Surgery for Endometrial Cancer

Surgery is used for uterine cancer for several reasons:

• For staging, to evaluate if and where the cancer has spread outside of the uterus.          
• For treatment, to remove all cancer in the abdomen and pelvis.          
• For symptom management, if the cancer has spread to distant parts of the body.    

Surgery usually includes a total hysterectomy (removal of the uterus and cervix), bilateral salpingo-oophorectomy (removal of both fallopian tubes and ovaries), and lymphadenectomy (assessment and removal of certain lymph nodes).

Typically, peritoneal lavage is also done during surgery.  The abdominal and pelvic cavities are “washed” with salt water (saline) which is then collected and sent to the lab to see if it contains cancer cells. The results of testing the fluid from the peritoneal lavage does not affect the current staging, but both FIGO and the American Joint Committee on Cancer (AJCC) recommend collecting the sample.

During surgery, the surgeon will also inspect the peritoneum (membrane around the abdominal and pelvic cavity) and will take biopsies of any areas that appear suspicious to check for cancer cells.If endometrial cancer cells are found the cancer’s surgical stage may change, and the next steps of treatment could be affected.

For surgical treatment, the goal is to remove as much  cancer as possible. This is called debulking or cytoreduction.     

If the surgery is being done to manage symptoms, the procedure will target specific symptoms, such as blocked bowels.      

How is a hysterectomy done for uterine cancer?

There are different surgical approaches:

• Minimally invasive surgery (MIS): An example is laparoscopic surgery.  For more information, see below. 

• Laparotomy: The uterus is removed through an incision (cut) in the abdomen (belly).

• Vaginal hysterectomy: The uterus is removed through the vagina. This may be an option for those who are not healthy enough for other types of surgery.

Laparoscopy is a minimally invasive surgical technique that lets the surgeon look at the inside of the abdomen and pelvis through narrow tubes put in through very small cuts (incisions) made in the belly. Surgical instruments can be controlled through the tubes. This lets the surgeon operate without making a large incision in the abdomen. This approach means less pain and less blood loss than a large incision, and recovery time after surgery is shorter.

Laparoscopic surgery for endometrial cancer seems to work just as well as more traditional open procedures if done by a surgeon who has a lot of experience in laparoscopic cancer surgeries.

A robotic approach can be used to do laparoscopic procedures, and results are much the same as with more conventional types of surgery. In robotic surgery, the surgeon sits at a control panel in the operating room and moves robotic arms to operate through many small incisions.

For any of these procedures, general anesthesia is used so the patient is in a deep sleep and doesn't feel pain during the operation.

Types of Hysterectomy

• Total hysterectomy – Removal of the uterus and cervix.
• Subtotal (partial) hysterectomy – Removal of the uterus, leaving the cervix intact.
• Radical hysterectomy – Removal of the uterus, cervix, upper vagina, and surrounding tissues.
• Hysterectomy with bilateral salpingo-oophorectomy – Removal of the uterus, cervix, both ovaries, and fallopian tubes (also called a radical hysterectomy).

The standard type of hysterectomy for uterine cancer is a simple hysterectomy. However, if the endometrial cancer is suspected to have spread to the cervix, a radical hysterectomy may be performed to ensure that all the cancer is removed.

Other surgery done with hysterectomy

Bilateral salpingo-oophorectomy

A bilateral salpingo-oophorectomy (BSO) is the removal of both ovaries and fallopian tubes.  It is usually done at the same time as the hysterectomy to treat endometrial cancers.      

Having both ovaries removed means that you'll go into menopause if you haven't done so already. If you have endometrial cancer and have not yet gone into menopause it may be safe to keep your ovaries if you have a low stage non-aggressive endometrial cancer.  Talk with your surgeon about this decision. When ovaries are removed there might be a lower chance of the cancer coming back, but for patients who keep their ovaries, there doesn’t seem to be an increased risk of dying from endometrial cancer.

Lymph node surgery

Sentinel lymph node dissection (SLND) and lymphatic mapping may be used in early-stage endometrial cancer if imaging tests don't clearly show signs that cancer has spread to the lymph nodes in your pelvis. To do this, a blue or green dye is injected into the  cervix. The surgeon then looks for the lymph nodes that turn blue or green (from the dye). This is called lymphatic mapping.  These lymph nodes are the ones that the cancer would first drain into and are called sentinel lymph nodes. They are removed and tested to see if there are cancer cells in them. This is a sentinel lymph node dissection. If they do have cancer cells, more lymph nodes may be taken out.  

If there are no cancer cells in the sentinel nodes, no more nodes are removed. This procedure is usually done at the same time as surgery to remove the uterus (hysterectomy). If a sentinel lymph node is not identified on both sides, then this is a failure of mapping. In this situation the lymph nodes should be removed from each side that failed to map.       

If imaging tests done before surgery show enlarged lymph nodes (indicating the cancer might have spread) the lymph nodes in specific areas from the pelvis and from the area next to the aorta will be removed. This is done during the hysterectomy. They are then tested to see if they contain cancer cells that have spread from the endometrial tumor. This information is part of finding the cancer’s surgical stage.

Omental biopsy

The omentum is a flat layer of fat on the surface of the abdominal organs. A sample from this structure is taken during surgery for aggressive types of endometrial cancer.

Recovery after surgery for uterine cancer

The hospital stay after an abdominal hysterectomy (laparotomy) is usually 2 to 7 days. Complete recovery can take  4 to 6 weeks. If the hysterectomy is done by a laparoscopic or robotic or vaginal approach, usually you will be able to leave the hospital on the same day or the next day. Full recovery takes about 3 to 4 weeks. Complications of these surgeries are not common and depend on the surgical approach. They include nerve or vessel damage, excessive bleeding, wound infection, blood clots, and damage to nearby tissues (the urinary and intestinal systems).

A radical hysterectomy affects the nerves that control the bladder, so a catheter is used to drain urine after surgery. It may be needed for a few days or up to 2 weeks. If the bladder hasn’t recovered completely when the catheter is removed, it may need to be put back in. Another option is that you're shown how to put a catheter in yourself several times a day to empty your bladder. Over time, bladder function should return     .

Long-term side effects of uterine surgery

Any hysterectomy causes infertility (you won't be able to get pregnant).

Removing the ovaries will cause menopause right away. This can lead to symptoms like hot flashes, night sweats, and vaginal dryness. It can lead to osteoporosis and increased risk for heart disease, which impacts all post-menopausal women.

Removing lymph nodes in the pelvis can lead to a build-up of fluid in the legs and genitals. This can become a life-long problem called lymphedema. It's more likely if radiation is given after surgery.

Surgery and menopausal symptoms can also affect your sex life. For more, see Sexual Side Effects.

Talk with your treatment team about side effects you might have right after surgery and later on. There might be things you can do to help prevent side effects. Know what to expect so you can get help right away.