Surgery for Endometrial Cancer

Surgery is often the main treatment for endometrial cancer and consists of a hysterectomy, often along with a salpingo-oophorectomy, and removal of lymph nodes. In some cases, pelvic washings are done, the omentum is removed, and/or peritoneal biopsies are done. If the cancer has spread throughout the pelvis and abdomen (belly), a debulking procedure (removing as much cancer as possible) may be done. These are discussed in detail below.

Hysterectomy

Types of hysterectomy

The main treatment for endometrial cancer is surgery to take out the uterus and cervix. This operation is called a hysterectomy. When the uterus is removed through an incision (cut) in the abdomen (belly), it's called a simple or total abdominal hysterectomy.

If the uterus is removed through the vagina, it's known as a vaginal hysterectomy. This may be an option for women who are not healthy enough for other types of surgery.

When endometrial cancer has spread to the cervix or the area around the cervix (called the parametrium), a radical hysterectomy is done. 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. This operation is most often done through the abdomen, but it can also be done through the vagina.

Surgeries done along with hysterectomy

It's rare to remove the uterus but not the ovaries when treating endometrial cancer. (Still, it might be done in certain cases for women who are premenopausal.) Removing the ovaries and fallopian tubes is called a bilateral salpingo-oophorectomy (BSO). It isn't really part of a hysterectomy. It's a separate procedure that's done during the same operation. (See the Bilateral salpingo-oophorectomy section below.)

To decide what stage the cancer is in, lymph nodes in the pelvis and around the aorta also need to be removed. This is called lymph node dissection. It can be done through the same incision as the abdominal hysterectomy. If the hysterectomy is done vaginally, lymph nodes can be removed with laparoscopic surgery. (See "Lymph node surgery" below.)

How is hysterectomy done?

As mentioned above, this surgery can be done through a large cut in the belly (abdomen). It can also be done through the vagina. Laparoscopic surgery or minimally invasive surgery is another option that's becoming more common.

Laparoscopy is a 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. Long, tiny surgical instruments can be controlled through the tubes. This allows the surgeon to operate without making a large incision in the abdomen. It's been linked to less pain and blood loss, and it can shorten recovery time after surgery.

Both a simple hysterectomy and a radical hysterectomy can be done through the abdomen using laparoscopic surgery. Laparoscopic surgery might also be used to help safely remove other organs and tissues when a vaginal hysterectomy is done.

Laparoscopic surgery for endometrial cancer 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.

A robotic approach is increasingly being used to do laparoscopic procedures, and outcomes are much the same. In robotic surgery, the surgeon sits at a control panel in the operating room and moves robotic arms to operate through many small incisions. Robotic surgeries do tend to take longer than regular laparoscopic surgeries.

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.

Bilateral salpingo-oophorectomy

This operation removes both fallopian tubes and both ovaries. It's 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'll go into menopause if you haven't done so already.

If you're younger than 45 and have stage I endometrial cancer, you may want to talk to your surgeon about keeping your ovaries. Even though women whose ovaries are removed might have a lower chance of the cancer coming back, removing the ovaries doesn’t seem to help them live longer.

Lymph node surgery

Pelvic and para-aortic lymph node dissection is an operation done to remove lymph nodes from the pelvis and the area next to the aorta. The nodes are tested to see if they contain cancer cells that have spread from the endometrial tumor. This information is part of finding the surgical stage of the cancer.

The surgery is called a lymph node dissection when most or all of the lymph nodes in the area are removed. This is usually done at the same time as the operation to remove the uterus (hysterectomy). If you're having an abdominal hysterectomy, the lymph nodes can be removed through the same incision. In women who have had a vaginal hysterectomy, lymph nodes may be removed by laparoscopic surgery.

When only a few of the lymph nodes in an area are removed, it’s called lymph node sampling.

Depending on the cancer type and grade, the amount of cancer in the uterus (tumor size), and how deeply the cancer invades the muscle of the uterus, and imaging test results , lymph nodes might not need to be removed.

Sentinel lymph node mapping

Sentinel lymph node (SLN) 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 area with the cancer, near the cervix. The surgeon then looks for the lymph nodes that turn blue or green (from the dye). These lymph nodes are the ones that the cancer would first drain into (the sentinel nodes). They're removed and tested to see if there are cancer cells in them. If so, more lymph nodes are taken out because they likely have cancer cells in them, too. If there are no cancer cells in sentinel nodes, no more nodes are removed. This procedure is usually done at the same time as surgery to remove the uterus (hysterectomy). Your doctor will talk with you about whether SLN mapping is an option for you.

Pelvic washings (peritoneal lavage)

In this procedure, the surgeon “washes” the abdominal and pelvic cavities with salt water (saline). The fluid is then collected (using suction) and sent to the lab to see if it contains cancer cells. This is also called peritoneal lavage. If there are endometrial cancer cells in the fluid, the cancer stage may change (the surgical stage) and the next steps of treatment could be impacted.

Other procedures that might be used to look for cancer spread

Omentectomy: The omentum is the layer of fatty tissue that covers the abdominal contents, sort of like an apron. Cancer sometimes spreads to this tissue. When this tissue is taken out, it's called an omentectomy. This may be done during a hysterectomy if cancer has spread there. Biopsies of the omentum might also be done to check for cancer spread. (Small pieces are taken out and tested for cancer cells.)

Peritoneal biopsies: The tissue lining the pelvis and abdomen is called the peritoneum. Peritoneal biopsies remove small pieces of this lining to check for cancer cells.

Tumor debulking

If cancer has spread throughout the abdomen, the surgeon might try to take out as much of the tumor as possible. This is called debulking. Debulking a cancer can help other treatments, like radiation or chemotherapy, work better. So, it might be helpful in treating some types of endometrial cancer.

Recovery after surgery

The hospital stay for an abdominal hysterectomy is usually 3 to 7 days. The average hospital stay after an abdominal radical hysterectomy is about 5 to 7 days. Complete recovery can take up to 4 to 6 weeks. A laparoscopic procedure and vaginal hysterectomy usually require a hospital stay of 1 or 2 days and 2 to 3 weeks for recovery. 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 right after surgery. It's often kept in for at least a few days. If the bladder hasn’t recovered completely when the catheter removed, it may be put back in. Another option is that you're shown how to put a catheter yourself several times a day to empty your bladder. Over time, bladder function returns.

Side effects of surgery

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

For women who were premenopausal before surgery, removing the ovaries will cause menopause right away. This can lead to symptoms like hot flashes, night sweats, and vaginal dryness. Long-term, it can lead to osteoporosis and increased risk for heart disease, which impact 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 Sex and the Woman With Cancer.

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.