A C TA Obstetricia et Gynecologica

ACTA REVIE W

Radical trachelectomy versus radical hysterectomy for the

treatment of early cervical cancer: a systematic review
LI XU1 , FU-QING SUN2 & ZAN-HONG WANG2
1
Department of Respiratory Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, and
2
Department of Gynecology, The First Hospital, Shanxi Medical University, Taiyuan, PR China

Key words Abstract

Cervical cancer, radical trachelectomy, radical
hysterectomy, systematic review, controlled
trail
Correspondence
Zan-Hong Wang, Department of Gynecology,
The First Hospital, Shanxi Medical University,
Taiyuan, 030001, PR China.
E-mail: wangzanhong@126.com
Conflict of interest
The authors have stated explicitly that there
are no conflicts of interest in connection with
this article.
Received: 21 January 2011
Accepted: 21 June 2011
DOI: 10.1111/j.1600-0412.2011.01231.x
Objective. To assess the efficacy and safety of radical trachelectomy (RT) and radical
hysterectomy (RH) for patients with early cervical cancer. Design. Systematic review
with meta-analysis. Population. Women who had early cervical cancer. Methods.
Prospective controlled clinical trials comparing RT with RH were identified using a
predefined search strategy. Recurrence, five-year recurrence-free survival rate, five-
year overall survival rate, postoperative mortality, intraoperative and postoperative
complications between the two operations were compared by using the methods
provided by the Cochrane Handbook for Systematic Reviews of Interventions. Re-
sults. Three controlled clinical trials involving 587 participants were included. Meta-
analysis showed that there was no significant difference between the two groups in
recurrence rate [1.38; 95% confidence interval (CI) 0.58–3.28, p=0.47], five-year
recurrence-free survival rate (1.17; 95% CI 0.54–2.53, p=0.69), five-year overall
survival rate (0.86; 95% CI 0.30–2.43, p=0.78), postoperative mortality (1.14; 95%
CI 0.42–3.11, p=0.80), intraoperative complications (1.66; 95% CI 0.11–25.28,
p=0.72), postoperative complications (0.52; 95% CI 0.11–2.48, p=0.41), blood
transfusion (0.29; 95% CI 0.06–1.36, p=0.12) and number of harvested lymph
nodes. However, RT, compared with RH, reduced blood loss and shortened dura-
tion to normal urine residual volume and postoperative hospital stay. Moreover,
RT may achieve to normal conception rates, while RH makes patients sterile. Con-
clusions. Radical trachelectomy has similar efficacy and safety to RH as the surgical
treatment for early cervical cancer. Moreover, it reduced blood loss and shortened
the duration to normal urine residual volumes and postoperative hospital stay. Rad-
ical trachelectomy can be used to treat early stage cervical cancer as an alternative
operation for patients who wish to preserve fertility.

Abbreviations:CCT, controlled clinical trial; CI, confidence interval; CLS, capillary

lymphatic space; OR, odds ratio; RCT, randomized controlled trial; RH, radical
hysterectomy; RT, radical trachelectomy

cancer and a noticeable shift from more advanced to earlier

Introduction
Worldwide, cancer of the cervix is the second most com-
mon cancer in women and the leading cause of death among
gynecological cancers. Wertheim (1) first reported using ab-
dominal hysterectomy to treat early cervical cancer in 1900.
Nowadays, radical hysterectomy in combination with pelvic
lymphadenectomy has been extensively used to treat early
cervical cancer (2–6). With the use of cervical carcinoma
screening, a decreased incidence and mortality from cervical
stage disease, together with late marriage, there will be an
increasing number of women who may wish to give birth
even if they are at risk of cervical cancer and thus possibly
requiring hysterectomy. Approximately 15% of all cervical
cancers and 45% of surgically treated stage IB cancers occur
in women under the age of 40years (7). Small invasive cancer
has become a more frequently encountered clinical problem
and is often diagnosed in women who wish to preserve their
childbearing prospects. It is a dilemma.


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L. Xu et al.
Daniel Dargent performed the first vaginal radical trach-
electomy associated with laparoscopic pelvic lymphadenec-
tomy (LARVT or Dargent’s operation) in 1986 and described
the approach in 1994 (8). This new surgical technique was
designed to effect a radical excision of the cervix (includ-
ing the proximal part of parametrium and the upper vaginal
cuff) while preserving the uterus corpus. In spite of initial
disbelief, this new approach was picked up by centers in
Europe and North America (8–11). The treatment of more
than 900 women with early stage cervical cancer who subse-
quently gave birth to around 200 children has been reviewed
(12). Subsequently, radical trachelectomy (RT), a fertility-
preserving surgical technique, has gained ever-increasing
recognition as a safe oncological alternative to radical hys-
terectomy (RH) for early stage cervical cancer patients of
childbearing age, and demand for this operation is likely to
grow in the future (13,14). However, it has not yet been fully
evaluated as an alternative to RH. A new surgical approach
for cancer can only be fully accepted if it matches the stan-
dard procedure, with regard to the extent of tissue removed,
the number of harvested lymph nodes, the safety profile and
the survival outcomes. We assessed the existing literature and
conducted a meta-analysis to compare the clinical effective-
ness of these two operations.
Methods
Search strategy
The methodology followed the Quality of Reporting of
Meta-analyses (QUORUM) statement (15). The following
databases were searched systematically: MEDLINE, EM-
BASE, PUBMED, SCIENCE-DIRECT, BIOSIS Previews, and
the China Biological Medicine Database (CBM) CNKI
(China National Knowledge Infrastructure Whole Article
Database) from January 1994 to November 2010, as well
as the Cochrane Central Register of Controlled Trials (CEN-
TRAL) on the Cochrane Library issue 4, 2010. All controlled
trials comparing radical trachelectomy and radical hysterec-
tomy in the surgical treatment of cervical cancer were iden-
tified. In this review, the following search terms were used:
cervical cancer, cervical tumor, cervical carcinoma, uterine
cervical neoplasm, radical hysterectomy and radical trach-
electomy. Both free text and a MeSH search for keywords
were used. The references for retrieved articles together with
the proceedings of relevant conferences were hand-searched
in order to identify other potentially eligible studies for in-
clusion in the analysis and missed by the initial search or
any unpublished data. Additional cross-searches were per-
formed in MEDLINE and PUBMED using the names of in-
vestigators who were the lead authors of at least one eligible
study.

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Efficacy and safety of radical trachelectomy
Inclusion and exclusion criteria
The types of studies were comparative trials with recorded
oncological outcomes (recurrence, five-year recurrence-free
survival rate, five-year overall survival rate and postoperative
mortality), operative results (intraoperative and postopera-
tive complications) and obstetrical outcomes were included.
Noncomparative studies, case series, case reports and studies
using historical controls were excluded. Patients with Inter-
national Federation of Gynecology and Obstetrics (FIGO)
stage I–IIA cervical cancer were included from trials com-
paring radical trachelectomy and radical hysterectomy. Trials
in which patients had distant metastasis, synchronous malig-
nancy in other organs, serious cardiovascular or respiratory
disorders, hepatic or renal failure were excluded. In the case
of overlap or duplicate studies, we retained only the most
comprehensive one. Trials were included. Trials comparing
the results of these two operations but where the patients
had also received preoperative or postoperative chemother-
apy were excluded.
All outcomes were defined prior to the literature search.
The primary outcomes were oncological results (recurrence,
five-year recurrence-free survival rate, five-year overall sur-
vival rate and postoperative mortality). The secondary out-
comes were operative outcomes (operation time, blood loss
during operation, transfusion, intra-/postoperative compli-
cations and so on) and obstetrical outcomes.
Data extraction and statistical analyses
All data were extracted independently by two reviewers (FQS
and ZHW), and differences of opinion were resolved by con-
sensus. Titles and abstracts were scanned first to make a list of
possibly related literature, and then full texts were obtained
for those articles identified as either relevant or not clear, but
only trials coincident with our predetermined criteria were
included.
As there was no consensus about quality assessment of
nonrandomized studies, the Cochrane Handbook for Sys-
tematic Reviews of Interventions, in which criteria for non-
randomized studies were the same as randomized controlled
trials (RCTs), was used to assess the methodological qual-
ity of included studies (16). The criteria included six items,
as follows: (1) adequate sequence generation; (2) allocation
concealment; (3) blinding, defined as such if results of mea-
surements were masked and if regarded as of low risk with
regard to both performance and detection bias (only wound
degree of surgery and postoperative morbidity included, not
considering five-year survival rates and postoperative mor-
tality); (4) incompletely addressed outcome data; (5) data free
of selective reporting; and (6) free of other bias. We consid-
ered missing outcome data in the categories <10% as low risk
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Efficacy and safety of radical trachelectomy
of bias, 10–15% as moderate risk of bias and >15% as high
risk of bias. The results of quality assessment were classified
as follows: yes (low risk of bias); probably yes (moderate risk
of bias); and no (high risk of bias). No rating of the studies
was performed; each was accepted or rejected based on the
six items noted above.
Using a predefined data extraction form, two reviewers
(FQS and ZHW) extracted data about characteristics of in-
cluded studies and baseline characteristics of patients inde-
pendently, which included following items: the first author,
publication date, country of the investigators, number of
patients, interventions, age, recurrence, five-year recurrence-
free survival rate, five-year overall survival rate, postopera-
tive mortality, operation time, blood loss during operation,
transfusion, number of harvested lymph nodes, postoper-
ative hospital stay, duration to normal urine residual vol-
umes and obstetrical outcomes. If necessary, the authors of
the original articles were contacted for additional data. Final
agreement was achieved through discussion.
The individual and pooled statistics were calculated us-
ing the fixed effect model (Mantel–Haenszel method) (17),
but if a p-value of the heterogeneity test was less than
0.1, a random-effect model was used. The results were ex-
pressed with incidence odds ratio (OR) for dichotomous
data and weighted mean differences for continuous data (16)
(http://www.cochrane-handbook.org/), and 95% confidence
intervals (CI) were also calculated. Heterogeneity between in-
cluded studies was tested using I 2 statistics, which describes
the percentage of total variation across studies that are due
to heterogeneity rather than chance (18). The interpretation
of I 2 depends on the magnitude and direction of effects, as
well as the strength of evidence for heterogeneity (such as
p-value from the χ 2 test, or a confidence interval for I 2 ). If
heterogeneity was present, we checked the potential reason
622 potentially eligible abstracts
from computer searches
16 trials retrieved for detail
Figure 1. Quality of Reporting of
3 prospective CCTs finally
Meta-analyses (QUORUM) flow chart for
included
studies on radical trachelectomy and radical
hysterectomy. CCT, controlled clinical trial.
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L. Xu et al.
with reference to aspects of study design and quality, differ-
ences in intervention and baseline characteristics of included
patients, by using methods of subgroup and sensitivity anal-
ysis. Statistical analysis was performed using RevMan 5.0.18,
which was provided by the Cochrane Collaboration. Funnel
plots were drawn to assess publication bias.
Results
Selection of included studies
Two trial assessors agreed on the selection of three CCTs.
The QUORUM flow diagram illustrates the main reasons for
trial exclusions (Figure 1). The overall sample included 587
patients in these three CCTs (19–21) comparing RT with RH.
Description and risk of bias of included studies
Characteristics of included studies, baseline characteristics of
patients and potential bias in included studies are listed in
Tables 1–3, respectively. There were 248 patients in the RT
and 339 patients in the RH groups, and the sample size of
studies ranged from 150 to 257 women. No randomization
and concealment of allocation were used. According to our
definition of blinding, this was unclear in all three included
studies. Completeness of data was good; only Marchiole et al.
(21) recorded four patients lost to follow up (two in each
group). The description of selective reporting and other bias
possibilities was not present in detail. Apart from a significant
difference in age in the studies of Beiner et al. (20) and Diaz
et al. (19), baseline characteristics were similar between RT
and RH groups.
606 abstracts excluded
Reasons: no valid survival data, reviews,
meta-analysis, retrospective studies
13 trials excluded
Reasons: low quality, duplicates,
retrospective design

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L. Xu et al. Efficacy and safety of radical trachelectomy

Table 1. Characteristics of included studies on radical trachelectomy and radical hysterectomy.

Study (author, year) Country Date Design Methods Interventions

Diaz et al. (2008;19) USA November 2001 to CCT Single-center, parallel group, RT vs. RH
June 2007 prospective study without
randomization
Beiner et al. (2008;20) Canada March 1994 to July CCT Single-center, parallel group, RVT vs. RH
2007 prospective study without
randomization
Marchiole et al. (2007;21) France December 1986 to CCT Single-center, parallel group, LARVT vs. LARVH
December 2003 prospective study without
randomization

(continue) Patients Outcomes

RT: patients with stage IB1 cervical carcinoma Oncological outcomes, operative results, obstetrical
RH: all women with stage IB1 cervical carcinoma and who would have been eligible outcomes, OR, blood loss, blood transfusion, lymph
for a fertility-sparing alternative node count
RVT: all patients who sought preservation of fertility with cervical cancer, tumor size Oncological outcomes, operative results, OR, blood loss,
≤2cm, and did not meet Society of Gynecologic Oncologists’ definition of blood transfusion, hospital stay, time to normal urine
microinvasive cancer residual volume
RH: patients with stage IA and IB cervical cancer
LARVT: women affected by an early cervical cancer (stage I–IIA) Oncological outcomes, operative results, OR, blood
LARVH: patients with stage I–IIA cervical cancer transfusion, lymph node count

Abbreviations: CCT, controlled clinical trial; LARVH, laparoscopic assisted radical vaginal hysterectomy;, LARVT, laparoscopic assisted radical vaginal
trachelectomy; OR, operative time; RH radical hysterectomy; RT, radical trachelectomy; and RVT, radical vaginal trachelectomy.

Table 2. Baseline characteristics of patients in included studies.

Study (author, year)

Diaz et al. (2008; 19) Beiner et al. (2008; 20) Marchiole et al. (2007; 21)

Age (years) [mean (range)] 32(20–43) vs. 37(22–45), 31(20–44) vs. 34(19–44), –
p<0.001 p<0.01
Sample size 40 vs. 110 90 vs. 90 118 vs. 139
FIGO IB1 IA/IB I–IIA

Histology

SCC 20 vs. 57 NS 39 vs. 39 NS 90 vs. 102 NS

Adenocarcinoma/adenosquamous 20 vs. 52 50 vs. 50 25 vs. 33
Other – 1 vs. 1 3 vs. 4
CLS invasion 9 vs. 30 NS 61 vs. 61 NS 43 vs. 35 NS
Lymph node metastasis 6 vs. 6 NS 0 vs. 0 NS 5 vs. 6 NS
Follow up (months) [mean(range)] 44(3–201) 51 vs. 58 95(31–234) vs. 113(36–249)∗

Note: Results are presented as No. RT vs. No. RH.

Abbreviations: CLS, capillary lymphatic space; FIGO, International Federation of Gynecology and Obstetrics; NS, not significantly different; SCC,
squamous cell carcinoma.
∗
There were two patients lost to follow up in each group.

Effects of interventions
Two studies (437 patients) (20,21) reported postoperative
recurrence rates, and the pooled OR was 1.38 (95% CI
0.58–3.28, p=0.47), suggesting that there was no significant
difference between the groups; the p-value of the heterogene-
ity test was 0.15 (Figure 2). The recurrence rate in the radical
trachelectomy group was not higher than in the radical hys-
terectomy group. For postoperative mortality, the pooled OR
was 1.14 (95% CI 0.42–3.11, p=0.80), suggesting that there
was no significant difference between the groups (p-value for
heterogeneity test 0.32; Figure 2).


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Table 3. Potential bias of included studies.

Adequate Incomplete
sequence Allocation outcome data Free of selective
Study (author, year) generation concealment Blinding addressed reporting Free of other bias

Diaz et al. (2008; 19) No No Probably yes Yes Probably yes Probably yes
Beiner et al. (2008; 20) No No Probably yes Yes Probably yes Probably yes
Marchiole et al. (2007; 21) No No Probably yes Yes Probably yes Probably yes

RT RH Odds Ratio Odds Ratio

Study or Subgroup Events Total Events Total Weight M-H, Fixed, 95% CI M-H, Fixed, 95% CI
1.1.1 Rate of recurrence
Beiner et al. (2008; 20) 5 90 1 90 10.8% 5.24 [0.60, 45.74]
Marchiole et al. (2007; 21) 7 118 9 139 89.2% 0.91 [0.33, 2.53]
Subtotal (95% CI) 208 229 100.0% 1.38 [0.58, 3.28]
Total events 12 10

Test for overall effect: Z = 0.73 (P = 0.47)

1.1.3 Post-operative mortality

Beiner et al. (2008; 20) 3 90 1 90 13.6% 3.07 [0.31, 30.08]
Marchiole et al. (2007; 21) 5 118 7 139 86.4% 0.83 [0.26, 2.70]
Subtotal (95% CI) 208 229 100.0% 1.14 [0.42, 3.11]
Total events 8 8

Test for overall effect: Z = 0.25 (P = 0.80)

0.01 0.1 1 10 100

Favours RT Favours RH

Figure 2. Comparisons of recurrence and postoperative mortality between radical trachelectomy (RT) and radical hysterectomy (RH).

The pooled OR for five-year recurrence-free survival in all
three studies was 1.17 (95% CI 0.54–2.53, p=0.69; p-value for
heterogeneity 0.13; Figure 3). Five-year overall survival rate
could be estimated from two studies (437 patients) (20,21).
The pooled OR was 0.86 (95% CI 0.30–2.43, p=0.78). There
was no difference between RT and RH (p-value for hetero-
geneity 0.53; Figure 3).
Two studies (20,21) could be used to estimate intraoper-
ative complications and postoperative overall complications
with pooled ORs of 1.66 (95% CI 0.11–25.28, p=0.72) and
0.52 (95% CI 0.11–2.48, p=0.41), respectively (p-value for
heterogeneity 0.008 and 0.01; Figure 4 ), suggesting no differ-
ence between the groups. Postoperative infectious and non-
infectious complications showed pooled ORs of 0.46 (95%
CI 0.16–1.33, p=0.15) and 0.53 (95% CI 0.09–3.03, p=0.48),
respectively (p-value for heterogeneity test 0.13 and 0.10).
Compared with RH, RT neither increased nor decreased the
risk of intraoperative and postoperative complications (Fig-
ures 4 and 5).
As we could not obtain the standard deviation (SD) of op-
erative time, blood loss, lymph node count, hospital stay and
time to normal urine residual volumes from most included
trials, pooled meta-analysis could not be done on these out-
comes, but they are listed in Table 4. In the study by Diaz
et al. (19), the operating time of radical trachelectomy was
significantly longer, but this was not the case in the two other
studies. Beiner et al. found no significant difference in oper-
ating time between RT and RH (20). In two studies (19,20),
blood loss during the operation was compared, with a sig-
nificant difference between the groups (Table 4). All three
studies could be used to estimate the need for blood transfu-
sions, with apooled OR of 0.29 (95% CI 0.06–1.36, p=0.12;
p-value for heterogeneity 0.02; Figure 6), suggesting no dif-
ference. In two of the studies (19,21), the count of lymph


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L. Xu et al. Efficacy and safety of radical trachelectomy

RT RH Odds Ratio Odds Ratio

Study or Subgroup Events Total Events Total Weight M-H, Fixed, 95% CI M-H, Fixed, 95% CI
1.2.1 Five-year recurrence-free survival rate
Diaz et al. (2008; 19) 38 40 95 110 20.9% 3.00 [0.65, 13.75]
Beiner et al. (2008; 20) 86 90 90 90 36.8% 0.11 [0.01, 2.00]
Marchiole et al. (2007; 21) 113 118 132 139 42.3% 1.20 [0.37, 3.88]
Subtotal (95% CI) 248 339 100.0% 1.17 [0.54, 2.53]
Total events 237 317

Test for overall effect: Z = 0.40 (P = 0.69)

1.2.2 Five-year overall survival rate

Beiner et al. (2008; 20) 89 90 90 90 19.5% 0.33 [0.01, 8.20]
Marchiole et al. (2007; 21) 112 118 132 139 80.5% 0.99 [0.32, 3.03]
Subtotal (95% CI) 208 229 100.0% 0.86 [0.30, 2.43]
Total events 201 222

Test for overall effect: Z = 0.28 (P = 0.78)

0.01 0.1 1 10 100

Favours RH Favours RT

Figure 3. Comparisons of rates of five-year recurrence-free survival and five-year overall survival between radical trachelectomy (RT) and radical
hysterectomy (RH).

nodes removed was compared. Marchiole et al. (21), removed
more lymph nodes at RT than at RH (p<0.05), while in the
other study there was no difference (19). Beiner et al. (22) re-
ported the hospital stay and duration to normal urine residual
volumes, both of which were significantly shorter for RT. Only
one study reported on pregnancy outcomes, i.e. a total of nine
pregnancies and four deliveries, one second-trimester mis-
carriage and two terminations. Because there were too few
included studies, we did not draw funnel plots to test for
publication bias.
Discussion
The standard surgical management for early stage cervical
carcinoma is a radical abdominal hysterectomy and pelvic
with or without para-aortic lymph node dissection, obvi-
ously eliminating the possibility of future conception. Radi-
cal trachelectomy is a fertility-preserving procedure that has
recently gained worldwide acceptance as a method of surgi-
cally treating small invasive cancers of the cervix. We have
compared oncological outcomes and operative results using
the method provided by the Cochrane Collaboration. The
meta-analysis showed that RT has similar efficacy and safety
to RH for early cervical cancer surgical treatment.
Undoubtably, the most accurate method to answer the
questions whether RT is more efficient and much safer than
RH is a randomized control trial; however, such a study is not
feasible for several reasons, as follows: (1) the issues involved
in recruiting young patients with small tumors who are anx-
ious to preserve fertility is ethically difficult; (2) the sample
size required to detect a difference in the recurrence-free sur-
vival rate as small as 5% is approximately 1 000; and (3) few
surgeons are sufficiently skilled to perform this procedure.
Therefore, the next best methodology to evaluate the efficacy
of this procedure is a case–control design. Three CCTs with
almost 600 patients were included in our review. In the study
of John et al. (19), radical vaginal trachelectomy and radi-
cal abdominal trachelectomy were done in 40 patients with
stage IB1 cervical carcinoma, and included 28 radical vaginal
trachelectomies and 12 radical abdominal trachelectomies.
According to our inclusion criteria, the two processes both
preserve fertility. Recurrences, five-year recurrence-free sur-
vival rates, five-year overall survival rates and postoperative
mortality were similar between the two operations. Com-
pared with RH, blood loss, postoperative hospital stay and
time to normal urine residual volume were significantly re-
duced in RT; however, the operation time and lymph node
count in RT were not analyzed in this review.
Heterogeneity was found between intra-/postoperative
complications and blood transfusion in all three studies. Sev-
eral factors contributed to heterogeneity. Firstly, there was a


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RT RH Odds Ratio Odds Ratio

Study or Subgroup Events Total Events Total Weight M-H, Random, 95% CI M-H, Random, 95% CI
1.3.1 Rate of intra-operative complications
Beiner et al. (2008; 20) 12 90 2 90 49.1% 6.77 [1.47, 31.19]
Marchiole et al. (2007; 21) 3 118 8 139 50.9% 0.43 [0.11, 1.65]
Subtotal (95% CI) 208 229 100.0% 1.66 [0.11, 25.28]
Total events 15 10

Test for overall effect: Z = 0.37 (P = 0.72)

1.3.3 Rate of post-operative overall complications

Beiner et al. (2008; 20) 4 90 16 90 45.3% 0.22 [0.07, 0.67]
Marchiole et al. (2007; 21) 25 118 28 139 54.7% 1.07 [0.58, 1.95]
Subtotal (95% CI) 208 229 100.0% 0.52 [0.11, 2.48]
Total events 29 44

Test for overall effect: Z = 0.83 (P = 0.41)

1.3.4 Rate of post-operative noninfectious complications

Beiner et al. (2008; 20) 1 90 6 90 34.5% 0.16 [0.02, 1.33]
Marchiole et al. (2007; 21) 23 118 27 139 65.5% 1.00 [0.54, 1.87]
Subtotal (95% CI) 208 229 100.0% 0.53 [0.09, 3.03]
Total events 24 33

Test for overall effect: Z = 0.71 (P = 0.48)

0.01 0.1 1 10 100

Favours RT Favours RH

Figure 4. Comparisons of rates of intraoperative and postoperative complications between radical trachelectomy (RT) and radical hysterectomy (RH).

RT RH Odds Ratio Odds Ratio

Study or Subgroup Events Total Events Total Weight M-H, Fixed, 95% CI M-H, Fixed, 95% CI
1.4.1 Rate of post-operative infectious complications
Beiner et al. (2008; 20) 3 90 10 90 91.5% 0.28 [0.07, 1.04]
Marchiole et al. (2007; 21) 2 118 1 139 8.5% 2.38 [0.21, 26.57]
Subtotal (95% CI) 208 229 100.0% 0.46 [0.16, 1.33]
Total events 5 11

Test for overall effect: Z = 1.44 (P = 0.15)

0.01 0.1 1 10 100

Favours RT Favours RH

Figure 5. Comparison of rate of postoperative infectious complications between radical trachelectomy (RT) and radical hysterectomy (RH).

significant difference in patients’ age (19,20), though other ing curves of surgeons, performance bias might have been
baseline characteristics were similar, which suggested a poten- been introduced. Thirdly, as seen in Table 3, blinding was
tial selection risk. Secondly, surgical outcomes were related unclear in all included studies, so measurement bias might
to the experience of the surgeon (23). Considering the learn- exist. Although common in surgical clinical trials, this may


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L. Xu et al. Efficacy and safety of radical trachelectomy

Table 4. Comparisons of operative time, blood loss, lymph node count, postoperative hospital stay and duration to normal urine residual volume
between radical trachelectomy and radical hysterectomy.

Study (author, year)

Diaz et al. (2008; 19) Beiner et al. (2008; 20) Marchiole et al. (2007; 21)

Operative time
[mean(range)/mean±SD]
Blood loss (ml) [mean(range)]
Lymph node count
[mean(range)/mean±SD]
Postoperative hospital stay
(days) [mean(range)]
Time to normal urine residual
volume (days [mean(range)]
300(100–630) vs. 2.9(1.5–5) vs. 2.8(1.6–5)h, 179±54 vs. 187±53min, NS
240(134–450)min, p=0.023 p=0.75
150(50–600) vs. 425(75–2700), 300(100–1100) vs. –
p<0.001 600(100–2300), p<0.001
26(12–64) vs. 28(1–64), NS – 19±8(5–42) vs. 17±7(5–44),
p<0.05
– 1(0–7) vs. 6(1–20), p<0.001 –
– 1(1–49) vs. 6(2–63), p<0.001 –

Abbreviation: NS, not significantly different.

RT RH Odds Ratio Odds Ratio

Study or Subgroup Events Total Events Total Weight M-H, Random, 95% CI M-H, Random, 95% CI
1.5.1 Rate of blood transfusion
Diaz et al. (2008; 19) 1 40 7 110 24.8% 0.38 [0.04, 3.17]
Beiner et al. (2008; 20) 2 90 21 90 32.6% 0.07 [0.02, 0.33]
Marchiole et al. (2007; 21) 15 118 24 139 42.6% 0.70 [0.35, 1.40]
Subtotal (95% CI) 248 339 100.0% 0.29 [0.06, 1.36]
Total events 18 52

Test for overall effect: Z = 1.57 (P = 0.12)

0.01 0.1 1 10 100

Favours RT Favours RH

Figure 6. Comparison of rate of blood transfusion between radical trachelectomy (RT) and radical hysterectomy (RH).

weaken the reliability of our results to some extent. Fourthly,
lost data could affect results, and there were two patients lost
to follow up in each group in one of the studies (21). Finally,
publication bias might exist with the small number of in-
cluded studies.
There were some significant differences between the RT
and RH groups. Blood loss, time to normal urination and
postoperative hospital stay were significantly shorter in the
RT group, similar to reports by other centers performing
RT (24), while there was no difference as regards intra-
/postoperative complications, with the pooled ORs being 2.77
(95% CI 0.35–22.19) and 0.55 (95% CI 0.18–1.69, p=0.30),
respectively. This suggests that RT is superior to RH to some
extent. Several studies (25–28) reported intraoperative com-
plication rates in RT from 0 to 25%. In this review, there were
23 patients (9%) who suffered such complications, and 16
(6%) had accidental cystotomy in the RT group. Monitoring
complication rates continuously is important for any new
surgical procedure.
The development of fertility-sparing surgery has provided
patients with early stage cervical carcinoma with the opportu-
nity to pursue conception after the treatment of their disease.
Beiner et al. (22) indicated that pregnancy rates for those
women who attempted conception were 41–79%. The rate of
first-trimester miscarriage was 18% for the pooled data, simi-
lar to that of the general population. Plante et al. (24) showed
that 31 of the women became pregnant (43%) and had a
total of 50 pregnancies, including 10 miscarriages (eight first
trimester and two second trimester), while Shepherd et al.
(26) reported that the five-year accumulated conception rate
was 52.8%. Diaz et al. (19) reported nine pregnancies, includ-
ing three term cesarean sections, one late preterm delivery at
35weeks, one second-trimester spontaneous abortion and
two second-trimester terminations. However, Covens et al.
(11) noted five pregnancies among women, including three
term cesarean sections and two spontaneous first-trimester
abortions, yielding an actuarial conception rate of 37% at
one year, a lower rate of conception.


C 2011 The Authors

Acta Obstetricia et Gynecologica Scandinavica 

C 2011 Nordic Federation of Societies of Obstetrics and Gynecology 90 (2011) 1200–1209 1207
Efficacy and safety of radical trachelectomy
It is important to evaluate emotional and sexual aspects as
well as quality-of-life issues after surgery for malignant cer-
vical tumors. Only one study has hitherto reported that these
aspects did not differ significantly by type of surgery (29). We
included prospective controlled clinical trials and retained
only the most comprehensive studies, which is different from
a previous systematic review (30). Radical trachelectomy has
similar efficacy and safety to RH for early cervical cancer, but
is associated with reduced blood loss, shorter time to resump-
tion of urinary function and shorter postoperative hospital
stay. An important subset of young women with early stage
cervical cancer can benefit from a fertility-sparing surgical
approach by radical trachelectomy.
Funding
The research was supported by the National Natural Science
Foundation of China (grant no. 30740016).
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