Minimally invasive surgery guidelines in paediatric surgical oncology - role of MIS in fertility preservation

Childhood cancers represent approximately 1% of all malignancies, with improved therapeutic strategies leading to an 80% long-term survival rate. However, these advancements come with potential long-term sequelae, among which fertility impairment is a major concern. Gonadotoxic treatments, including chemotherapy, radiotherapy and mutilating surgery, significantly impact reproductive potential, necessitating fertility preservation strategies. Minimally invasive surgery (MIS) plays a crucial role in preserving fertility in paediatric patients. Ovarian and genital tract-sparing surgery should be prioritised for benign ovarian tumours, which constitute 90% of childhood ovarian lesions, to avoid unnecessary loss of ovarian reserve. Ovarian transposition is recommended for patients requiring pelvic radiotherapy, relocating the ovaries outside the radiation field to mitigate ovarian damage. Additionally, uterine transposition has been explored to protect reproductive organs from radiation exposure. Ovarian tissue cryopreservation remains a promising option, particularly for prepubertal patients undergoing gonadotoxic treatments. Cryopreserved ovarian fragments can later be used for autografting or <i>in vitro</i> maturation, though the risk of malignant cell transmission remains a challenge. MIS contraindications are limited, primarily related to tumour size and the risk of rupture during laparoscopic procedures. A multidisciplinary approach involving oncologists, surgeons, radiotherapists and fertility specialists is essential for optimising outcomes. This chapter discusses the indications, techniques and challenges associated with MIS in fertility preservation, emphasising its role in ensuring reproductive potential while maintaining oncological safety in paediatric cancer patients.