Cervical Surgery: An Overview of Removal Methods

Trachelectomy is the removal of the cervix to treat precancer and early-stage cervical cancer while preserving the uterine body. Options include simple trachelectomy for noninvasive and minimally invasive conditions and radical trachelectomy for early invasive cancer, which additionally involves removing surrounding tissue and the upper vagina, as well as assessing lymph nodes. It is an organ-preserving alternative to hysterectomy and allows for the preservation of pregnancy potential in carefully selected patients. [1]

Radical trachelectomy is indicated primarily for early invasive cervical cancer in patients wishing to preserve fertility. According to current European guidelines, it is acceptable for low-risk stages provided safety criteria are met, including limited tumor size, no evidence of lymph node involvement, and the ability to achieve clear resection margins. During the procedure, a permanent suture is usually placed at the site of the new internal os to prevent uterine dilation during pregnancy. [2]

It is important to distinguish between trachelectomy and cervical amputation. Amputation shortens the elongated cervix and is used primarily for prolapse and functional deformities, whereas trachelectomy removes the cervix as an organ and adjacent tissues for oncological purposes. These procedures address different objectives and are chosen for different indications. [3]

In recent years, updated guidelines from European professional societies have been published, systematizing the place of trachelectomy among organ-preserving approaches. These guidelines emphasize the need for surgeries to be performed in experienced centers, standardized lymph node staging, and strict selection criteria, which are related to safety and long-term outcomes. [4]

Table 1. Types of cervical ablation surgeries

Option	Volume of removal	Lymph nodes	Target
Simple trachelectomy	Neck, minimal surrounding tissues	According to the readings	Precancerous and microinvasive forms when preserving the uterus is desired
Radical trachelectomy	Cervix, parametria, upper vagina	Obligatory lymph node stage	Early invasive cancer with fertility preservation
Amputation of the neck	Distal part of the neck	Not related to oncology	Correction of cervical elongation and prolapse

Summarized from clinical guidelines. [5]

Indications and limitations

The key indications for radical trachelectomy are early-stage invasive cervical cancer in patients desiring uterine preservation. European guidelines state that organ-preserving treatment is possible with a small tumor size, no signs of lymph node involvement based on preoperative examination, and a high probability of achieving clear resection margins. Aggressive histological variants preclude organ-preserving treatment. [6]

Simple trachelectomy is considered for adenocarcinoma in situ and some microinvasive conditions that require a more extensive excision than conization, but without parametrectomy. If negative margins cannot be achieved after repeated excisions, hysterectomy is preferred; if fertility preservation is desired, repeat conizations and extended diagnostics with close follow-up are acceptable. [7]

Significant limitations of radical trachelectomy include large tumor size, extensive stromal involvement, unfavorable histotypes, and identified lymph node metastases. For tumors larger than 2 centimeters, the risk of recurrence is higher, requiring particular caution in the choice of approach and often altering the surgical plan. [8]

The decision to preserve organs is made through a multidisciplinary process and discussed with the patient, taking into account oncological safety, fertility plans, and alternatives. Review studies and recommendations emphasize that organ-preserving strategies, when properly selected, yield acceptable oncological outcomes, but are not suitable for rare, aggressive variants. [9]

Table 2. Indications and contraindications for organ-preserving surgery

Criterion	It can be considered	Not recommended
Size of the fire	Small early stage tumors	Tumors larger than 2 cm without strong reservations
Lymph nodes	No signs of metastases	Confirmed metastases
Histology	Squamous cell carcinoma, typical adenocarcinomas	Neuroendocrine, HPV-independent adenocarcinomas
Resection margin	Expectedly clean	High risk of positive margin

According to ESGO and modern reviews. [10]

Preoperative examination and selection

The preoperative phase includes staging based on clinical data and imaging, assessment of the cervix and parametria, and planning of lymph node staging. Preoperative risk stratification and discussion of all treatment alternatives with documented consent are recommended. This improves oncological safety and predictability of outcomes. [11]

When planning organ preservation, a lymph node staging strategy is important. In early stages, sentinel lymph node biopsy with mandatory ultrastaging is acceptable, which reduces morbidity compared to extended pelvic lymph node dissection with comparable diagnostic yield in experienced centers. If metastases are detected, the surgical plan is revised. [12]

Selection for simple trachelectomy for adenocarcinoma in situ relies on achieving negative margins and ruling out invasion. If clear margins cannot be achieved after repeated excisions, hysterectomy is recommended; if fertility is desired, a conservative approach under enhanced surveillance is considered in some patients. [13]

The histological subtype is always taken into account. For rare, aggressive variants, organ preservation is not recommended due to the increased risk of recurrence. The selection decision is made by a specialized team, taking into account the surgeon's experience and the facility's infrastructure. [14]

Table 3. Preoperative checklist

Step	What to confirm
Visualization and staging	Early stage confirmation data, lymph node staging plan
Histology	Tumor type without aggressive rare variants
Margins and volume	Realistic opportunity to get clean edges
Lymph node map	Sentinel nodes with ultrastaging or lymph node dissection
Alternatives	Hysterectomy and radiation strategies were discussed.

Summarized from ESGO and related publications. [15]

Technique of surgery

Radical trachelectomy can be performed via vaginal, abdominal, laparoscopic, or robotic access. Regardless of the approach, the goal is the same: to remove the cervix with parametria and the upper vagina, perform reliable lymph node staging, and create a uterovaginal anastomosis with prophylactic circular suturing. The choice of approach is determined by the anatomy, size of the lesion, and the experience of the team. [16]

Following the publication of a randomized trial of radical hysterectomy, questions have arisen regarding the oncological safety of minimally invasive techniques. There are no randomized trials for radical trachelectomy, and the accumulated retrospective data are heterogeneous: some meta-analyses and cohorts have found no worsening of oncological outcomes, while others point to a potential risk. Therefore, the choice of approach requires individualization and open discussion with the patient. [17]

European guidelines emphasize the importance of quality standards: center experience, tumor dissemination protection, and accurate lymph node staging. For tumors larger than 2 centimeters, an abdominal approach with meticulous oncological technique is often preferred. A permanent suture is placed on the internal os during surgery. [18]

Simple trachelectomy is technically less extensive and is used in limited indications, such as for adenocarcinoma in situ in patients who wish to preserve the uterus. In these cases, the key criterion remains achieving negative margins and subsequent follow-up according to a standardized protocol. [19]

Table 4. Stages of radical trachelectomy

Stage	Target
Lymph node staging	Detection of metastases and determination of further tactics
Resection of the cervix with parametria	Oncological control of a local lesion
Resection of the upper vagina	Reducing the risk of local recurrence
Uterovaginal reconstruction and suturing	Preservation of pregnancy potential

Systematization of patient memos and guidelines. [20]

Oncological efficacy: what the data show

Current guidelines recognize radical trachelectomy as an acceptable option for carefully selected patients in early stages. When selection criteria and performance are met, the surgery demonstrates comparable early oncological outcomes to alternative radical approaches in low-risk cases. This is supported by international guidelines and observational series. [21]

Several cohort studies and meta-analyses have compared open and minimally invasive approaches to trachelectomy and found no statistically significant differences in survival; however, the evidence base is limited by design and sample size. In parallel, experience with radical hysterectomy highlights the potential risks of minimally invasive techniques, requiring caution when choosing an approach. [22]

For tumors larger than 2 centimeters, the results of organ preservation are less clear, with some authors reporting better oncological outcomes with the abdominal approach, while also noting lower fertility rates. This emphasizes the need for an individualized balance between oncological control and reproductive goals. [23]

In practical terms, the key to good results is rigorous selection, centralized implementation, and correct staging of lymph nodes. If metastases are detected intraoperatively, the strategy shifts to chemoradiation, as continuing radical surgery does not improve survival. [24]

Table 5. Comparison of approaches for key oncology metrics

Criterion	Radical trachelectomy	Radical hysterectomy
Early oncological outcomes in low-risk patients	Comparable with proper selection	A benchmark radical approach
Impact of access	The data is contradictory, the decision is individual	For hysterectomy, the advantage of open access has been demonstrated.
The role of lymph node staging	Critically important, a guard node strategy is possible	Standard lymph node dissection or as indicated

Summarized from guides and reviews. [25]

Fertility and pregnancy after trachelectomy

Trachelectomy preserves the potential for pregnancy. Pregnancy after surgery is possible, but requires specialized obstetric management, as the risks of shortening the residual cervix, preterm labor, and obstetric complications increase. During surgery, a permanent suture is typically placed, serving as prophylactic cervical support. [26]

Systematic reviews and observational series report clinical pregnancy in a significant proportion of patients. Several publications demonstrate high pregnancy and live birth rates, with preterm births occurring more frequently than in the general population. These data are heterogeneous due to differences in access, selection criteria, and follow-up protocols. [27]

The recommended method of delivery after radical trachelectomy is a planned cesarean section at full term, which is associated with the risks of injury and bleeding when attempting vaginal delivery. Monitoring includes monitoring the cervical length in the second trimester, limiting stress and sexual abstinence, and individualized supportive therapy. [28]

When comparing approaches, there are indications that vaginal radical trachelectomy results in higher pregnancy rates, but the statistical robustness of the differences is limited. Regardless of approach, success is determined by careful selection, team experience, and standardized follow-up. [29]

Table 6. Pregnancy after trachelectomy: guidelines for the patient

Parameter	Typical recommendations
Planning	Individually, after oncological monitoring and consultation
Pregnancy monitoring	Assessment of cervical length, prevention of premature birth according to indications
Method of delivery	Planned cesarean section at full term
Risks	Higher risk of preterm birth compared to the general population

Summarized from reviews and memos. [30]

Postoperative follow-up: how to reduce the risk of recurrence

Following organ-preserving treatment, regular examinations with cytology and human papillomavirus testing are recommended. European guidelines specify intervals for human papillomavirus monitoring at 6, 12, and 24 months, and then as clinically indicated, supplemented by imaging methods as needed. This allows for early detection of relapses and maintains oncological safety. [31]

During the first 2 years, visits are typically more frequent, then the frequency decreases. Monitoring programs consider quality of life, potential late effects, and sexual health. Adherence to visits and appointments are directly related to long-term outcomes. [32]

If human papillomavirus infection persists and cytological abnormalities are present, a more in-depth evaluation with colposcopy and biopsy is indicated. If persistence or relapse is suspected, verification is performed and a change in strategy, including treatment escalation, is discussed. This step-by-step algorithm is outlined in practical materials. [33]

Post-treatment vaccination against human papillomavirus (HPV) is recommended as part of secondary prevention as part of comprehensive care. This is reflected in current European guidelines and should be discussed at the consultation. [34]

Table 7. Observation schedule after organ-preserving treatment

Period	What to do
0-24 months	Examinations every 3-4 months, cytology and human papillomavirus according to the protocol
24-60 months	Examinations every 6 months, testing as indicated
After 5 years	Annual visits, quality of life assessment
In case of deviations	Colposcopy, biopsy, imaging, and revision of tactics

From pocket guides and reviews. [35]

Possible complications and their prevention

Early complications include bleeding, infection, lymphatic seromas, pain, and urinary dysfunction. These are usually resolved with standard therapy and prophylaxis. Patient information leaflets detail the expected symptoms and signs requiring urgent attention. [36]

Late complications may include uterovaginal anastomosis stenosis, chronic pelvic pain, lymphedema after lymph node dissection, sexual dysfunction, and reproductive difficulties. The risk of lymphatic complications is reduced with the sentinel node strategy, which has shown lower early lymphatic morbidity compared with extended lymph node dissection.[37]

If lymph node metastases are detected during surgery, further radical resection does not improve survival and increases morbidity; in such cases, it is preferable to proceed to chemoradiation therapy. This principle has been confirmed by an international retrospective study. [38]

Comprehensive rehabilitation includes hygiene training, exercise management, pelvic floor physiotherapy, pain management, and sexual health support. Individual plans are developed through a multidisciplinary approach and are reviewed at follow-up visits. [39]

Table 8. Complications and prevention

Complication	How to warn	When to see a doctor urgently
Bleeding, infection	Asepsis, antibacterial prophylaxis according to indications, memo	Increasing pain, fever, profuse discharge
Lymphatic complications	Preference for guard node strategy in experienced centers	Increased limb size, pain, swelling
Anastomotic stenosis	Accurate reconstruction, subsequent control	Violation of the outflow of menstrual blood, pain
Sexual dysfunction	Individual rehabilitation and consultations	Pain syndrome, decreased quality of life

Summarized from studies and guidelines. [40]

Key findings

Trachelectomy is a proven organ-preserving option for carefully selected patients with early cervical cancer who desire to preserve fertility. Safety is determined by strict selection criteria, proper lymph node staging, quality of performance, and standardized follow-up. The choice of approach is discussed individually, taking into account the heterogeneity of data on minimally invasive techniques. Pregnancy after surgery is possible, but requires specialized management and most often results in an elective cesarean section. [41]