Surgery for endometrial cancer

Hysterectomy

The main treatment for endometrial cancer is an operation to remove the uterus and cervix (called a hysterectomy). When the uterus is removed through an incision in the abdomen, it is called a simple or total abdominal hysterectomy (TAH). If the uterus is removed through the vagina, it is known as a vaginal hysterectomy. Removing the ovaries and fallopian tubes, a bilateral salpingo-oophorectomy (BSO), is not actually part of a hysterectomy; it is a separate procedure that is often done during the same operation (see below). For endometrial cancer, removing the uterus but not the ovaries or fallopian tubes is seldom recommended. To decide what stage the cancer is in, lymph nodes in the pelvis and around the aorta will also need to be removed (see below). This can be done through the same incision as the abdominal hysterectomy. If a vaginal hysterectomy is done, lymph nodes can be removed by laparoscopy (this is discussed in detail below).

A radical hysterectomy is done when endometrial cancer has spread to the cervix or the area around the cervix (the parametrium). In this operation, the entire uterus, the tissues next to the uterus (parametrium and uterosacral ligaments), and the upper part of the vagina (next to the cervix) are all removed. For endometrial cancer, a BSO is done at the same time. This operation is most often done through an incision in the abdomen, but it can also be done going in through the vagina.

When a vaginal approach is used, laparoscopy is used to help safely remove all of the correct tissues. Laparoscopy is a technique that lets the surgeon look at the inside of the abdomen and pelvis through tubes inserted into very small incisions. Small surgical instruments can be controlled through the tubes, allowing the surgeon to operate without a large incision in the abdomen. This can shorten the time needed for recovery from surgery. Both a hysterectomy and a radical hysterectomy can also be done through the abdomen using laparoscopy.

Surgery for endometrial cancer using laparoscopy seems to be just as good as more traditional open procedures if done by a surgeon who has a lot of experience in laparoscopic cancer surgeries. The DaVinci ^® robot is increasingly used to perform laparoscopic procedures.

For any of these surgeries, either general anesthesia or regional anesthesia will be used so the patient is asleep or sedated during these operations.

Bilateral salpingo-oophorectomy

This operation removes both fallopian tubes and both ovaries. This procedure is usually done at the same time the uterus is removed (either by simple hysterectomy or radical hysterectomy) to treat endometrial cancers. Removing both ovaries means that you will go into menopause if you have not done so already.

If you are younger than 45 when you get stage I endometrial cancer, you may discuss keeping your ovaries with your surgeon, because although women whose ovaries were removed had a lower chance of the cancer coming back, removing the ovaries didn’t seem to help them live longer.

Lymph node surgery

Pelvic and para-aortic lymph node dissection: This operation removes lymph nodes from the pelvis and the area next to the aorta to see if they contain cancer cells that have spread from the endometrial tumor. It is called a lymph node dissection when most or all of the lymph nodes in a certain area are removed. This procedure is usually done at the same time as the operation to remove the uterus. If the patient is having an abdominal hysterectomy, the lymph nodes can be removed through the same incision. In women who have had a vaginal hysterectomy, these lymph nodes may be removed by laparoscopic surgery.

Laparoscopy is a technique that lets the surgeon look at the inside of the abdomen and pelvis through tubes inserted into very small incisions. Small surgical instruments can be controlled through the tubes, allowing the surgeon to remove lymph nodes. This approach avoids the need for a large incision in the abdomen and so can shorten the time needed for recovery from surgery. A recent study showed that laparoscopic surgery (including lymph node removal) works as well (at least in the short-term) as open abdominal surgery.

Lymph node sampling: When only a few of the lymph nodes in an area are removed, it is called lymph node sampling.

Depending on the grade, amount of cancer in the uterus and how deeply the cancer invades into the muscle of the uterus, lymph nodes may not need to be removed.

Pelvic washings

In this procedure, the surgeon “washes” the abdominal and pelvic cavities with salt water (saline) and sends the fluid to the lab to see if it contains cancer cells. This is also called peritoneal lavage.

Other procedures that may be used to look for cancer spread

• Omentectomy: The omentum is a layer of fatty tissue that covers the abdominal contents like an apron. Cancer sometimes spreads to this tissue. When this tissue is removed, it is called an omentectomy. Sometimes the omentum is removed during a hysterectomy to see if cancer has spread there.
• Peritoneal biopsies: The tissue lining the pelvis and abdomen is called the peritoneum. Peritoneal biopsies involve removing small pieces of this lining to check for cancer cells.

Tumor debulking

If cancer has spread throughout the abdomen, the surgeon may attempt to remove as much of the tumor as possible. This is called debulking. Debulking a cancer can help other treatments, like radiation or chemotherapy, work better. Tumor debulking is helpful for other types of cancer, and it may also be helpful in treating some types of endometrial cancer.

Recovery after surgery

For an abdominal hysterectomy the hospital stay is usually from 3 to 7 days. The average hospital stay after a radical hysterectomy is about 5 to 7 days. Complete recovery can take about 4 to 6 weeks. A laparoscopic procedure and vaginal hysterectomy usually require a hospital stay of 1 to 2 days and 2 to 3 weeks for recovery. Complications are unusual but could include excessive bleeding, wound infection, and damage to the urinary or intestinal systems.

Side effects

Any hysterectomy causes infertility (not being able to start or maintain a pregnancy). For those who were premenopausal before surgery, removing the ovaries will cause menopause. This can lead to symptoms such as hot flashes, night sweats, and vaginal dryness. Removing lymph nodes in the pelvis can lead to a build up of fluid in the legs, a condition called lymphedema. This occurs more often if radiation is given after surgery.