Surgery maintains fertility after cancer treatment – 05/24/2023 – Equilibrium

Cancer is not a disease that causes infertility, unless it has specifically affected reproductive organs. However, radiotherapy treatment can lead to the death of the eggs or damage to other parts of the region – which can lead to infertility.

With that in mind, the researcher and oncology surgeon at the Institute of Robotic Surgery of Paraná, Reitan Ribeiro, developed the technique, in the experimental phase, which became known worldwide as uterine transposition.

The goal is to preserve fertility in women undergoing radiotherapy sessions for cancer treatment.

The method, carried out within a research protocol, consists of transferring the reproductive organs to the upper part of the abdomen, in order to keep them intact during therapies. At the end of the treatment, the uterus, tubes and ovaries are replaced in their original location.

One of the beneficiaries of the transposition was makeup artist Carem dos Santos, 33 years old.

In June 2018, she discovered a liposarcoma (a rare tumor that begins in the body’s fatty tissue) in her pelvis and, as part of the treatment, in addition to surgery, it would be necessary to undergo radiotherapy sessions to treat the cancer cells. However, the radiation would affect her uterus, preventing a future pregnancy.

“I didn’t have a boyfriend or children, but I thought, after 30 years, of building a family. So, this news was very sad and the radiotherapy doctor gave me some time to see what I could do”, he recalls.

During this period, she learned about the uterine transposition technique, an ongoing study that was being carried out in Curitiba, which aimed precisely at preserving the organ for a later pregnancy.

“The doctor was very sincere in saying that it was still a study and that no woman had ever gotten pregnant, so he couldn’t guarantee that I would get pregnant later, but I listened to myself and had the surgery,” says the makeup artist.

Carem recalls that the postoperative period was quite painful in the first fifteen days, but other than that, there were no complications. Then, three months after the radiotherapy sessions, the organs were relocated to their proper places.

Later, she discovered two more cancers, one in the pleura and the other in the lung, and underwent the respective treatments. “I met my husband in 2021 and, when I was finalizing these processes, I found out I was pregnant”, she says.

“Today I look back and think: my God, this was the right decision I made in my entire life, because I fell in love with motherhood. Courage and faith were very important to me and we have to talk about it, because it is the dream of many women”, she concludes.

Cervical cancer

In 2020, 33-year-old newlywed hairdresser Angelica Hodecker Azambuja was diagnosed with cervical cancer through routine examinations.

“The doctor’s first option was to remove the uterus, ovaries and tubes, but as my cancer was only in the cervix, it had not affected these organs. And even so, I came to consider the hypothesis”, she recalls.

Initially, says Angélica, it was very difficult to assimilate the news that, in addition to being sick, she would not fulfill her dream of motherhood in the future.

“I was destroyed, because a woman may not even want to be a mother, and that’s okay, but when someone says you won’t be able to have children, that you don’t have a choice, it really messes with us”, she vents.

She underwent surgery to remove part of her cervix and then came the difficult decision. “Either I stopped the treatment to get pregnant, or I lost the chance to have children, because I had to undergo radiotherapy”, she reports.

However, she was not satisfied with the options presented and went in search of an alternative. That’s when she learned about uterine transposition. “At first, I was insecure because it was a very new study and I wasn’t sure if it would work”, she says.

Even so, Angélica made the transposition, and after fifteen days she underwent treatment with chemotherapy and radiotherapy.

“A week after I finished chemo and radio, I had the transposition surgery again, in March, and I got really well, I had a smooth recovery”, comments the hairdresser.

Already in October 2021, she received the diagnosis of remission of the disease and then decided it was time to try to have a child. To her surprise, she became pregnant naturally the following year.

“Uterine transposition was the best option I had and the best decision we (she and her husband) made”, says Angélica, mother of five-month-old Isabel.

How does uterine transposition work?

It is a minimally invasive surgery, performed with robotic technology, which removes the uterus, fallopian tubes and ovaries from their original location and repositions them in the upper part of the abdomen, temporarily, to preserve them during radiotherapy treatment. performed in the pelvic region.

This is because, even if it is not directed directly to the uterus, the side effect of radiotherapy is harmful to the eggs, causing infertility or early menopause.

According to Ribeiro, the Brazilian surgeon responsible for developing the technique, the surgery is low risk and patients are usually discharged one or two days after the procedure, and may experience pain or discomfort in the postoperative period, “but, in general, they have a relatively normal life, even with the uterus temporarily in an abnormal position”.

It is noteworthy that the uterus continues to function normally, even repositioned, as well as the ovarian function. And, at the end of the sessions, the reproductive organs are relocated in their proper place.

Transposition may be indicated for patients who need radiotherapy to treat tumors in the rectum, intestine, bladder, vagina, vulva (among others) and cases of sarcomas, which are malignant tumors in soft tissues, such as muscles, fat and tendons, in that just a few sessions of radiation would be enough to generate infertility.

According to Renato Moretti Marques, coordinator of the Robotic Surgery in Gynecology Program at Hospital Israelita Albert Einstein, there are contraindications for transposition.

“It is essential that the disease has not compromised the uterus, tubes and ovaries. And if this patient does not have functioning ovaries, it is not possible to move the uterus, because there would be no way to nourish it, and if she has already received pelvic radiotherapy, it is also not possible. to perform this surgery”, says Marques, who is also coordinator of the Department of Oncology Gynecology at Hospital Municipal Vila Santa Catarina.

Patients’ quality of life

Ribeiro emphasizes that today the purpose of oncology is not just to cure the patient, but also to ensure that she has the same quality of life she had before undergoing the treatment. This was his main motivation for studying transposition surgery.

“Ten years ago, we tried to cure cancer at all costs and even went to excess. Today, we don’t just want to cure a patient with cancer, we want to cure her and for her to have a normal life. For example, if she has a tumor in her leg , we don’t want to amputate the limb, we want it to heal and for the person to keep walking”, describes the researcher, adding that now this is a very important concept in oncology.

For the coordinator of the Robotic Surgery in Gynecology Program at Hospital Israelita Einstein, there are other reproductive alternatives, such as in vitro fertilization techniques, “but perhaps this is the most physiological, where it is possible to preserve the physiology of the inner part of the uterus, which is called the endometrium, and the physiology of the ovary, allowing patients to have spontaneous pregnancies. Therefore, this may be the best path to follow”.

Uterine transposition in experimental phase

Although several surgeries have already been performed, uterine transposition is still an experimental study.

The technique was already presented at an international congress of gynecological oncology in 2016, and the study is currently in the publication phase.

The first surgery was performed in October 2015 in Brazil by physician and researcher Reitan Ribeiro and, since then, has been adopted in several countries, such as Germany, Russia, Argentina, Colombia, United States, Israel, among others.

Dozens of patients have already undergone uterine transposition, twenty of them in Brazil alone.

However, there is a history of unsuccessful cases in which the uterus necrosed after a clot clogged the artery, preventing the patient’s organ from being nourished.

Marques says “she was going to lose it anyway due to the radiotherapy treatment, so this is a chance for the patient to preserve the reproductive organ.”

This is a phase 3 experimental study, done with the patients themselves, in the long term.

“There are two surgeries that serve as a basis and their combination ends up becoming this third surgery, and now we are in phase 3 of the studies, with a large number of patients to be evaluated in the long term, because there are patients who have not even tried to get pregnant yet, because are very young”, explains Ribeiro.

The technique is not yet available in the SUS (Unified Health System).

“To be inserted into the SUS, we need to make a request to Conitec (National Commission for the Incorporation of Technologies in the Unified Health System), responsible for evaluating the request, seeing if it is economically viable and if the literature justifies it. So, they price it and, finally, they authorize it. This process can take from one to two years and, perhaps, even more”, evaluates Ribeiro.

According to Ribeiro, four hospitals in Brazil are authorized by Conep (National Research Ethics Committee) to perform this surgery. They are: Hospital Erasto Gaertner, Hospital Israelita Albert Einstein, ACCamargo Cancer Center and Instituto de Câncer de Manaus.

“It’s good to make it clear that it’s a surgery that’s being done with Conep’s approval, and it’s being performed in referral hospitals, because people might question whether I can really do that, and yes, I can”, clarifies Ribeiro.

To perform the procedure, women of childbearing age diagnosed with cancer in the pelvic region and who are interested in performing the uterine transposition technique can ask their doctor for a referral form to the Erasto Gaertner Hospital (PR), requesting evaluation for inclusion in the study.

The medical team will evaluate the case to check whether it is really within the indications of the research, which has been carried out since 2017 at no cost to patients and, if selected, the care protocol will be initiated.

This text was published here