Due to the earlier onset of cervical cancer and late marriage of contemporary women, many patients with early cervical cancer have not given birth. Therefore, more attention is being paid to fertility-preserving surgery. RT was developed as a fertility-preserving surgery for early-stage cervical cancer. RT was first performed by Dargent vaginally in 1986 , but the most frequently referenced publication was in 1994. Accordingly, ART and LRT were reported in 1997 and 2005 respectively. However, different surgical modalities for the treatment of cervical cancer can lead to diverse oncological outcomes, as evidenced by the multicenter randomized trial Laparoscopic Approach to Cervical Cancer. . Although the trial on the laparoscopic approach to cervical cancer focuses on radical hysterectomy, these data raise the question of whether its results can be extrapolated to all surgical modalities for cervical cancer. uterus. Therefore, we performed a retrospective review of 33 cases of early-stage cervical cancer diagnosed and treated at a single institution from January 2005 to June 2017 and investigated the oncological and obstetrical outcomes of abdominal RT and laparoscopic. In this study, there is no significant difference in postoperative recurrence rate and overall survival rate between the two surgical modalities. However, the ART group had a higher clinical pregnancy rate than the LRT group. The overall recurrence rate in our study is 6.06% (2/31), which is higher than the median recurrence rate of 3.3% reported in a systematic review . We consider this acceptable in a retrospective cohort. Also, it is thought to be oncological equal to a radical hysterectomy when the recurrence rate is between 1.8-7.0% .
The total clinical pregnancy rate in our study is 40% (6/15), which is comparable to that published in previous research . However, the clinical pregnancy rate is demonstrably lower than in reported patients who underwent VRT, ART, or LRT alone. [12, 17, 19, 20]. We consider that the lower clinical pregnancy rate may be related to the shorter follow-up time of patients who underwent LRT (of the 9 pregnancy-free patients in our study, 4 patients underwent surgery after 2018 and every 4 patients underwent LRT). As we know, the clinical pregnancy rate after RT is affected by many factors. Cervical factors, including cervical stenosis, length of the cervix and absence of cervical mucus, have been considered the most important causes of infertility in patients treated with RT [17, 21, 22]. It is widely accepted that patients with cervical length less than 1 cm are more likely to be infertile than patients with cervical length ≥ 1 cm . In this study, there was one patient (1/6) with cervical stenosis, three patients (3/6) with fallopian tube obstruction, one patient with ovulation disorder (1/6) and the remaining patient with another unknown factor (this patient did not undergo a systematic examination for infertility).
LRT offered a number of benefits such as better visualization, less blood loss and faster recovery in our study, which has also been proven by previous studies. [18, 23, 24]. In our study, there was no significant difference in operative time and histopathological results between the two surgical approaches. However, the operative time of LRT is reported to be longer compared to that of ART in another study . As laparoscopic radical trachelectomy requires refined skills, the laparoscopic approach can increase the difficulty of the operation and increase the duration of the operation when not performed skillfully. Regarding the fertility outcomes of the two surgical modalities, the higher pregnancy rate was observed in the ART group compared to the LRT group. [13, 18]. Nevertheless, the pregnancy rate of robot-assisted assisted reproduction can reach 81% , which is comparable to that of the VRT. Therefore, the relatively lower pregnancy rate in the LRT group may be related to the shorter follow-up time.
The total recurrence rate of RT is at a low level. In previous studies, the median recurrence rate was 3.3% (range 0-25%) after a median follow-up of 48 months (range 2-202 months) . In most LRT studies, the recurrence rate was 0% to 4% in each reported article [17, 18, 20, 23, 24], which may be related to the short follow-up time. ParkJY et al.  reported 9 (9/79) recurrent cases after a median follow-up of 44 months in patients treated with LRT and concluded that a tumor size greater than 2 cm and a depth of stromal invasion greater than 50% were the main recurrence risk factors. In this study, 2 patients (1 abdominal/1 laparoscopic) developed a recurrence, and the total RT recurrence rate was 6.06%. Moreover, there is no significant difference in postoperative recurrence rate and overall survival rate between the two surgical modalities. However, Ramirez et al.  reported a multicenter, prospective, randomized, controlled study of minimally invasive manual surgery for cervical cancer, and highlighted that minimally invasive treatment of cervical cancer has disease-free survival and overall survival inferior to those of laparotomy. Nevertheless, this study has limitations. The minimally invasive arm was heavily biased toward laparoscopic surgery in this study, which may not reflect current practices. Moreover, this was a multinational and multicenter study with different surgical skills. Therefore, further studies are needed to determine whether minimally invasive surgery affects oncological outcomes in patients with early-stage cervical cancer. Although the long-term benefits of performing a fertility-preserving laparoscopic radical trachelectomy remain to be defined, women with early-stage cervical cancer may be offered a minimally invasive surgical modality when ‘they undergo a radical trachelectomy.
RT has been reported as a feasible treatment for patients with tumors ≦ 2 cm in most studies. However, fertility preservation surgery has been controversial for early-stage cervical cancer patients with tumors larger than 2 cm. NACT could reduce tumor volume and effectively inhibit micrometastases of paracervical tissue and pelvic lymph nodes [26, 27]. Therefore, NACT plus conization has been reported to be used for early-stage cervical cancer patients with tumors less than 2 cm in diameter. [7, 28] and NACT combined with RT surgery for early-stage cervical cancer patients with tumors larger than 2 cm in diameter [10, 11, 29]. Viveros-Carreno D et al.  even reported that fertility preservation surgery combined with NACT was used in women with early-stage cervical cancer with tumors larger than 4 cm in diameter, and survival without disease at 4.5 years was 92.3% and the overall survival rate at 4.5 years was 100%. In our study, there were four patients who received NACT, and the reason all four patients received NACT was that these patients needed delayed surgery due to serious complications that needed to be addressed before the operation. .
The limitations of this study lie in its retrospective nature, the small number of patients and the absence of randomisation. Additionally, four patients received NACT due to delayed surgery and one patient with parauterine lymph node metastases received only postoperative chemotherapy, which may lead to bias in this study. In addition, longer follow-up is needed to better assess clinical pregnancy rate and oncological outcomes. Nonetheless, we believe this study should be useful for patients with early-stage cervical cancer as well as gynecologists considering RT.