From 10 to 14 March, SurgicalPerformance’s Professor Andreas Obermair attended the Society of Gynecologic Oncology 2017 Annual Meeting in Washington D.C. and was fortunate enough to witness the introduction of a new surgical procedure he had never heard of before. Below is his report.
“Dr Reitan Ribeiro from Brazil presented the case of a 26-year-old woman diagnosed with rectal cancer who required chemoradiation to the pelvis. In premenopausal women with intact reproductive organs, radical chemoradiation to the pelvis will damage not only the ovaries but also the uterus beyond repair.
While fertility is not a big issue for some women, it may be a big issue for others; in particular if there are ways to avert surgically-induced infertility.
The maximally tolerated radiation dose causing ovarian failure is only 15 Gy; the maximally tolerated dose to the uterus and the cervix is slightly higher (20 Gy to 30 Gy). By contrast, the dose used for radiation treatment for rectal cancer is approximately 50 Gy, which is significantly higher.
During chemoradiation treatment, the entire pelvis will be treated with radiation. In addition, the patient will receive chemotherapy in order to increase the effectiveness of the radiation. Rectal cancer is rather sensitive to radiation and treatment outcomes are often excellent. However, and invariably, all pelvic organs receiving significant amounts of radiation will suffer damage.
The particular patient was a young woman who had not had children yet. In order to save this patient’s fertility, he offered her a laparoscopic transposition of the uterus, moving the uterus and ovaries out of the radiation field. This means repositioning the uterus temporarily to the upper abdomen (see picture). After her radiation treatment was completed the uterus and the ovaries were repositioned into the pelvis, back to its normal position.
I share this case report with you because I have not heard about such a procedure before. I do believe that the procedure is worth studying not only because it is new but also because technically it is similar to a radical trachelectomy, a procedure many gynaecological oncologists offer patients already.
Dr. Ribeiro and his team conducted the entire procedure laparoscopically without an abdominal incision. The basis for this procedure is that the blood vessels to the ovaries provide also good blood supply for the uterus at the same time.
In his presentation to a packed room of gynaecological oncologists, Dr. Ribeiro acknowledged that further studies are needed to evaluate the viability of the uterus, as well as the procedure’s safety and effectiveness. Herniation of the small bowel, viability of the uterus and the ovaries and oncological concerns about the potential to spread tumour will need to be evaluated.
A brief review of the literature has not revealed that such a procedure has been performed previously. As a gynaecological oncologist, I am familiar with transposing ovaries for patients who require radiation treatment to the pelvis for cervical cancer and who should not develop radiation-induced menopause.
For many surgeons like me, this new surgical procedure will be a modest extension of our existing surgical capabilities. Therefore, I believe that gynaecological oncologists will quickly learn and adapt to this new procedure.
However, we need to remain vigilant and cautious about possible adverse events and Dr. Ribeiro’s presentation did touch on the possibility of complications. One of the potentially serious complications we need to be concerned about is the possibility of spreading tumour that would have been potentially curable but has now been moved into locations that are not amenable for radiation treatment.
It is imperative that we collaborate with our colorectal surgical colleagues in order to select the appropriate patients for such experimental treatment. We need to do our best that a new and potentially valuable surgical procedure is being evaluated and offered to the right patients.
Have you heard of uterine transposition before and will you consider offering it to your patients?”