Surgery for uterine cancer

Surgery is a medical procedure to examine, remove or repair tissue. Surgery, as a treatment for cancer, means removing the tumour or cancerous tissue from your body.

Most people with uterine cancer have surgery. The type of surgery you have depends mainly on the size of the tumour, the type of uterine cancer you have, and the stage and grade of the cancer. When planning surgery, your healthcare team will also consider other factors, such as your age, overall health and whether you want to have children in the future.

Surgery may be the only treatment you have or it may be used along with other cancer treatments. You may have surgery to:

• determine the stage of the cancer
• completely remove the tumour
• remove as much of the tumour as possible (called debulking)
• reduce pain or ease symptoms (called palliative surgery)

Staging describes or classifies cancer based on how much cancer there is in the body and where it is when first diagnosed. This is often called the extent of cancer. It’s very important to stage uterine cancer accurately so the healthcare team can plan treatment.

Sometimes, tests and procedures done during diagnosis give the healthcare team enough information about the cancer to assign a stage and plan the treatment. But this isn’t common.

In most cases, uterine cancer can only be staged after surgery to remove the cancer. This is called surgical staging. During this surgery, in addition to removing the whole tumour or as much cancer as possible, and surrounding tissues and organs as necessary, the surgeon may also:

• remove lymph nodes in the pelvis and around the aorta (called a lymph node dissection)
• biopsy a sample of tissues that cancer may have spread to, from an organ they are not removing at this time, such as the peritoneum
• rinse the pelvic and abdominal cavities with saline and collect a sample of the fluid (called pelvic or peritoneal washings)

All tissues and samples removed during surgery are looked at in a lab by a pathologist and the information collected is combined with the results of diagnostic tests. Together, this gives the healthcare team information on aspects of the cancer that are used to help stage it, including:

• which parts of the uterus are affected by cancer
• if the cancer has grown into tissues around the uterus
• if the cancer has spread to the lymph nodes
• if the cancer has spread to distant sites (called metastasis)
• the tumour grade
• the molecular subtype
• the type of endometrial carcinoma or uterine sarcoma

Surgical staging is not a separate surgery from the one you have to treat uterine cancer. The tissues removed during surgery to treat the cancer are also used to stage the cancer after the surgery is over. Which type of surgery you have determines how much tissue is removed and depends on results of diagnostic tests and what the surgeon finds during the surgery.

If you want to conceive (get pregnant) in the future, or if you can’t have surgery, you typically won’t have uterine cancer surgically staged. Instead, a biopsy may be done through dilation and curettage or hysteroscopy during diagnosis to help stage the cancer. Find out more about fertility preservation and biopsy during diagnosis of uterine cancer.

Find out more about the stages of uterine cancer. Your healthcare team will talk to you about how the stage that the cancer is given differs if you didn't have cancer surgically staged.

The following types of surgery are commonly used to treat endometrial carcinoma and uterine sarcoma, the two main types of uterine cancer. You may also have other treatments before or after surgery.

A hysterectomy is surgery to remove the uterus. It’s the most common surgery used to treat uterine cancer. Most people who have uterine cancer will have a hysterectomy.

A total hysterectomy is surgery to remove the uterus and the cervix. You’ll usually have a total hysterectomy for early-stage endometrial carcinoma or uterine sarcoma when cancer has not spread to the cervix or to tissues outside the uterus.

A radical hysterectomy is surgery to remove the same tissues as a total hysterectomy, as well as:

• the upper vagina
• tissues surrounding the uterus

You may have a radical hysterectomy for advanced-stage uterine cancer or when cancer has spread to the cervix.

It isn’t always possible to determine which type of hysterectomy you’ll have before the surgery. Once the surgeon can see the uterus, they’ll determine which organs and how much tissue they’ll need to remove. The surgeon will remove only as much healthy tissue as is necessary.

It’s important to talk to your healthcare team about fertility before you have a hysterectomy. This is surgery to remove the uterus, so you won't be able to get pregnant or give birth after a hysterectomy. If you want to have children in the future, your doctor will talk to you about your fertility-preservation options depending on the type and stage of uterine cancer you have.

A hysterectomy may be done in a few different ways.

In a laparoscopic hysterectomy, the surgeon uses several small incisions (surgical cuts) in the abdomen through which the surgeon passes the laparoscope and surgical tools into the body to remove the uterus and other tissues. Most people will have a hysterectomy by laparoscopy (called a laparoscopic hysterectomy). It is done under general anesthesia.

The surgeon may also use robots to help them during a laparoscopic hysterectomy. This is known as robot-assisted surgery.

In an abdominal hysterectomy, the surgeon removes the uterus and other tissues through a single, large incision in the abdomen. Abdominal hysterectomies are not as common as they used to be because they have an increased risk for serious side effects such as infection and take longer to heal and recover. You are more likely to have this kind of hysterectomy if you have advanced-stage uterine cancer. It is done under general anesthesia.

In a vaginal hysterectomy, the surgeon removes the uterus and any additional tissues necessary through the vaginal canal. They will cut through the vaginal wall to access the uterus and remove it through this surgical cut. A vaginal hysterectomy can be done under general or regional anesthesia.

Vaginal hysterectomies are used when someone isn’t healthy enough to have an abdominal or laparoscopic hysterectomy or when someone can’t have general anesthesia.

Find out more about hysterectomy.

A bilateral salpingo-oophorectomy is surgery to remove the 2 ovaries and 2 fallopian tubes. It’s usually done at the same time as a hysterectomy, as part of the treatment for endometrial carcinoma or uterine sarcoma. Most people who have surgery for uterine cancer will have a bilateral salpingo-oophorectomy.

After both ovaries are removed, if you haven’t already, you will go into menopause. Menopause caused by a treatment (like a bilateral salpingo-oophorectomy) is called treatment-induced menopause.

If you have low-risk, stage 1 endometrial carcinoma or leiomyosarcoma (a type of uterine sarcoma) and haven’t started menopause yet, you may not need to have your ovaries removed. Although not removing the ovaries typically increases the risk of uterine cancer coming back, it helps avoid side effects of menopause such as loss of bone density. If you don’t have your ovaries removed, you will usually still have both fallopian tubes removed (called a bilateral salpingectomy). Your healthcare team will talk to you about the risks and benefits of keeping your ovaries if they think you may benefit from it.

Uterine-sparing surgery removes cancerous tissue in and around the uterus. By not removing the uterus and keeping at least 1 ovary, you may be able to still get pregnant after surgery. It’s a type of fertility preservation technique that may be used instead of a hysterectomy for low-grade, early-stage endometrial stromal sarcoma (a type of uterine sarcoma) that is only in the endometrium. Uterine-sparing surgery may be done through laparoscopy or hysteroscopy. Uterine-sparing surgery is always given with another treatment such as hormone therapy.

A myomectomy, the surgery that is often used to remove non-cancerous tumours of the uterus, is a type of uterine-sparing surgery. After you’ve finished having children, you will usually have a hysterectomy and bilateral salpingo-oophorectomy. If at any point after uterine-sparing surgery there are signs that the uterine cancer has recurred, you’ll have a total hysterectomy and bilateral salpingo-oophorectomy as soon as possible, regardless of whether you still want to conceive (get pregnant).

Uterine-sparing surgery isn’t a standard treatment for uterine sarcoma. The risk of cancer recurring is greater in people who have fertility-sparing treatment. Very few people will have uterine-sparing surgery.

A lymph node dissection is done to remove lymph nodes. It’s often done at the same time as a hysterectomy. The surgeon may remove the lymph nodes around the pelvis (pelvic lymph nodes) and the lymph nodes around the aorta (para-aortic lymph nodes). Most people who have surgery for uterine cancer will have a lymph node dissection to remove all or most of the pelvic and para-aortic lymph nodes.

A sentinel lymph node biopsy (SLNB) removes the lymph nodes that are the first to receive lymph fluid from an organ or tissue (called sentinel lymph nodes). It’s also called a sentinel lymph node dissection.

Some people with stage 1 endometrial carcinoma will be offered an SLNB instead of a complete lymph node dissection. The lymph nodes removed in an SLNB are used to help stage uterine cancer.

Find out more about lymph node dissection and sentinel lymph node biopsy.

A pelvic exenteration removes most of the organs and tissues in the pelvis. You may have a pelvic exenteration as salvage therapy for uterine cancer that comes back in the pelvis (called locally recurrent uterine cancer) when you’ve already had radiation therapy. It may remove:

• the uterus
• the cervix
• fallopian tubes
• ovaries
• pelvic and para-aortic lymph nodes
• parts of the peritoneum
• parts of the omentum
• the bladder
• the rectum
• the vagina
• the vulva

If your bladder or rectum is removed as part of a pelvic exenteration, you’ll need an ostomy. The surgeon will create an opening in your abdomen called a stoma from which urine (pee) or stool (poop) will drain. Find out more about living with an ostomy.

If your vagina is removed as part of a pelvic exenteration, you may also need another surgery called a vaginal reconstruction. Vaginal reconstruction is a surgery done to repair or reconstruct the vagina following a pelvic exenteration. Vaginal reconstruction helps restore the structure and function of the vagina. Most people will have another surgery to reconstruct the vagina, but sometimes it can be done at the same time as pelvic exenteration.

The vagina can be created out of skin, pieces of intestinal tissue, or muscle and skin grafts. Skin can be taken from the buttock, flaps of muscle can be taken from the wall of the abdomen, and flaps of muscle and skin can be taken from the inner thighs to reconstruct the vagina.

The surgeon shapes the flaps and skin and sews them into the area where the vagina was. Once it heals, the newly created vagina (called a neovagina) is almost the same size and shape as the original vagina.

Not everyone chooses to have vaginal reconstruction. It will be needed if you want to continue having vaginal sex. Some people also feel that having reconstruction is important for their body image and quality of life.

A reconstructed vagina doesn’t produce the natural lubricants that a normal vagina does. These natural lubricants help keep the vagina clean and help moisten the vagina during sex. After surgery, your healthcare team will teach you how to keep your neovagina clean and manage vaginal dryness.

People who have had reconstructive surgery are encouraged to continue regular vaginal sex after surgery. They can also use a vaginal dilator (a plastic rod used to open and stretch the vagina) to maintain the shape and function of the neovagina.

If you don’t have a vaginal reconstruction, the surgeon will close your vaginal opening with a flap of skin.

Find out more about pelvic exenteration.

When cancer has spread throughout the pelvis or abdomen, the surgeon tries to remove as much cancerous tissue as possible. This procedure is called tumour debulking. You may have tumour debulking as part of a surgery for uterine cancer that has spread outside of the uterus or has come back after other treatments. Tumour debulking can help to treat uterine cancer or relieve pain and other symptoms.

Tumour debulking is usually done at the same time as a hysterectomy or other surgery to remove uterine cancer. How much tissue is removed during debulking is different for each person. Once the surgeon has started the surgery, they will determine how much tissue they need to remove.

Side effects of surgery will depend mainly on the type of surgery, the route of the surgery and your overall health. Tell your healthcare team if you have side effects that you think are from surgery. The sooner you tell them of any problems, the sooner they can suggest ways to help you deal with them.

Surgery for uterine cancer may cause these side effects:

• pain
• vaginal bleeding
• treatment-induced menopause
• fertility problems, including infertility
• sexual problems, including vaginal dryness and painful intercourse
• bladder problems, including losing control of your bladder (urinary incontience)
• bowel obstruction
• lymphedema in the legs and pelvis
• numbness or tingling in the upper legs
• blood clots
• infection
• a fistula between your bowel or bladder and abdominal cavity (the hollow part in the abdomen)

Find out more about surgery and side effects of surgery. To make the decisions that are right for you, ask your healthcare team questions about surgery.