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Ms. RAMYA T S 1STYEAR MSc NURSING OBSTETRICAL AND GYNAECOLOGICAL NURSING 2012-2014 SHREE SIDDAGANGA INSTITUTE OF NURSING SCIENCES AND RESEARCH CENTRE, B.H.ROAD, TUMKUR-572102 RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES KARNATAKA, BANGALORE. SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION 1 NAME OF THE CANDIDATE AND ADDRESS Ms. RAMYA T S I YEAR M.SC.NURSING SHREE SIDDAGANGA INSTITUTE OF NURSING SCIENCES AND RESEARCH CENTRE, B.H.ROAD, TUMKUR-572 102 2 NAME OF THE INSTITUTION SHREE SIDDAGANGA INSTITUTE OF NURSING SCIENCES AND RESEARCH CENTRE, B.H.ROAD, TUMKUR.-572 102. 3 COURSE OF STUDY AND SUBJECT MASTER OF SCIENCE IN NURSING OBSTETRICAL AND GYNAECOLOGICAL NURSING DATE OF ADMISSION 10-07-2012 STATEMENT OF THE PROBLEM A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE REGARDING RADICAL VAGINAL TRACHELECTOMY AS A FERTILITY PRESERVATION IN CERVICAL CANCER AMONG FINAL YEAR BSC NURSING STUDENTS IN SELECTED NURSING COLLEGES IN TUMKUR. 4 5 1 6.0 BRIEF RESUME OF THE INTENDED WORK 6.1 INTRODUCTION "Motherhood is priced Of God, at price no man may dare To lessen or Misunderstand." --Helen Hunt Jackson Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, reproductive health addresses the reproductive processes, functions and system at all stages of life.1 Reproductive health is defined as a state of physical, mental, and social wellbeing and not merely the absence of disease or infirmity in all matters relating to the reproductive system and its function and process. It implies that people are able to have a satisfying and safe sex life, are informed about to have access to safe, effective, affordable and acceptable methods of family planning as well as other methods of their choice for regulation of fertility which are not against the law, are able to have access to appropriate health care services that will enable women to go safely through pregnancy and child birth and provide couples with the best chance of having healthy babies. 2 Cancer is an oncogenes regulate cell growth in a positive fashion. Oncogenes include transforming genes of viruses and normal cellular genes that are activate by mutation to promote cell growth to a partly malignant behavior. It needs one mutational event for its gain of function.3 2 The last fifty years have seen an exploration in our understanding of this most fundamental of diseases and new discoveries are occurring on an almost weekly basis. A trend analysis of the data on cancer incidence for the period 1975-2008 has demonstrated that the overall occurrence of cancer is increasing among females. The most common cancers among females is cervical cancer and breast cancer.4 Cervical cancer is defined as an abnormal cell proliferation in the cervix or abnormal cell growth in the cervix.3 Cervical cancer in women is the second most common cancer worldwide, next only to breast cancer. In India, cervical cancer is the most common women related cancer, followed by breast cancer. Every year about 500,000 new cases of cervical cancer are diagnosed worldwide and are responsible for about 280000 deaths, and 80% of total deaths occur in developing countries.5 Cancer prevalence in India is estimated to be around 2.5 million with 8,00,000 new cases and 5,50,500 deaths occurring each year due to this disease. Moreover, the prevalence rate of cervical cancer in India is 40% against global rate of about 20%. According to the Tribune survey of India, cervical cancer is most common in South India and highest in Chennai.6 The cervical cancer treatment including surgery, radiation therapy, and chemotherapy can cause infertility in patients. Infertility is the diminished ability or the inability to conceive and have offspring. The experience of infertility can be extremely stressful and associated with a range of psychiatric problems in infertile women. Generally, some of the risk factors which may lead to psychiatric problems 3 are repeated unsuccessful treatment of infertility, low socio-economic status, lack of partner support, life events etc.7 Recent advances in the management of gynecological cancer have resulted in women experiencing improved prognosis and survival rates. However, premenopausal women who have not completed childbearing phase the prospect of impaired or loss of fertility. The fertility is improved through surgical technique and advances in assisted reproductive technology have made it possible for some women to achieve a successful pregnancy, to ensure fertility concerns in women with gynecological cancer are addressed, oncology nurse require an understanding of the impact of treatment of fertility and an awareness of available fertility preservation method.8 Radical vaginal trachelectomy is the removal of the uterine cervix and adjacent tissues was originally introduced in 1987 by Dr.Daniel Dargent. He performed a laproscopic pelvic lymphadenectomy and a radical vaginal trachelectomy. In a short period of time, several centers presented studies regarding slightly modified radical vaginal trachelectomy. The choice for abdominal or vaginal route as well as laparotomy or laparoscopic approach depends mainly on the surgeon’s preferences and level of expertise. Robert –assisted laproscopy is also rapidly increasing as a possibility in fertility-sparing surgery for early cervical cancer. The oncological safety of these procedures in the treatment of early invasive cervical cancer is well established in many retrospective studies and is associated with an acceptable live birth rate.9 4 6.2 NEED FOR THE STUDY Cervical cancer is the leading cancer among women in terms of incidence rates in 02 out of the 12 population based cancer registries (PBCRs) in India, and has the second highest incidence rate after breast cancer in the rest of the PBCRs. The incidence of cervical cancer is highest in Chennai, a metropolitan city in the south and lowest in Thiruvanathapuram, the capital of Kerala (National cancer registry programme and world health organization). There is a high incidence belt in the north eastern districts of Tamil nadu, as well as in two districts in the North-eastern region of the country.10 Cervical cancer ranks as the 2nd most frequent cancer among women between 15 and 44 years of age in Kenya. Women in England and Northern Ireland and currently offered cervical cancer screening at 03 to 05 year intervals between ages 25 and 64. In Wales, screening for women is offered between the ages of 20 and 64 every three years. In Scotland, women are offered screening every three years between the ages of 20 and 60.11 India has a population of 366.58 million women ages 15 years and older who are at risk of developing cervical cancer. The current estimation indicates that every year 134420 women are diagnosed with cervical cancer and 72825 die from the disease. Cervical cancer ranks as the 1st most frequent cancer among women in India and the 1st most frequent cancer among women between 15 and 44 years of age. About 7.9% of women in the general population are estimated to harbor cervical HPV infection at a given time and 82.5% of invasive cervical cancer is attributed to HPVs 16 or 18.12 5 A survey conducted in Bangalore city supported this observation. In 1982, 32.4% cervical cancer cases per 100,000 populations were reported every year in Bangalore, which decreased to 27.2, 18.2, and 17.0% in 1991, 2001, and 2005 years, respectively.13 Nowadays the treatment of gynecological cancer is possible through surgery, radio therapy and chemotherapy which lead to high remission and long term survival rates. In these curved patients, quality of life is increasingly important mean while the ability to produce and raise normal children is considerable (partoidge 2004 ) now a day’s delaying childbearing for social and financial reasons leads to more women suffering from fertility threats due to early stage cancer being discovered (Maltaris 2006). The patient may suffer from premature menopause and infertility which may impact her quality of life and self-esteem significantly.14 Cervical cancer treatment removes the uterus, fallopian tubes or ovaries, radiation therapy; some chemotherapy medicines can also cause infertility. In India cervical cancer is the second most cancer in women and accounts for about 25% to 33% of all cancer. Women with stage 1 cervical cancer who desire future fertility, hysterectomy had a impact on fertility. In India, incidence of female infertility at least two million of annual cases. 15 Over the past decade, the treatment of cervical cancer has evolved with an increased emphasis on preservation of fertility. There has been a gradual abandonment of radical surgical procedures in favor of more conservative techniques in an effort to decrease morbidity and preserve fertility without compromising overall survival. Radical vaginal trachelectomy (RVT) with laparoscopic pelvic lymphadenectomy is a fertility-preserving procedure that has recently gained 6 worldwide acceptance as a method of surgically treating small invasive cancers of the cervix. Since the original description of RVT by Daniel Dargent in 1994, over 500 cases of utilization of this technique have been reported in the literature, with over 100 live births reported following this procedure. The morbidity associated with RVT is low, with a tumor recurrence rate of 5% and a mortality rate of 3%. The current literature indicates no difference in the rate of recurrence with this technique compared with radical hysterectomy when proper selection criteria are used. Combining RVT with laparoscopic sentinel lymph-node biopsy can further reduce the duration, extent, and complications of surgery.16 Over a last 15 years, Radical vaginal tarchelectomy has been recognized as a valuable fertility-preservation option for young women with early stage disease. Sonoda and others recently published an interesting 16 year study examining all women undergoing a Radical vaginal tarchelectomy. These results indicated that a substantial proportion of patients with early stage disease may quality for this fertility preserving procedure.17 In the light of above incidence and prevalence, the researcher found that it is desirable to have at least knowledge regarding radical vaginal trachelectomy. The investigator through her community field experiences have observed so many women having a complain of infertility. By seeing all the above things investigator felt that there is need for assessing the knowledge for students regarding radical vaginal trachelectomy as a fertility preservation technique. 7 6.3 REVIEW OF LITERATURE An observational study was conducted on Radical abdominal trachelectomy is a safe and fertility preserving option for women with early stage cervical cancer in Department of Gynaecological oncology, Turkey. The data obtained from medical and pathological records of the 08 patients who undergone Radical abdominal trachelectomy. The study results shown that among 08 patients, 03 patients had late post-operative complications, 03 patients became pregnant which resulted in 03 live births and the spontaneous pregnancy rate was 50%. The study concluded that Radical abdominal trachelectomy is a reliable surgical option for a patient with early stage cervical cancer who wants to preserve fertility.18 A descriptive study was conducted to analyze the reproductive outcomes of patients undergoing fertility-preserving radical trachelectomy (RT) for the treatment of early-stage cervical cancer. This study analyzed data of 105 patients who undergone fertility-sparing surgery with radical trachelectomy, pelvic lymphadenectomy. The study results shown out of the 105 patients who undergone RT, out of 105 patients 66 patients (63%) were nulliparous, 35 women were actively attempting conception 06 months after surgery, and 23 (66%) women were successful in conceiving: there were 20 live births, 03 elective terminations, and 4 spontaneous miscarriages. Four patients had 02 pregnancies each, and delivered their second pregnancy between 32 and 36 weeks. The study concluded that majority of women who attempted to conceive after radical trachelectomy were successful, and most of their pregnancies resulted in full-term births. Assisted reproduction played an important role in select women.19 8 An observational study was conducted regarding radical trachelectomy and fertility outcomes in patients with early-stage cervical cancer. The study analyzed the published literature in search of all articles addressing obstetrical results in patient undergoing radical trachelectomy for cervical cancer. The study result shows that, a total of 520 patients had been reported to have undergone a radical vaginal trachelectomy. Approximately 43% of patients who undergo a radical trachelectomy subsequently attempt to become pregnant, and 70% of these women are successful at achieving a pregnancy. The study concluded that Radical trachelectomy is safe and feasible and pregnancy outcomes are very favorable.20 A retrospective study was conducted on pregnancies after redical vaginal trachelectomy for early-stage cervical cancer in Quebec City Canada. The study retrospectively reviewed first 30 patients treated by laparoscopic pelvic lymphadenectomy, followed by radical vaginal trachelectomy. The median age of the patients was 32 years (range 22-42 years) in that 15 were nulligravid, and 19 were nulliparous. The study result shows that only 06 patients attempted pregnancy so far has they succeeded, 04 have had healthy babies delivered by cesarean section at 39, 38, 34, and 25 weeks of gestation, 02 are currently 33 and 08 weeks pregnant. The study concluded that radical vaginal trachelectomy appears to be a valuable procedure in well selected patients with early stage cervical cancer.21 An observational study was conducted to analyze the fertility rates, complication and recurrences in a group of women who have undergone radical vaginal trachelectomy and pelvic lymphadenectomy for early stage cervical cancer. The sample was 123 consecutive women who undergone radical vaginal trachelectomy pelvic lymphadenectomy for early stage cervical cancer. Data were 9 collected prospectively. A total of 123 women were followed up for an average of 45 months. The study findings shown that out of 123, 66 women attempted pregnancy, there were 55 pregnancies, out of 55 pregnancies 26 were preterm and 28 were fullterm pregnancy. The 05 year cumulative pregnancy rate among women trying to conceive was 52.8%. The study concluded that for selected women with early-stage cervical cancer, radical vaginal trachelectomy and pelvic lymphadenectomy are fertility-sparing options.22 A retrospective study was conducted regarding treatment in patients with earlystage cervical cancer, radical vaginal trachelectomy (RVT) as a fertility-preserving surgery can be put on a par with radical hysterectomy as to oncologic safety. Prospective collection of fertility data of patients treated with RVT. Descriptive statistical analysis was performed, 212 patients were followed up after RVT. The study results shown that only 76 patients (35.9%) were seeking parenthood currently. 60 pregnancies occurred in 50 women. Five patients (8.3%) had first-trimester miscarriage, 3 had second-trimester miscarriage (5.0%), 2 patients decided for pregnancy termination (3.3%), and 1 patient (1.7%) had an ectopic pregnancy. Three women (5.0%) delivered prematurely before 28th weeks of gestation, 15 (25.0%) delivered between 28 and 36 weeks, and 27 women (45.0%) reached full term, four women had pregnancy. The study concluded that Preservation of childbearing function is a great advantage for patients with early-stage cervical cancer. Many patients do not seek parenthood immediately.23 A case study was conducted on Radical abdominal trachelectomy is a safe and fertility preserving option for women with early stage cervical cancer. The study obtained data of 08 patients who undergone RAT, from medical and pathological 10 records. The study results shows that the 03 (37.5%) patients had a tumor size smaller than 02 cm, and 05 (62.5%) patients had a tumor size larger than 02 cm, 07 (87.5%) patients had stage IB1 and 01 (12.5%) patient had stage IIA tumor. There were no recurrences. 03 patients became pregnant which resulted in 02 live births and 01 aborts. The spontaneous pregnancy rate was 50%. The study concluded that RAT is a reliable surgical option for a patient with early stage cervical cancer who wants to preserve fertility.24 A cohort study was conducted to prove the surgical and oncological safety of radical vaginal trachelectomy (RVT) and laparoscopic lymphadenectomy for patients with early-stage cervical cancer who are seeking parenthood. A database of 225 patients with early-stage cervical cancer and intention to treat by RVT after laparoscopic lymphadenectomy was prospectively maintained. A total of 212 patients were treated according to the protocol. The study results shows that in the cohort of patients treated according to protocol, 8 recurrences occurred and 4 patients died from recurrence, no severe long-term complications occurred. The study concluded that Radical vaginal trachelectomy combined with laparoscopic lymphadenectomy is a safe method for treatment of patients with early-stage cervical cancer who are seeking parenthood.25 An observational study was conducted to determine whether medical trechelectomy, combined with pelvic lymphadenectomy, can be a feasible method for the treatment of early-state cervical carcinoma in women who want to preserve their fertility. The sample was 12 women with stage 1 carcinoma of the cervix were undergone radical trachelectomy and pelvic lymphadenectomy of the intact uterus as treatment. The study result shows that four pregnancies have occured, with 2 third- 11 trimester deliveries and 2 preterm deliveries, respectively. The study concluded that radical trachelectomy, combined with pelvic lymphadenectomy, can be a feasible method of treatment for early-stage cervical carcinoma in women who want to preserve their fertility.26 6.4 STATEMENT OF THE PROBLEM “A study to assess the effectiveness of structured teaching programme on knowledge regarding radical vaginal trachelectomy as a fertility preservation in cervical cancer among final year Bsc nursing students in selected nursing colleges in Tumkur.” 6.5 OBJECTIVES OF THE STUDY To assess the knowledge regarding radical vaginal trachelectomy as a fertility preservation in cervical cancer among final year Bsc nursing students. To assess the effectiveness of structured teaching programme on knowledge regarding radical vaginal trachelectomy as fertility preservation in cervical cancer among final year Bsc nursing students. To find out the association between pre-test level of knowledge with selected socio-demographic variables. 6.6 OPERATIONAL DEFINITIONS Effectiveness: In this study it refers to the extent to which the structured teaching programme on knowledge regarding radical vaginal trachelectomy as a fertility preservation in cervical cancer achieved its objectives in improving knowledge in final year Bsc nursing students. Structured teaching programme: In this study it refers to the information provided through systematically organized teaching regarding radical vaginal trachelectomy as a fertility preservation in cervical cancer 12 for duration of 45 minutes with the help of audio visual aids such as charts and overhead projector. Knowledge: In this study it refers to correct response given by final year nursing students regarding radical vaginal trachelectomy as a fertility preservation in cervical cancer as it is elicited through self administered knowledge questionnaire. Radical vaginal trachelectomy: In this study Radical vaginal trachelectomy technique involves a laparoscopic pelvic lymphadenectomy followed by vaginal resection of a portion of the cervix Fertility preservation: In this study fertility preservation offers couples or individuals the opportunity to preserve their ability to have children’s in the future. Cervical cancer-In this study cervical cancer is a malignant neoplasm of the cervical area. Final year Bsc nursing students: In this study it refers to the students those who are studying in IV Bsc (N) class and having knowledge about the obstetrical and gynaecological related health problems. 6.7 ASSUMPTIONS Final year Bsc nursing students may have limited knowledge regarding radical vaginal trachelectomy as a fertility preservation in cervical cancer. Structured teaching programme is one of the best teaching strategies in imparting knowledge regarding radical vaginal trachelectomy as a fertility preservation in cervical cancer among final year Bsc nursing students. 6.8 HYPOTHESIS H1: There will be a significant difference between pre test and post test knowledge scores regarding radical vaginal trachelectomy as a fertility preservation in cervical cancer among final year Bsc nursing students. 13 H2: There will be a significant association between the pre test level of knowledge with selected socio demographic variables. 6.9 VARIABLES Independent variable - structured teaching programme. Dependent variable - knowledge score. 7 MATERIALS AND METHODS 7.1 Source of data Information will be collected by means of self administered knowledge questionnaire regarding radical vaginal trachelectomy as a fertility preservation in cervical cancer among final year Bsc nursing students. 7.2 METHOD OF DATA COLLECTION 7.2.1 Research design Pre experimental one group pre test- post test research design. 7.2.2 Settings of the study Selected nursing colleges in Tumkur 7.2.3 Population Final year Bsc nursing students in selected nursing colleges in Tumkur. 7.2.4 Sample Final year B.Sc Nursing students in selected nursing colleges in Tumkur. 7.2.5 Sampling technique Simple random sampling technique. 14 7.2.6 Sample size 60 final year B.Sc Nursing students. 7.2.7 Sampling criteria Inclusive criteria: 1. Final year BSc nursing students who are willing to participate in the study. 2. Final year BSc nursing students who are Eligible to write forthcoming annual examination. Exclusive criteria: 1. Final year B.Sc nursing students those who are not available at the time of data collection. 7.2.8 Tool for data collection The tool for the present study is self administered knowledge questionnaire. It consists of two sections: Section A - Socio- demographic variable. Section B- Self administered Knowledge questionnaire regarding radical vaginal trachelectomy as a fertility preservation in cervical cancer. 7.2.9 Method of data collection The data will be collected from IV year B.Sc Nursing students by using self administered questionnaire after obtaining permission from the college authority to conduct the main study. On the day first, pre test will be given to the students on the same day structured teaching programme will be given. On the day eight the post test will be given to same students to evaluate the effectiveness of structured teaching programme. 15 7.3 DATA ANALYSIS AND INTERPRETATION Descriptive statistics Descriptive statistical techniques such as Mean, Median, Mean deviation, Standard deviation, percentage and frequency. Inferential statistics Chi-square test and Paired ‘t’test 7.4 ETHICAL CLEARANCE: 7.4.1.Does the study require any investigation or interventions to be conducted on patients or other human or animals? NO. 7.4.2. Has ethical clearance been obtained from your institution in case of 7.4? Yes. Ethical clearance will be obtained from the institution. 16 8. BIBLIOGRAPHY: 1. WHO-Reproductive health (cited on nov15), Available from www.who.int/topics/reproductive health /in/ 2. Wikipedia, the free encyclopedia, International conference on population and development, Available from: http://www.unfpa.org/icpd.icpd.htm 3. D.C Dutta “Text book of gynecology” 6th edition, new central book agency pvt.Ltd.page no: 254 4. SEER Cancer statistics review, 1975-2008, National cancer institute, Brthesda, SEER publication November 2010. 5. Tharu R. Cervical cancer [Online]. [2009?] [cited 2012 Oct 30]; [14 screens]. Available from URL: http://www.medindia.net/patients 6. Dinshaw k.A. rao DN, Ganesh B Tata .Memorial Hospital cancer registry annual report, Mumbai India ; 1999, Tharu R, cervical cancer (online),(2012) (cited 2012) Available from URL;http;//www.medindia.net/patients 7. Alarming incidence of cervical cancer among Indian women .Available from URL;http;//www.tribuneindia.com/2003/ 8. Nattress, Kathyn < Fertility preservation in Gynaecological cancer (online) .Australian journal of cancer nursing, the vol, 11, nov. 1, jul2010:17-22 Available from http://www.search.informat.com 9. International journal of surgical Oncology volume 2012 (2012), Article ID 936534, 11 pages, Review Article fertility- sparing surgery for Early-Stage cervical cancer Available from URL.http://www.surgical.oncology.com 10. Cervical cancer in India Ambika Satija South Asia centre for chronic disease. 11. Cervical cancer incidence statistics: Cancer Research UK . Available from www.cancerresearchuk.org/cancer.../cancerstats/.../cervix/incidence 17 12. WHO/ICO information centre on HPV and cervical cancer (HPV information centre), human papilloma virus and related cancer in India, summary report 2010.(Dat accessed ).Available at www.who.int/hpvcentre . 13. Imran Ali*, Waseem A. Wani and Kishwar Saleem Cancer Scenario in India with Future Perspectives Research Article *Department of Chemistry, Jamia Millia Islamia (Central University), New Delhi-110025, INDIA. 14. Mojgan karimi zarchi, Azamsadat Mousavi, Mitra modares Gilani, Esmat Barooti, omid Amini rad, Fatemeh Ghaemmaghami. Mini-Rewiew Fertility sparing treatments in young patients with Gynecological cancers:Iranian experience and literature review. 15. Atlana G A. Department of Health and Human Sciences, Centers for Disceace Control and prevention and National Cancer Institute; 2010.Available from:http://www.cdc.gov/use. 16. World Health Organization. Infertility Prevalence of primary and secondary infertility Geneva. Programme on maternal and child health and family planning, Division of family health W.H.O (1991).Available from:http://www.indiaonlinepaper.com. 17. Yael Hashilon Doler, Amit Kalpan, Shri Shkeeli-Rafid. Human. Reprod. 2011; 26(11): 3045-3053. Available from : http://humrep.oxfordjournals.org 18. Karateke A, Kabaca C, Radical abdominal trachelectomy is a safe and fertility preserving option for women with early stage cervical cancer.Department of Gynecologic Oncology, Zeynep Kamil Women and Children Diseases Education and Research Hospital, Istanbul, Turkey. Eur J Gynaecol Oncol. 2012; 33(2):200-3. 18 19. Kim CH, Abu-Rustum NR, Chi DS, Gardner GJ, Leitao MM Jr, Carter J, Barakat RR, Sonoda Y, Reproductive outcomes of patients undergoing radical trachelectomy for early-stage cervical cancer. Department of Surgery, Gynecology Service, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA. Gynecol Oncol. 2012 Jun;125(3):585-8. Epub 2012 Mar 16. 20. Ramirez PT, Schmeler KM, Soliman PT, Frumovitz M Fertility preservation in patients with early cervical cancer: radical trachelectomy. Department of Gynecologic Oncology, The University of Texas MD Anderson Cancer Center, Houston, Gynecol Oncol. 2008 Sep;110(3 Suppl 2):S25-8. Epub 2008 May 23. 21. Michel Roy, Marie Plante, pregnancies after radical vaginal trachelectomy for early-stage cervical cancer, department of gynecology, centre hospitalier universitaire, Quebec, Canada. 22. J.H Shepherd, C Spencer < J Herod,TEJ Ind, Radical vaginal trachelectomy as a fertility- sparing procedure in women with early- stage cervical cancer – cumulative pregnancy rate in a series of 123 women. 23. Speiser D, Mangler M, Köhler C, Hasenbein K, Hertel H, Chiantera V, Gottschalk E, Lanowska M Fertility outcome after radical vaginal trachelectomy: a prospective study of 212 patients. Department of Gynecology, Charité University Medicine, Berlin, Germany. Int J Gynecol Cancer. 2011 Dec;21(9):1635-9. 24. Karateke A, Kabaca C Radical abdominal trachelectomy is a safe and fertility preserving option for women with early stage cervical cancer. Department of Gynecologic Oncology, Zeynep Kamil Women and Children Diseases 19 Education and Research Hospital, Istanbul, Turkey. Eur J Gynaecol Oncol. 2012;33(2):200-3. 25. Lanowska M, Mangler M, Spek A, Grittner U, Hasenbein K, Chiantera V, Hertel H, Schneider A, Köhler C, Speiser D. Radical vaginal trachelectomy (RVT) combined with laparoscopic lymphadenectomy: prospective study of 225 patients with early-stage cervical cancer. Department of Gynecology, Charité University Medicine, Berlin, Germany. Int J Gynecol Cancer. 2011 Nov;21(8):1458-64. 26. John B. Schlaerth, MD,a Nicola M. Spirtos, MD,b and Alan C. Schlaerth,MD,a a Pasadena and bPalo Alto, Calif, General obstetrics and gynaecology: radical trachelectomy and pelvic lymphadenectomy with uterine preservation in the treatment of cervical cancer. Available from www.womenscancercenter.com/resource/research/radtrach.html 20 21