Surgery for Uterine Sarcomas

Surgery is the main treatment for early stage uterine sarcoma. The goal of surgery is to remove all of the cancer in one procedure, and if possible in one piece. This usually means removing the entire uterus with the cervix (total hysterectomy). In some cases, the fallopian tubes, ovaries, and part of the vagina may also need to be removed. Some lymph nodes or other tissue may be taken out as well to see if the cancer has spread outside the uterus. What's done depends on the type and grade of the cancer and how far it has spread. (See How Is Uterine Sarcoma Staged?) The patient's overall health and age are also important factors.

In some cases, tests done before surgery let the doctor plan the operation ahead of time. These tests include imaging studies, like ultrasound, CT scan, or MRI, as well as a pelvic exam, endometrial biopsy, and/or D&C. In other cases, the surgeon has to decide what needs to be done based on what they find during surgery. For example, sometimes there's no way to know for sure that a tumor is cancer until it's removed during surgery.

Total hysterectomy

This surgery removes the whole uterus (the body of the uterus and the cervix). The loose connective tissue around the uterus (called the parametrium), the tissue connecting the uterus and sacrum (the uterosacral ligaments), and the vagina are not removed. Removing the ovaries and fallopian tubes is not part of a hysterectomy -- officially it's a separate procedure known as a bilateral salpingo-oophorectomy (BSO). The BSO is often done along with a hysterectomy in the same operation (see below).

If the uterus is removed through an incision (cut) in the front of the abdomen (belly), the surgery is called an abdominal hysterectomy. When the uterus is removed through the vagina, it's called a vaginal hysterectomy. When it is removed through small incisions on the belly using a laparoscope it is called a laparoscopic hysterectomy. A laparoscope is a thin lighted tube with a video camera at the end. It can be put into the body through a small incision in the abdomen and lets the doctor see inside the body without making a big incision. The doctor can use long, thin tools that are put in through other small incisions to operate. A laparoscope is sometimes used to help remove the uterus when the doctor is doing a vaginal hysterectomy. This is called a laparoscopic assisted vaginal hysterectomy. The uterus can also be removed through the abdomen with a laparoscope, sometimes with a robotic approach, in which the surgeon sits at a control panel in the operating room and moves robot arms to operate. Laparoscopic procedures have shorter recovery times than abdominal hysterectomies, but are not possible to all patients. Talk with your surgeon about how the surgery will be done and why it's the best plan for you.

If lymph nodes or other organs need to be seen, removed, or tested, this can be done through the same incision as the abdominal hysterectomy or laparoscopic hysterectomy. If a hysterectomy is done through the vagina, lymph nodes can be removed after the hysterectomy by using a laparoscope. 

Either general or regional anesthesia is used for the procedure. This means that the patient is in a deep sleep or is sedated and numb from the waist down.

For an abdominal hysterectomy the hospital stay is usually 3 to 5 days. Complete recovery takes about 4 to 6 weeks. Someone who gets a laparoscopic procedure or vaginal hysterectomy can usually go home the same day as the surgery and recovery often takes 2 to 3 weeks.

After a hysterectomy, a woman cannot become pregnant and give birth to children. Surgical complications are rare but could include bleeding, wound infection, and damage to the urinary (bladder and/or ureters) or bowel systems.

Radical hysterectomy

This operation removes the entire uterus as well as the tissues next to the uterus and cervix (parametrium and uterosacral ligaments) and the upper part of the vagina (near the cervix). This operation is not often used for uterine sarcomas, but may be needed if the tumor appears to have spread to the nearby tissues.

Radical hysterectomy is most often done through an abdominal surgical incision or with a laparoscope, with or without a robotic approach (in which the surgeon sits at a control panel in the operating room and moves robot arms to operate) but it can also be done through the vagina. Most people having a radical hysterectomy also have some lymph nodes removed, either through the abdominal incision or with a laparoscope. A radical hysterectomy is done using general anesthesia.

Because more tissue is removed by a radical hysterectomy than with a total hysterectomy, the hospital stay might be longer.

After this surgery, a person cannot become pregnant and give birth to children.

Complications associated with a radical hysterectomy can include bleeding, wound infection, and damage to the urinary (bladder and/or ureters) or bowel systems. If some of the nerves of the bladder are damaged, a catheter is often needed to empty the bladder for some time after surgery. This usually gets better with time and the catheter can be taken out later.

Bilateral salpingo-oophorectomy (BSO)

This operation removes both fallopian tubes and both ovaries. In treating uterine sarcomas, this operation is usually done at the same time the uterus is removed. If both of your ovaries are removed, you will go into menopause if you have not done so already.

Lymph node surgery

Sometimes during surgery it looks like the cancer might have spread outside the uterus or nearby lymph nodes look swollen on imaging tests. In this case, your surgeon might do a lymph node dissection or a lymph node sampling, which removes lymph nodes in the pelvis and/or those around the aorta (the main artery that runs from the heart down along the back of the abdomen and pelvis). These lymph nodes are then checked in the lab to see if they have cancer cells. If cancer is found in the lymph nodes, it means that the cancer has already spread outside the uterus. Cancer in the lymph nodes is often associated with a poorer prognosis (outlook).

This operation is done through the same surgical incision in the abdomen as the abdominal hysterectomy or laparoscopic hysterectomy. If a vaginal hysterectomy has been done, the lymph nodes can be removed with laparoscopic surgery.

While some people might have their lymph nodes removed during surgery for uterine sarcoma, it is still not known if this improves their outlook (unless the nodes have cancer cells in them). Studies are being done to help answer this question. 

A side effect of removing lymph nodes in the pelvis can lead to a build-up of fluid in the legs, called lymphedema. This is more likely if radiation is given after surgery. You can find out more about this in Lymphedema.

Other procedures that may be done during surgery

• Omentectomy: The omentum is a layer of fatty tissue that covers the abdominal contents like an apron. Cancer sometimes spreads to this tissue. When this tissue is removed, its called an omentectomy. The omentum is sometimes removed at the same time the hysterectomy is done if cancer has spread there, or as a part of staging.
• 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.
• Pelvic washings: In this procedure, the surgeon "washes" the abdominal and pelvic cavities with salt water (saline), collects it, and then sends the fluid to the lab to see if it s has cancer cells.
• Tumor debulking: If cancer has spread throughout the abdomen, the surgeon may attempt to remove as much of the tumor as possible. This is called debulking. For some types of cancer, debulking can help other treatments (like radiation or chemotherapy) work better.

Sexual impact of surgery

If you are premenopausal, removing your uterus stops menstrual bleeding (periods). If your ovaries are also removed, you will go into menopause. This can lead to vaginal dryness and pain during sex. These symptoms can be improved with non-hormonal treatments or in some cases, estrogen treatment.Estrogen treatment isn't safe for all women with uterine sarcoma.

While physical and emotional changes can affect the desire for sex, these surgical procedures do not prevent a woman from feeling sexual pleasure. A woman does not need ovaries or a uterus to have sex or reach orgasm. Surgery can actually improve a woman's sex life if the cancer had caused problems with pain or bleeding during sex. See Sex and the Adult Female with Cancer for more on this.