Uterine Cervical Surgery

Overview

The cervix is at the bottom of the uterus, where it opens into the vaginal canal. It protects the uterus from external pathogens and produces various types of mucus depending on the stage of the menstrual cycle.

It also aids in the retention of the fetus in the uterus. Cells in the cervix begin to alter before cancer begins. These aberrant cells have the potential to become cancer if left untreated over time, which is why early identification may help give a better prognosis.

If you have cervical cancer, your doctor can treat it in a variety of methods. Which one they prescribe will be determined by the type of cervical cancer you have, your age, and whether or not you plan to have children in the future.

It will also be determined whether or not the malignancy has spread. Doctors refer to this as the "stage" it is in. Surgery is only one of the options you should consider with your doctor.

Types of Cervical Surgery

Surgery for cervical pre-cancers:

Two types of procedures can be used to treat pre-cancers of the cervix:

• Ablation destroys cervical tissue with cold temperatures or with a laser rather than removing it.
• Excisional surgery (conization) cuts out and removes the pre-cancer.   

    1. Cryosurgery:

Cryosurgery is a form of ablation that involves placing an extremely cold metal probe directly on the cervix. The aberrant cells are killed by freezing. It is employed in the treatment of cervical intraepithelial neoplasia (CIN). This is something that can be done at a doctor's office or clinic. For a few weeks after cryosurgery, you may have a watery brown discharge.

    2. Laser ablation:

Laser ablation uses a concentrated laser beam to melt (burn out) abnormal cells in the vagina. Because it causes greater discomfort than cryotherapy, this may be performed in a doctor's office under local anesthesia (numbing drugs) or in the operating room under general anesthesia. It is also employed in the treatment of cervical intraepithelial neoplasia (CIN).

    3. Conization;

Conization is an excisional operation used to treat cervical intraepithelial neoplasia (CIN). A cone-shaped piece of tissue is removed from the cervix by the doctor. The tissue removed in the cone includes the transformation zone, which is where most cervical pre-malignancies and cancers begin. A cone biopsy is used to diagnose more than just pre-malignancies and cancers. It can also be used as a therapy since it can occasionally totally eradicate pre-malignancies and some early cancers.

The procedure can be done in different ways:

• Using a surgical blade (cold knife cone biopsy).
• Using a laser beam (laser conization).
• Using a thin wire heated by electricity (the loop electrosurgical excision procedure, LEEP or LEETZ procedure).

Surgery for invasive cervical cancer:

Procedures to treat invasive cervical cancer are:

• Hysterectomy (simple or radical).
• Trachelectomy.

    1. Simple hysterectomy:

A basic hysterectomy removes the uterus (both the body and the cervix) but not the tissues around the uterus (parametria and uterosacral ligaments). The lymph nodes in the vaginal and pelvic regions are not removed. Unless there is another cause to remove the ovaries, they are normally kept in situ.

Certain cases of severe CIN or very early cervical cancer can be treated with a simple hysterectomy.

There are different ways to do a hysterectomy:

• Abdominal hysterectomy: The uterus is removed through a surgical incision in the front of the abdomen.
• Vaginal hysterectomy: The uterus is removed through the vagina.
• Laparoscopic hysterectomy: Laparoscopy is used to remove the uterus. To look inside the belly and pelvis, a thin tube with a tiny video camera at the end (the laparoscope) is introduced into one or more extremely small surgical incisions created on the abdominal wall. Small tools can be manipulated via the tube(s), allowing the surgeon to cut around the uterus without creating a big incision in the abdomen. The uterus is then removed through a vaginal incision.
• Robotic-assisted surgery: In this approach, the laparoscopy is done with special tools attached to robotic arms that are controlled by the doctor to help perform precise surgery.

General anesthesia is used for all of these operations.

The hospital stay for a laparoscopic or vaginal hysterectomy is generally 1 to 2 days, followed by a 2- to 3-week recuperation period. An abdominal hysterectomy typically requires a hospital stay of 3 to 5 days, with full healing taking 4 to 6 weeks.

Possible adverse effects include: Infertility arises from any form of hysterectomy (inability to have children). Complications are rare, although they might include bleeding, infection, or injury to the urinary or gastrointestinal systems, such as the bladder or colon.

A woman's capacity to sense sexual pleasure is unaffected by hysterectomy. Orgasm does not require a uterus or cervix in a woman. The region around the clitoris and the vaginal lining are still as sensitive as before the hysterectomy.

     2. Radical hysterectomy:

The uterus, as well as the tissues surrounding it (the parametria and the uterosacral ligaments), the cervix, and the upper section (approximately 1 inch [2-3cm]) of the vagina adjacent to the cervix, are removed during this procedure. Unless there is another medical cause, the ovaries are not removed. A radical hysterectomy removes more tissue than a basic one, thus the hospital stay may be longer. At the same time, certain lymph nodes will be removed and examined for malignancy.

This procedure is often performed through a big abdominal incision (also known as open surgery). Some pelvic lymph nodes are frequently removed as well. 

A radical hysterectomy can also be performed with the use of laparoscopy or a robot. These procedures are also known as minimally invasive surgery. When compared to open surgery, laparoscopic (or robotic) surgery can result in less discomfort, less blood loss, and a shorter hospital stay. However, new research has indicated that women who have minimally invasive radical hysterectomies for cervical cancer have a greater risk of the disease returning and dying from the cancer than those who had surgery through an abdominal incision (open surgery).

Having a radical hysterectomy through an abdominal cut is the preferred type of surgery in most cases. Laparoscopic surgery may still be an option for a small specific group of women with early stage cancer, but you should discuss your options carefully with your doctor.

A modified radical hysterectomy is similar to a radical hysterectomy but does not remove as much of the vagina and tissues next to the uterus (the parametria and the uterosacral ligaments) and lymph nodes are usually not removed.

Possible side effects: This operation leads in infertility since the uterus is removed. Because part of the nerves to the bladder are destroyed, some women may have difficulty emptying their bladder following this procedure and may require a catheter for a period of time. Complications are rare, although they might include bleeding, infection, or injury to the urinary and gastrointestinal systems, such as the bladder or colon.

Lymphedema can occur when certain lymph nodes are removed to screen for malignancy (leg swelling). This is not common, although it can occur after surgery and be treated in a variety of ways.

A woman's capacity to enjoy sexual pleasure is unaffected by radical hysterectomy. Despite the fact that the vagina is shorter, the region around the clitoris and the vaginal lining remain as sensitive as before. Orgasm does not require a uterus or cervix in a woman. When cancer has caused discomfort or bleeding during sexual activity, a hysterectomy may actually improve a woman's sex life by alleviating these symptoms.

     3. Trachelectomy

A radical trachelectomy allows women to be treated while still being able to bear children. The procedure is performed either through the vagina or the abdomen, and laparoscopy is occasionally used.

The cervix and the top section of the vagina are removed, but the uterus's body is not. The surgeon next inserts a permanent "purse-string" stitch into the uterine cavity to keep the uterine hole closed, as the cervix typically does.

Laparoscopy is also used to remove adjacent lymph nodes, which may necessitate additional incision (cut). The procedure is performed either through the vagina or the abdomen.

After trachelectomy, some women are able to carry a pregnancy to term and deliver a healthy baby by cesarean section, although women who have had this surgery might have a higher risk of miscarriage.

     4. Pelvic exenteration

This procedure is reserved for particularly specific situations of recurrent cervical cancer. All of the same organs and tissues are removed as in a radical hysterectomy with pelvic lymph node dissection. In addition, depending on where the cancer has progressed, the bladder, vagina, rectum, and a portion of the colon are removed.

If your bladder is removed, you will require a new method of storing and disposing of pee. This generally entails employing a small section of intestine as a replacement bladder. When the patient inserts a catheter into a urostomy, the new bladder may be linked to the abdominal wall and pee emptied on a regular basis (a small opening). Alternatively, urine is continually drained into a little plastic bag affixed to the front of the abdomen.

If the rectum and a portion of the colon are removed, a new method of disposing of solid waste must be devised. The remaining intestine is attached to the abdominal wall, allowing fecal waste to flow via a small aperture (stoma) into a little plastic bag worn on the front of the belly. In certain circumstances, the malignant section of the colon (near to the cervix) may be removed and the colon ends reconnected, eliminating the need for bags or external appliances.

If the vagina is gone, a new vagina can be surgically created from skin, intestinal tissue, or muscle and skin grafts (myocutaneous).

Recovery from total pelvic exenteration takes a long time. Most women don't begin to feel like themselves again for about 6 months after surgery. Some say it takes a year or two to adjust completely.

Nevertheless, these women can lead happy and productive lives. With practice, they can also have sexual desire, pleasure, and orgasms.

Surgery to remove nearby lymph nodes.

    1. Para-aortic lymph node sampling:

During a radical hysterectomy, the lymph nodes adjacent to the aorta (the main artery in the belly) are usually removed. This is referred to as para-aortic lymph node sampling. During the procedure, the lymph nodes may be transferred to the lab for immediate examination. If the para-aortic lymph nodes test positive for malignancy, the operation may be postponed and replaced with radiation and chemotherapy. If no malignancy is found in the lymph nodes, the pelvic lymph nodes are routinely removed and the radical hysterectomy is performed. Any surgically removed tissue will be analyzed to check if the cancer has spread there. If this is the case, radiation therapy with or without chemotherapy may be indicated.

    2. Pelvic lymph node dissection:

Cancer that begins in the cervix can spread to the pelvic lymph nodes (pea-sized collections of immune system cells). The surgeon may remove part of these lymph nodes to check for lymph node spread. This is known as lymph node sample or pelvic lymph node dissection. It is performed concurrently with a hysterectomy or trachelectomy.

The removal of lymph nodes may result in fluid drainage issues in the legs. This might result in significant leg swelling, a disease known as lymphedema.

    3. Sentinel lymph node mapping and biopsy:

Sentinel lymph node mapping and biopsy is a process in which the surgeon discovers and removes just the lymph node(s) where the cancer is most likely to spread first. To do this, the surgeon injects a radioactive material and/or a blue dye into the cervix at the start of the procedure. These compounds will be carried by lymphatic veins along the same course that the cancer would most likely go. The sentinel node is the first lymph node to which the dye or radioactive material goes (s). Removing only one or a few lymph nodes reduces the chance of complications from the procedure, such as leg swelling, commonly known as lymphedema.

After the chemical is injected, the sentinel node(s) may be identified by either using a particular equipment to detect radioactivity in the nodes or by checking for nodes that have become blue. Both procedures are frequently used to double-check. The node(s) containing the dye or radioactivity are subsequently removed by the surgeon.

Certain instances of stage I cervical cancer may benefit from sentinel lymph node mapping. It is most effective for tumors smaller than 2 cm in size. If your surgeon intends to do sentinel lymph node biopsies, you should explore whether this operation is right for you.

Even if sentinel lymph node mapping does not show any lymph nodes to biopsy, the surgeon will most likely still remove the lymph nodes on that side of the pelvis to make sure cancer is not missed. Also, any enlarged or suspicious lymph nodes need to be removed at the time of surgery, even if they do not map with dye.

What to Expect After the Procedure?

The length of your recovery depends on your health before to the treatment and the type of trachelectomy you have.

Trachelectomies performed with laparoscopy or a robotic arm are often simpler to recover from since they are less invasive. Most patients will be hospitalized for three to five days.

After the trachelectomy, you can expect:

• vaginal bleeding for two or more weeks
• pain (you’ll be prescribed pain medication)
• a urinary catheter (a thin tube inserted into the bladder to release urine) in place for one to two weeks postsurgery
• instructions to limit physical activity, such as exercising, climbing stairs, or even driving, possibly for several weeks
• instructions to refrain from sex or putting anything in your vagina until you get your doctor’s OK, usually four to six weeks after surgery
• to be out of work for four to six weeks

Possible Side Effects

Possible short-term physical side effects include

• pain
• physical weakness
• urinary incontinence
• painful periods
• vaginal discharge
• risk of infection
• limb swelling

RT can have additional consequences. According to a 2014 study, during the year after surgery, women undergoing RT were more likely than women who didn’t have the procedure to have:

• sexual dysfunction
• lower sex drive (although desire returned to normal at the end of the 12 months)
• sexual worry

Conclusion

For some people, surgery may be the only treatment needed. Surgery is usually recommended when the tumor is in the cervix only. The type of surgery you have will depend on how far within the cervix cancer has spread. Your surgeon may also remove some lymph nodes during surgery.