In Australia, cancer of the uterus (uterus cancer) is the most common gynaecological cancer with more than 3,000 women newly diagnosed every year. Most typically it is a disease of postmenopausal women. Endometrial cancer (arising from the inner layer of the uterus) is the most common cell type.
Symptoms of uterine cancer (endometrial cancer symptoms) include a postmenopausal bleeding episode or vaginal spotting. Other signs of uterine cancer may include an unusual or abnormal discharge from the vagina. Uterine cancer symptoms can also include pelvic pain.
We distinguish two types:
- Type 1 uterine cancer is the most common form, most likely caused by metaboilic syndrome (obesity, diabetes mellitus, high cholesterol). These cancers require treatment and patients normally can expect a good prognosis. The cancer type (cell type) is endometrioid and not uncommonly, endometrial hyperplasia (with cellular atypia) is a precancerous condition leading to uterine cancer if left untreated.
- Type 2 uterine cancer includes serous and clear cell types, sarcomas and other rather aggressive types of uterine cancer. the causes of these cancer types are unknown. Aggressive treatment is required and includes surgery, often followed by radiotherapy, chemotherapy or a combination of both.
Sometimes uterine cancer can be inherited. See Lynch syndrome.
Prior to surgery, the diagnosis of uterine cancer needs to be established by endometrial sampling (Pipelle, in the office) or a hysteroscopy and a curette (day surgery).
Before surgery, medical imaging (CT scans) and blood tests are routinely taken and provide useful information prior to surgery. Usually no bowel prep is required. Patients require to fast at least 6 hours prior to surgery. Please stop smoking before the operation as it makes your postoperative recovery much easier. Before surgery, all blood thinnign medication should be stopped for a week or two.
Surgery for uterine cancer will remove the uterus, tubes and the ovaries (full hysterectomy & salpingo-oophorectomy) with removal of some lymph nodes in some cases to determine the extent of the disease.
Sentinel node biopsy is a technique that is now routinely used as part of endometrial cancer surgery.
According to the SLND concept, tumour cells spread first to one or two lymph nodes before involving other lymph nodes. Identification occurs via a small amount of dye injected into the uterine cervix and is transported via lymphatic channels towards the lymphatic basins in the pelvis. The first node the tracer reaches and highlights in the pelvis is called the “sentinel lymph node”. After identifying the sentinel node and performing a SLND, the surgeon will proceed to a hysterectomy.
I will remove sentinel lymph glands from both side walls of the pelvis along the large vessels in the patient’s pelvis and abdomen. Only 6% to 10% of patients will have involved lymph glands and it is very important to test the lymph nodes in exactly those patients. Patients with involved lymph nodes will need further postoperative treatment (radiotherapy, chemotherapy, or combinations of both).
The procedure usually takes 2 to 3 hours and is routinely carried out laparoscopically (“keyhole hysterectomy”). For an overview on types of hysterectomy go here. The procedure requires general anaesthesia.
When you wake up from general anaesthesia you will have a drip to give you the necessary fluids and a catheter will drain the urine from your bladder. An oxygen mask will supply oxygen to the respiratory system. These lines will be removed once I am happy that your body functions have returned to normal, which is usually after a few hours.
The final histopathological report may take a few days. It forms the basis for the decision if any further treatment is required. If further treatment is required I will bring you in contact with the respective specialist (chemotherapy, radiation).
Surgery always carries risks and every surgeon will go to lengths to minimise those risks even before surgery. I give antibiotics before the skin incision in order to mimimise the risk for skin and other infections. Commencing prior to surgery I give calf-compression stockings in order to prevent the formation of blood clots in the legs. At surgery sterile handling of instruments further reduces the risk of infectious complications. However, there are some immanent risks of surgery for uterine cancer and they also include some basic hysterectomy side effects:
- Laparoscopic surgery may need to be converted to open surgery through the opening of the abdomen (approximate 3%). The vast majority (97%) of all laparoscopic procedures will be completed laparoscopically.
- While the risk for medical and anaesthetic complications are very small, complications associated with general anaesthetic, with epidural analgesia or with postoperative pain control do exist. In patients with pre-existing medical conditions these risks are slightly higher.
- There is a risk of injury to pelvic organs, such as the bowel, the bladder, the ureters, blood vessels and nerves (~1.5%). These injuries usually get repaired during surgery. However, in an exceedingly small proportion of patients these injuries can unfortunately escape to be recognised during surgery or injuries may even develop after surgery. Then more surgery is required to repair those defects. Injury to big blood vessels may result in bleeding and the need of blood transfusion. Injury of nerves is common in patients who require removal of lymph nodes in the pelvis. In that case, patients will experience some numbness of the skin around the upper thigh.
- The risk of a bleed to the vagina is approximately 4%. A bleed can be triggerd by an infection and may develop into a haematoma. In the majority of patients, a course of antibiotics will solve the problem.
- Lymph oedema: Lymphatic fluid usually drains from the legs via the lymph glands in the pelvis and the aorta back into the blood circulation. When lymph glands have to be removed, some fluid may accumulate in the legs (lymph oedema). The risk of lymph oedema is around 20% in patients who had to have a lymph node dissection. Patients with lymphoedema require lymph drainage.
- In young women, oophorectomy (ovary removal) may be necessary for cancer treatment and will lead to instant surgical menopause. Estrogen Replacement Therapy (ERT) may be required to alleviate menopausal symptoms. ERT is far easier to manage than combined Estrogen + Progestin replacement.
Other possible hysterectomy complications include ...
- Infections to the bladder, the abdominal wound, the lungs (~7%) with resulting temperatures and septicaemia.
- Thromboembolic complications (formation of blood clots) in the legs that can even travel to the lungs and cause life-threatening emboli. This risk is very small (less than 1%) because of our efforts to minimise them.
- Shoulder tip pain is common after laparoscopic surgery. It is caused by the CO2 gas that s needed for the surgery. It normally lasts only for a day but painkillers are not effective.
- After hysterectomy a vaginal discharge that can even be blood-stained is very common for up to 6 weeks (bleeding after hysterectomy).
- Changes in bowel habits are not uncommon for a couple of months post surgery. I recommend regulation of the bowels with natural substances such as yoghurt, prune juice and natural fibre.
Hysterectomy recovery time: You need to stay in hospital for one or two days. I recommend you give yourself a good break for the next couple of weeks.
The three most important tips to consider after hysterectomy:
1. Take your painkillers regularly; even if you are not in pain. If you develop pain, it may intensify rapidly and you may require admission to hospital, including blood and medical imaging tests.
2. Avoid intercourse, vaginal tampons, full baths and any straining (pilates, yoga) for 6 weeks and other factors that could disrupt wound healing or facilitate an infection.
3. Use laxatives for the first couple of weeks because some of the anaesthetic medication and pain killers may cause severe constipation.
The DO'S and DONT'S post hysterectomy are described separately. Recovery from hysterectomy is difficult to predict. All going well, a patient should be able to go back to work and do nortmal housework after two weeks.
Please notify me immediately if your condition becomes worse after you have been discharged from hospital.
Follow-UP: After surgery, all patients with uterine cancer (except those with very low risk of recurrence) should be seen regularly for follow-up for 5 years. These examinations will always include pelvic examinations. I will discuss with my patients if any other tests (PAP smears, medical imaging, blood tests) are required. After five years, the risk of a recurrence becomes very low. Should you experience any bleeding or pain, please do not wait but contact my office straight away.
Exercise after hysterectomy: Whenever possible we will mobilise patients on the day or the day after a hysterectomy with the help of experienced physiotherapy staff. At discharge, I recommend to "take it easy" for a week. Gentle exercise is possible as is light homeduties. Competitive training should be avoided for a few weeks.
Outcomes: Cancers of all types and stages may recur. Recurrence may be local (vagina), in the pelvis or distant (abdomen, lungs). Treatment of recurrent cancer is more challenging than treatment of primary cancer. Survival rates for Type 1 uterine cancer are generally very good (>80% survival rate at 5 years from surgery across all stages). Our research group has developed software that enables us to predict the probability of a recurrence in individual patients (www.gyncan.org)