A 32-year-old nulliparous woman visited because of atypical squamous cells, to consider high-grade squamous intraepithelial lesions on cervical cytology. Cervical intraepithelial neoplasia III was seen on cervical biopsy; thus, we conducted loop electrical excision procedure, and the pathologic finding demonstrated microinvasive squamous cell carcinoma with a vertical invasion of 1 mm/3 mm in total thickness and horizontal spread of 4 mm without lymphovascular space invasion. To preserve her fertility, cold knife conization was performed again because of a positive resection margin showing high-grade dysplasia. However, the pathologic findings showed invasive squamous cell carcinoma with a vertical invasion of 4.5 mm/10 mm in total thickness and horizontal spread of 8 mm with negative surgical margin on the 12 to 3 o’clock specimen. To establish the clinical stage of cervical cancer, we performed computed tomography (CT) and magnetic resonance imaging (MRI) of the pelvis, which demonstrated no evidence of local tumor invasion or lymph node metastasis. Positron emission tomography-CT showed no definite malignant lesion, and sigmoidoscopy and cystoscopy showed no abnormal findings. Finally, she was diagnosed with stage IB1 cervical cancer, and we proceeded with a robot-assisted uterine artery-preserving radical trachelectomy, considering her strong desire to preserve fertility.

For this surgery, a four-arm da Vinci Si system (Intuitive Surgical, Inc., Sunnyvale, CA, USA) with a standard port placement and a set of robotic instruments for the pelvic surgery were used for the procedure [6]. In the pelvic cavity, we identified one enlarged lymph node in the left external iliac artery area, which was negative for malignant cells upon frozen section. Then, we performed systematic pelvic lymphadenectomy and para-aortic lymph node sampling until the level of the inferior mesenteric artery. Thereafter, radical trachelectomy preserving the uterine arteries was performed (Fig. 1), and a cerclage was placed with a transvaginal MERSILENE^® polyester fiber suture. Uterovaginal reanastomosis was made through the vaginal approach, and a 6fr 2-way Foley catheter was placed in the uterine cavity to maintain patency.

Total operation time was 330 minutes, and blood loss was approximately 200 mL. The final pathological examination showed no residual tumor in a 3.5 cm-sized specimen of the cervix and vagina, and no lymph node metastasis among the 17 resected lymph nodes. Six months after surgery, no abnormal findings were observed (Fig. 2), and she was deemed fit for pregnancy through assisted reproductive technology.

She received clomiphene citrate for five days from the second day of her menstrual cycle, and human menopausal gonadotropin for seven days followed by successful implantation with intrauterine insemination 14 months after surgery. Progesterone intramuscular injection and vaginal tablets were used for implantation support.

As with other mothers, nuchal translucency measurements and pregnancy-associated plasma protein-A levels were checked at 12 weeks of gestation, and a Quad test was performed at 16 weeks of gestation. The integrated test showed low risk. She had no risk factors except for antibiotic treatment with repeated acute pyelonephritis during pregnancy.

She presented with abdominal pain at 21 weeks and three days of gestation, and a 2 cm bulge of amniotic sac was observed on ultrasonography and speculum examination. Thereafter, she was hospitalized and treated with prophylactic antibiotics due to incompetent internal os of the cervix. At 22 weeks and one day of gestation, membrane rupture occurred. At 24 weeks and three days of gestation, uterine contraction occurred and patient was started on tocolytics. Although she had received tocolytics for suppression of uterine contractions, regular contraction and fetal descent proceeded abruptly at 26 weeks and 3 days of gestation. Since the fetus had already descended to stage 3 and there was no fetal heart rate deceleration, we decided to proceed vaginal delivery instead of preparing for cesarean section. Because the fibrotic ring at the level of uterovaginal anastomosis interfered with fetal descent, we removed the cerclage knot and incised the ring with scissors at 2,10 o’clock to facilitate vaginal delivery.

As a result, she immediately delivered a preterm male baby with no anomalies, weighing 830 g, with APGAR scores of 1 and 4 at 1 and 5 minutes, respectively. Umbilical cord PH 7.334 showed no fetal hypoxia. After delivery, the incision wound healed without suture as with the lacerated cervix. Although the baby had been treated at the neonatal intensive care unit, he presented with no complications, and was healthy five years after delivery.