connective or lymphatic tissue remain on the pelvic sidewall. The main technical challenges of LEP are caused by the difficulty in ligating large caliber vessels (internal iliac artery and vein) and the variable anatomic distribution of pelvic sidewall veins. Conclusion LEP is a feasible technique for removing pelvic sidewall recurrences, aiming to obtain surgical free margins.

After total or anterior pelvic exenteration, a urinary diversion must be performed. The Bricker conduit, a non-continent urinary diversion tailored from the ileum, sigmoid colon, or other bowel parts, is most frequently used in gynecologic oncology surgery because of its simplicity and reliability

Mibayashi invented super-radical hysterectomy, and his operative method was intended for radical surgery in patients with stage IIIB cervical cancer. However, the combination of intracavitary and external radiation currently provides a good outcome with good quality of life in patients with advanced cervical cancer. However, the survival rate of patients with stage IIIB cancer is approximately 50-65%, and further efforts to improve the outcome should be continued. As described by Mibayashi himself, a parametrial lymph node metastasis fixed to the origin of the cardinal ligament can be identified at laparotomy in some patients with clinical stage IB-IIB disease, and super-radical hysterectomy is a useful surgical approach in such patients. Regarding the safety of this operative method, because the internal iliac vessels can be clearly visualized after lymph node dissection during current curative surgery for cervical cancer, it is possible to perform super-radical hysterectomy safely. Although super-radical hysterectomy is not a surgical procedure of routine use for cervical cancer, it is an important operative method that should be used in a flexible manner as indicated, depending on the tumor findings at laparotomy.

Objective: Invasive cervical cancer is one of the most common cancers, with 500,000 new cases diagnosed annually. Fertility preservation has become an important component of the overall quality of life of many cancer survivors. Expert opinion has suggested that fertility-sparing surgery should be limited to those patients diagnosed with cervical cancer less than 2 cm in diameter. Our objective was to report our abdominal radical trachelectomy (ART) experience in the opposite group of patients-those with a cervical cancer more than 2 cm in diameter.Methods: Between 1999 and 2006, a total of 45 patients with cervical carcinoma at International Federation of Gynecology and Obstetrics stage IB1-IB2 measuring more than 2 cm in diameter underwent fertility-sparing ART and pelvic lymphadenectomy at the 3 institutions where the authors are based (Budapest, Hungary; London, United Kingdom; New York, United States). They were followed up for more than 5 years.Results: For 69% of patients (n = 31), completed ART was considered to have been curative, and no adjuvant treatment was advised. Of those patients, 93.5% (n = 29) were alive at the time of follow-up. Thirty-one percent of patients (n = 14) underwent immediate completion of radical hysterectomy. Three of 8 patients who wished to fall pregnant delivered healthy neonates.Conclusions: The 5-year survival rate (93.5%) for this case series is equal (or better) to rates reported in the literature for patient treated with radical hysterectomy. Our survival data seem to support the hypothesis that ART is a safe treatment option for patients with invasive cervical cancer lesions of more than 2 cm.

INTRODUCTION:Recurrence originating from the pelvic lymph node containing fibro-fatty tissue has consistently been identified as the most frequent pattern of treatment failure in early-stage cervical cancer. A surgical technique for the complete removal of the connective tissue content of the pelvis was introduced at St. Stephen Hospital in 1993 to improve oncological outcome by reducing the risk of recurrence from the pelvis. Efficacy and toxicity of the procedure were studied in 563 patients with stage IB cervical cancer with a completed 5-year follow-up.METHODS:Final pathology in 492 (87.4%) of 563 consecutive completed radical hysterectomies suggested that all tissue, which could contain tumor dissemination, was removed from the pelvis; thus, no adjuvant treatment was applied. Adjuvant chemoradiotherapy was advised in 71 cases (12.6%), where pathologic finding alluded tumor spread beyond the study criteria.FINDING:At completed 5-year follow-up, the overall survival of 492 patients who had surgery without adjuvant therapy was 94.0%. Pathologic stage, lymphovascular space involvement, pelvic lymph node metastases, histology classification, and grade had no significant influence on prognosis. The only factor that influenced the overall survival was International Federation of Gynecology and Obstetrics stage (IB1 or IB2). Five-year overall survival of 71 patients to whom adjuvant therapy was recommended was 56.3%. Five-year overall survival of the whole cohort (n = 563) was 88.8%. The complication rate did not seem to be different from the published data on traditional radical surgery in cervical cancer.CONCLUSIONS:Our results (in accordance with other recent publications) suggest that complete excision of the connective tissue content of the pelvis provides equal or better survival chances without any adjuvant treatment for almost 90% of operable patients with stage IB cervical cancer than less radical surgery with or without adjuvant treatment. We suggest this strategy to be mentioned as one alternative in future treatment protocols.

The idea of using organ transplantation to solve quality-of-life issues was first introduced a century ago, with cornea transplants and thrusted before the world again in 1998, following a controversial hand transplant. Uterus transplantation (UTn) has been proposed as another quality-of-life transplant for the cure of permanent uterine factor infertility. In order to proceed in humans, a greater appreciation of the immunological mechanisms that underlie UTn is desirable. Allogeneic UTn (animal model) was first described by 2 studies in 1969. The first and only human UTn, performed in 2000, was an early attempt with limited use of animal model experiments prior to moving onto the human setting. Since then, work using rat, mouse, ovine, goat, and nonhuman primate models has demonstrated that the uterus is a very different but manageable organ immunologically compared to other transplanted organs. Therefore, specifically exploring immunological issues relating to UTn is a valuable and necessary part of the inevitable scientific process leading to successful human UTn.

We read with interest the case report by Gurney et al.1Gurney E.P. Blank S.V. Postpartum radical trachelectomy for IB1 squamous cell carcinoma of the cervix diagnosed in pregnancy.Am J Obstet Gynecol. 2009; 201: e8-e10Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar We have authorship of the initial work in the field of abdominal radical trachelectomy and also ongoing studies examining the outcomes of patients treated in this manner.2Smith J.R. Boyle D.C. Corless D.J. et al.Abdominal radical trachelectomy: a new surgical technique for the conservative management of cervical carcinoma.Br J Obstet Gynaecol. 1997; 104: 1196-1200Crossref PubMed Scopus (204) Google Scholar, 3Palfavi L. Ungar L. Boyle D.C.M. Del Priore G. Smith J.R. Announcement of a healthy baby boy born following abdominal radical trachelectomy.Int J Gynaecol Cancer. 2003; 13: 249Crossref Scopus (36) Google Scholar, 4Ungar L. Smith J.R. Palfavi L. Del Priore G. Abdominal radical trachelectomy during pregnancy to preserve pregnancy and fertility.Obstet Gynaecol. 2006; 108: 811-814Crossref PubMed Scopus (86) Google Scholar We were pleased to read of the successful outcomes relating to the patient investigated by Gurney et al and also the positive way in which fertility-sparing options were presented in the article.However, we were slightly surprised to read that the patient was advised to undergo immediate radical hysterectomy and lymphadenectomy with fetus in situ on diagnosis, and it was only that she was extremely resistant to hysterectomy that conservative management options were discussed. Also, it was disappointing that only postpartum fertility-sparing management options were discussed and not options that were available to her during the pregnancy, such as neoadjuvant chemotherapy and those explored by Ungar et al in our case series.4Ungar L. Smith J.R. Palfavi L. Del Priore G. Abdominal radical trachelectomy during pregnancy to preserve pregnancy and fertility.Obstet Gynaecol. 2006; 108: 811-814Crossref PubMed Scopus (86) Google ScholarAlthough 3 of 5 pregnancies were lost after radical trachelectomy in our case series as mentioned by Gurney et al,1Gurney E.P. Blank S.V. Postpartum radical trachelectomy for IB1 squamous cell carcinoma of the cervix diagnosed in pregnancy.Am J Obstet Gynecol. 2009; 201: e8-e10Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar 2 of these 3 were in fact the first 2 cases performed. This is significant because the surgical technique was being improved constantly as both knowledge and experience of the procedure was gained. In particular, more careful dissection of the uterine arteriovenous tree was used in later surgeries. Therefore, current surgical outcomes during pregnancy are likely to be far more favorable, as demonstrated in the later cases of the series.Currently all of the women treated in our series during pregnancy with radical abdominal trachelectomy have retained fertility with a median follow-up of more than 3 years.We thank the authors for their work in producing this case report, which highlights that favorable oncological outcomes are possible using abdominal radical trachelectomy as a fertility-preserving surgical technique. We read with interest the case report by Gurney et al.1Gurney E.P. Blank S.V. Postpartum radical trachelectomy for IB1 squamous cell carcinoma of the cervix diagnosed in pregnancy.Am J Obstet Gynecol. 2009; 201: e8-e10Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar We have authorship of the initial work in the field of abdominal radical trachelectomy and also ongoing studies examining the outcomes of patients treated in this manner.2Smith J.R. Boyle D.C. Corless D.J. et al.Abdominal radical trachelectomy: a new surgical technique for the conservative management of cervical carcinoma.Br J Obstet Gynaecol. 1997; 104: 1196-1200Crossref PubMed Scopus (204) Google Scholar, 3Palfavi L. Ungar L. Boyle D.C.M. Del Priore G. Smith J.R. Announcement of a healthy baby boy born following abdominal radical trachelectomy.Int J Gynaecol Cancer. 2003; 13: 249Crossref Scopus (36) Google Scholar, 4Ungar L. Smith J.R. Palfavi L. Del Priore G. Abdominal radical trachelectomy during pregnancy to preserve pregnancy and fertility.Obstet Gynaecol. 2006; 108: 811-814Crossref PubMed Scopus (86) Google Scholar We were pleased to read of the successful outcomes relating to the patient investigated by Gurney et al and also the positive way in which fertility-sparing options were presented in the article. However, we were slightly surprised to read that the patient was advised to undergo immediate radical hysterectomy and lymphadenectomy with fetus in situ on diagnosis, and it was only that she was extremely resistant to hysterectomy that conservative management options were discussed. Also, it was disappointing that only postpartum fertility-sparing management options were discussed and not options that were available to her during the pregnancy, such as neoadjuvant chemotherapy and those explored by Ungar et al in our case series.4Ungar L. Smith J.R. Palfavi L. Del Priore G. Abdominal radical trachelectomy during pregnancy to preserve pregnancy and fertility.Obstet Gynaecol. 2006; 108: 811-814Crossref PubMed Scopus (86) Google Scholar Although 3 of 5 pregnancies were lost after radical trachelectomy in our case series as mentioned by Gurney et al,1Gurney E.P. Blank S.V. Postpartum radical trachelectomy for IB1 squamous cell carcinoma of the cervix diagnosed in pregnancy.Am J Obstet Gynecol. 2009; 201: e8-e10Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar 2 of these 3 were in fact the first 2 cases performed. This is significant because the surgical technique was being improved constantly as both knowledge and experience of the procedure was gained. In particular, more careful dissection of the uterine arteriovenous tree was used in later surgeries. Therefore, current surgical outcomes during pregnancy are likely to be far more favorable, as demonstrated in the later cases of the series. Currently all of the women treated in our series during pregnancy with radical abdominal trachelectomy have retained fertility with a median follow-up of more than 3 years. We thank the authors for their work in producing this case report, which highlights that favorable oncological outcomes are possible using abdominal radical trachelectomy as a fertility-preserving surgical technique. Postpartum radical trachelectomy for IB1 squamous cell carcinoma of the cervix diagnosed in pregnancyAmerican Journal of Obstetrics & GynecologyVol. 201Issue 4PreviewStandard management of stage IB1 cervical cancer in pregnancy is radical hysterectomy with fetus in situ if diagnosis precedes viability, or cesarean radical hysterectomy. Postpartum abdominal radical trachelectomy was performed as an alternative, fertility-preserving surgery in a 30-year-old nulliparous woman diagnosed with stage IB1 cervical at 21 weeks' gestation. Full-Text PDF

To the Editor: W read with interest the guidelines for the management of invasive cervical cancer during pregnancy proposed by Morice et al.1 Traditionally, the management of pregnant patients with cervical cancer consisted of termination of pregnancy, followed by treatment of the cervical tumor. This can unfortunately lead to loss of future fertility. The recommendations described by Morice et al are based on a literature review conducted by the members of a working group in France, set up in 2007. They are split into 3 groups: (a) tumor diagnosed at term with fetal maturity (almost) complete, (b) tumor diagnosed pre-term with patient wishing to preserve the fetus, and (c) patients with a more aggressive histological subtype. We were surprised, however, that the authors failed to mention radical trachelectomy (RT) as a relatively recent and safe option for young women with early-stage cervical cancer. We have authorship of the initial work in the field of abdominal RT and also ongoing studies examining the outcomes of patients treated in this manner. In our 2006 article, we presented 5 pregnant patients who underwent abdominal RT. We reported the birth of 2 healthy term infants and the loss of 3 fetuses in the 7th, 8th, and 15th gestational week (GW). The patients were followed up for 40 months with no record of relapse. However, on closer analysis of the lost fetuses, we note that 2 of these 3 were in fact the first 2 cases in which the procedure was performed. We believe this to be of significance because since then, the surgical technique has improved constantly as both knowledge and experience of the procedure have increased. In particular, more careful dissection of the uterine arteriovenous tree has been used in subsequent surgeries. Therefore, current surgical outcomes during pregnancy are likely to be far more favorable. In fact, since the above report, all of the women treated in our series during pregnancy with radical abdominal trachelectomy have retained fertility with a median follow-up of more than 3 years. Mandic et al and Abu-Rustum et al also reported their experiences of performing abdominal RT on pregnant women in the 19th and 15th GW, respectively. In both cases, the patients had a cesarean delivery in the 36th and 39th GW, respectively, and delivered a healthy newborn. No further relapse has been demonstrated after RT. In addition to the above abdominal RT reports, van de Nieuwenhof et al performed the first case of vaginal RTon a pregnant patient in the 18th GW to treat cervical carcinoma stage IB1. The patient delivered a healthy infant in the 35th GW via an elective cesarean delivery followed by a radical hysterectomy that, on further analysis, revealed no tumor spread. A 9-month follow-up period revealed no relapse. We acknowledge the challenge of treating cervical malignancy while simultaneously maintaining pregnancy and thank the authors for producing the aforementioned guidelines. We would also respectfully suggest that RT should be offered at highly specialized gyneoncological centers as an alternative approach to managing invasive cervical cancer in the second trimester of pregnancy. Srdjan Saso, MBBS, BSc Laszlo Ungar, MD, PhD Laszlo Palfalvi, MD Giuseppe Del Priore, MD, MPH J. Richard Smith, MD, FRCOG Department of Obstetrics and Gynaecology Hammersmith Hospital, Imperial College London, United Kingdom srdjan.saso@imperial.ac.uk

The Obstetrician & GynaecologistVolume 12, Issue 1 p. 64-65 Abdominal radical trachelectomy—a fertility-sparing treatment for cervical cancer Simon A Hurst MBBS BSc (Hons), Simon A Hurst MBBS BSc (Hons) Academic Clinical Fellow Imperial College London, UK simonhurst@doctors.org.ukSearch for more papers by this authorDr Giuseppe Del Priore MD MPH, Dr Giuseppe Del Priore MD MPH Associate Professor, Vice President Research Weil Cornell, New York, USA New York Downtown Hospital, New York, USASearch for more papers by this authorDr Laszlo Ungar MD, Dr Laszlo Ungar MD Consultant in Obstetrics and Gynaecology St Stephen's Hospital, Budapest, HungarySearch for more papers by this authorMr J Richard Smith MD FRCOG, Mr J Richard Smith MD FRCOG Consultant Gynaecological Surgeon, Adjunct Associate Professor Imperial College London, UK New York University, New York, USASearch for more papers by this author Simon A Hurst MBBS BSc (Hons), Simon A Hurst MBBS BSc (Hons) Academic Clinical Fellow Imperial College London, UK simonhurst@doctors.org.ukSearch for more papers by this authorDr Giuseppe Del Priore MD MPH, Dr Giuseppe Del Priore MD MPH Associate Professor, Vice President Research Weil Cornell, New York, USA New York Downtown Hospital, New York, USASearch for more papers by this authorDr Laszlo Ungar MD, Dr Laszlo Ungar MD Consultant in Obstetrics and Gynaecology St Stephen's Hospital, Budapest, HungarySearch for more papers by this authorMr J Richard Smith MD FRCOG, Mr J Richard Smith MD FRCOG Consultant Gynaecological Surgeon, Adjunct Associate Professor Imperial College London, UK New York University, New York, USASearch for more papers by this author First published: 24 January 2011 https://doi.org/10.1576/toag.12.1.064b.27561Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume12, Issue1January 2010Pages 64-65 RelatedInformation

OBJECTIVES:To report a series of patients treated with modified radical abdominal trachelectomy to preserve fertility in benign disease that would normally result in hysterectomy. DESIGN:We reviewed all cases of radical abdominal trachelectomy performed for nonneoplastic indications. PATIENT(S):Of the >160 radical abdominal trachelectomies we performed, four cases were performed for benign indications. One patient had a 10-year history of progressive endometriosis with worsening hydronephrosis, failed medical therapy, and infertility. Two myomectomy patients had intraoperative consultation and a third had preoperative consultation for large lower segment/cervical myomas with conversion to trachelectomy rather than hysterectomy. INTERVENTION(S):Modified radical trachelectomy was successfully completed in all patients. MAIN OUTCOME MEASURE(S):We measured the successful completion of the surgery without hysterectomy, complications, and follow-up. RESULT(S):Hysterectomy was avoided in all patients, and all resumed normal menses. There were no intraoperative or postoperative complications. One required hysterectomy for recurrence 1 year later, and the remainder were symptom free at 1-5 years of follow-up. CONCLUSION(S):Although traditionally performed with cervical cancer, radical abdominal trachelectomy can be modified to preserve fertility for benign indications that would otherwise require hysterectomy.

Uterine transplantation may be a possible treatment option in the future for absolute uterine infertility. The tolerance of human uterine tissue to cold ischemic preservation is one of the issues that need to be resolved. The objective of this study was to assess the morphological changes in human uterine tissue after cold ischemic preservation in a transplant solution. Small tissue samples of human uteri were subjected to cold ischemia (2-8 degrees C for up to 48 hours) in Celsior transplant solution. Histological analysis by light and electron microscopy was used to assess evidence of cold ischemic injury. Histological examination did not show any major changes of the uterine tissue after 48-hour cold preservation; whereas, electron microscopy after 24 hours confirmed unchanged structural integrity of the uterine myoendometrium. The human uterus is morphologically resistant toward cold ischemia in Celsior preservation solution for up to 24 hours and may be suitable for transplantation purposes.

Despite the reports of a number of leading institutions concerning the use of primary exenteration, there are differences in regard to definition, indications, and interpretation of results of this treatment approach to cervical cancer. In this paper we present our own experience with 41 cervical cancer patients treated with primary exenteration at St. Stephen Hospital Budapest. We explore some important unsettled aspects (definition, indications, and quality of life consequences) of this treatment modality in view of our own experience and the literature. Between January 1993 and June 2006, 2540 invasive cervical cancer patients were seen at the gynecologic oncology service of the St. Stephens Hospital Budapest. Two hundred twelve (8%) of these patients were surgically explored with the plan of an exenterative surgery. Exenteration was the primary treatment in 41 (25%) of 166 completed exenterations; these 41 cases included 2 cases of supralevator total exenteration, 9 cases of supralevator anterior exenteration, and 30 cases of partial supralevator anterior exenteration. In the 2 total exenteration patients, anal function was restored with a low rectal anastomosis, with a temporary defunctioning colostomy in 1 patient. Urethral function was restored in 9 out of 11 supralevator exenteration cases with the Budapest pouch bladder replacement technique. In the remaining 2 cases, a Bricker conduit was used for urinary diversion. There was no operation-related mortality in this cohort of patients. An external fecal or urinary stoma was avoided in 38 (93%) out of the 41 primary exenteration patients; in 1 patient a temporary defunctioning colostomy was used; and in 2 patients a permanent ileal conduit was created. In 9 patients (22%), complications (ileus and peritonitis, occlusion of the femoral artery, stricture of the implanted ureter, and postoperative ureterovaginal fistula) necessitated surgical intervention. A quality of life study revealed the need for prolonged self-catheterization, partial (mainly night time) incontinence, and lymphedema in 7 patients. We consider and suggest that an en bloc resection of part(s) of the urinary bladder and/or the rectum with the uterine cervix should be considered an exenteration (partial exenteration). A 50% survival rate of a select group of stage IVA cervical cancer patients treated with primary exenteration can be considered significant, but cannot be considered superior to that of chemoradiation therapy. The same applies when considering treatment-related mortality and complications that require operative interventions. Low rectal anastomosis and orthotopic bladder replacement with a relative low risk of fistula formation in non-irradiated patients constitute a strong quality of life argument in favor of primary exenteration in a select group of stage IVA cervical cancer patients.

OBJECTIVE: To determine if a uterus can be retrieved for reproductive organ transplantation and to describe the surgical technique.METHODS: We participated in a local organ donor network retrieval team for over 6 months. Heart-beating, brain-dead multi-organ donors were identified through an existing donor network following routine protocols.RESULTS: After institutional review board and organ donor network approval of the uterus transplantation project, approximately 1,800 eligible organ donors were identified as required by legislation. Multi-organ procurement surgery took place in approximate 150 of these, with nine specifically consented for the uterus retrieval. Regularly performed multi-organ transplantation retrievals included the uterus without complications in eight donors. Peclicles used included the ovarian, uterine, or internal iliac vessels. After retrieval, serial histology sections throughout the period of cold ischemia, taken every 15-30 minutes, showed no signs of change over 12 hours of cold ischemia.CONCLUSION: The human uterus can be obtained from local organ donor networks using existing protocols.

This study was designed to establish if pulse oximetry (O(2)Sat) and perfusion index (PI) could be used to assess the contribution that uterine and ovarian vessels make to the overall perfusion of the uterus. During routine hysterectomies, the O(2)Sat and PI were measured over the right and left uterine cornu. These measurements were taken before any vessels were ligated (baseline), after only the ovarian vessels were clamped and then after the uterine vessels were clamped. Clamping the ovarian vessels alone decreased the uterine O(2)Sat and PI by a statistically significant amount. Subsequent clamping of the uterine vessels produced further significant decreases in O(2)Sat and PI. We concluded that both pairs of vessels contribute almost equally to uterine perfusion and that there may be a role, particularly for O(2)Sat and possibly for PI variables, in determining the success of uterine and ovarian vessel reanastomosis in uterine transplantation.