Fertility-Sparing Surgery for Early Cervical Cancer

Cervical cancer is diagnosed in a substantial number of women of childbearing age, and standard treatment — radical hysterectomy or chemoradiotherapy — ends fertility. For selected women with early-stage disease, fertility-sparing surgery offers a genuine alternative: removing the cervix, the surrounding supporting tissue and the pelvic lymph nodes while leaving the body of the uterus so that pregnancy remains possible. Since Dargent introduced radical trachelectomy, several surgical routes have been developed, including vaginal, abdominal, laparoscopic and robot-assisted approaches, and less radical options such as cone biopsy or simple trachelectomy for smaller tumours. The Chinese expert consensus sets out who is suitable and how it should be done.

Who is eligible

Eligibility is deliberately narrow because the procedure sacrifices the standard operation's margins for the sake of fertility. Typical criteria: a strong wish to preserve fertility; early stage disease — generally IA1 with lymphovascular invasion, IA2 or IB1; tumour size usually no more than about 2 cm; squamous, adenocarcinoma or adenosquamous histology; no evidence of lymph node metastasis on imaging; and no spread beyond the cervix. More aggressive histological types — such as small-cell neuroendocrine carcinoma, gastric-type adenocarcinoma — and larger tumours are generally excluded from this approach.

Assessment before surgery

Imaging is the decisive step. The consensus recommends PET/CT or contrast-enhanced MRI as the best option for pre-operative tumour assessment, because the critical question is whether lymph nodes and the upper vagina are clear. Examination under anaesthesia, cervical conisation or a diagnostic procedure to measure the tumour precisely, and pathological review by a gynaecological pathologist complete the assessment. Counselling must be explicit: fertility-sparing surgery is a non-standard treatment compared with radical hysterectomy, the evidence comes from observational series rather than randomised trials, and it may be abandoned intra-operatively if findings are unfavourable.

The operation and its variants

Radical trachelectomy removes the cervix, parametria and upper vagina with preservation of the uterine arteries where possible, and includes a pelvic lymph node assessment — usually sentinel node mapping or full pelvic lymphadenectomy. A permanent cerclage is placed at the new uterine opening to support a future pregnancy, and a temporary stitch is often placed to reduce bleeding. Approaches include vaginal (the classic Dargent-type), abdominal, laparoscopic and robotic routes; choice depends on anatomy, prior surgery and surgical expertise. For very small, low-risk tumours, a cone biopsy or simple trachelectomy with node assessment may be sufficient and carries better obstetric outcomes.

Outcomes

Oncological outcomes in properly selected women are comparable to radical hysterectomy, with recurrence rates in the low single digits and excellent survival — which is why the procedure has become accepted. Obstetric outcomes are encouraging but not normal: roughly half to two-thirds of women who try conceive successfully, with increased rates of second-trimester loss and preterm delivery related to the shortened cervix and the cerclage. Delivery is by caesarean section. Follow-up after the procedure includes cytology, HPV testing, colposcopy and imaging, since recurrence can occur in the remaining cervix or elsewhere.

Practical guidance

Choose a centre that performs these procedures regularly and has both gynaecological oncology and fertility expertise. Ask: is my tumour within the accepted size and stage limits, what does my imaging show about lymph nodes, which route is planned and why, what is the chance of converting to a standard operation, and what are this team's recurrence and pregnancy rates? If pregnancy is not achieved naturally, assisted reproduction is an option — and discussing fertility preservation, including egg or embryo freezing, before any treatment begins is worth doing early.