Gynaecological Cancer Surgery

 

Cancers that start in a woman's reproductive system are called gynaecological cancers. Surgery for gynecologic cancer typically involves removal of the tumor, and may include removal of the:

  • Cervix

  • Uterus

  • Ovaries

  • Other pelvic organs

 

Cervical Cancer

Cervical cancer is when abnormal cells in the lining of the cervix grow in an uncontrolled way. The main symptom is unusual bleeding from the vagina. Surgery is one of the main treatments for cervical cancer :

Surgery to remove the cervix (radical trachelectomy) :
A radical trachelectomy is an operation to remove most of the cervix and the upper part of the vagina. The tumour is usually removed through your vagina. Some doctors may make a cut (an incision) in the tummy (abdomen) to do the operation instead.

Surgery to remove the womb (radical hysterectomy) :
During the operation, the doctor will remove:

  • The womb (including the cervix)

  • All the tissues holding the womb in place

  • The top of the vagina

  • All the lymph nodes around the womb

This is called a radical hysterectomy (or Wertheim's hysterectomy).

 

Ovarian Cancer :

Ovarian cancer is when abnormal cells in the ovary begin to grow and divide in an uncontrolled way, and eventually form a growth (tumour). The types of ovarian cancer include :

  • Epithelial Ovarian Cancer

  • Primary Peritoneal Cancer

  • Fallopian Tube Cancer

  • Ovarian Teratoma (Germ Cell Tumours)

  • Stromal Tumours (Granulosa Tumours)

  • Sarcomas

Types of Surgery includes :

Total Abdominal Hysterectomy (TAH) and Bilateral Salpingo – Oophorectomy (BSO) :
Hysterectomy is a surgery to remove the uterus and cervix. A bilateral salpingo-oophorectomy is a surgery to remove both the ovaries and fallopian tubes.

Endometrial Cancer :
Endometrial cancer is a cancer that arises from the endometrium (the lining of the uterus or womb). It is the result of the abnormal growth of cells that have the ability to invade or spread to other parts of the body.
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.
When endometrial cancer spreads 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. Both fallopian tubes and ovaries are removed at the same time.

Lymph node surgery :
Pelvic and para-aortic lymph node dissection. This operation removes lymph nodes from the pelvis and the area next to the aorta to see if they contain cancer cells that have spread from the endometrial tumor. It is called a lymph node dissection when most or all of the lymph nodes in a certain area are removed.

Sentinel lymph node mapping :
Sentinel lymph node mapping (SLN) may be used in early-stage endometrial cancer if the x-ray result shows that there has been no obvious spread of cancer to the lymph nodes in the pelvis.

Pelvic washings (peritoneal lavage) :
In this procedure, the surgeon “washes” the abdominal and pelvic cavities with salt water (saline) and sends the fluid to the lab to see if it contains cancer cells. This is also called peritoneal lavage.

Other procedures that may be used to look for cancer spread :

  • 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, it is called an omentectomy. This may be done during a hysterectomy if cancer has spread there or to check for cancer spread.

  • 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 may attempt to remove as much of the tumor as possible. This is called debulking.

 

Vaginal cancer

Vaginal cancer is very rare. It starts in the vagina, which is the passage that leads from the neck of the womb (cervix) to the vulva. Vaginal cancer is more common in older women.

There are several types of vaginal cancer, including :

Squamous cell carcinoma :
This type of cancer starts in the vaginal lining and develops slowly. These cancers start in the squamous cells that make up the epithelial lining of the vagina. They are most common in the upper part of the vagina near the cervix. If not treated, they can grow deeper and, over time, through the vaginal wall spread to the nearby tissues. They can also spread to other parts of the body, most often the lungs, but also the liver and bones.

Adenocarcinoma :
This type of cancer starts in the vaginal gland cells. It is most common in women over 50. It is the second-most common type of vaginal cancer. Another type, called clear cell adenocarcinoma, is more common in young women who were exposed to diethylstilbestrol (DES) in utero (when they were in their mother’s womb).

Melanoma :
As with the more common skin cancer type of melanoma, this type of cancer starts in the cells that give skin color. Melanoma tends to affect the lower or outer portion of the vagina. The tumors vary greatly in size, color, and growth pattern.p>

Sarcoma :
Sarcomas are cancers that start in the cells of bones, muscles, or connective tissue. It starts in the vaginal walls. These cancers form deep in the wall of the vagina, not on its surface. There are several types of sarcomas. Rhabdomyosarcoma is the most common type of sarcoma that affects the vagina. It is most often found in children and is rare in adults. A sarcoma called leiomyosarcoma is seen more often in adults. It tends to occur in women older than 50.

Types of surgery used for vaginal cancer:

Wide Local excision :
The surgeon takes out the cancer along with a nearby edge or rim of normal tissue. For VAIN (Vaginal Intraepithelial Neoplasia), a local excision may be needed. For small stage I cancers, treatment may include a local excision along with surgery to check the lymph nodes.

Vaginectomy :
Vaginectomy is a surgery to remove the vagina. If the entire vagina is removed, it is called a total vaginectomy. A radical vaginectomy is the removal of the vagina along with the supporting tissues around it. An operation to remove the upper part of the vagina is a partial vaginectomy.

Trachelectomy :
Vaginal cancer most often starts in the upper part of the vagina (near the cervix), so removing the cancer sometimes means also removing the cervix. If only the cervix is removed (leaving the rest of uterus behind), the operation is called a trachelectomy.

Radical Hysterectomy :
This is required if the cancer has spread through the wall of the vagina and into the surrounding tissues. A part or all of the vagina is removed along with :

  • The womb (uterus)

  • All the tissues holding the womb in place

  • All the lymph nodes around the womb

This is called a radical hysterectomy or Wertheim's hysterectomy. The surgeon removes the surrounding tissues in case cancer cells have spread there. Removing them helps to prevent the cancer from coming back in the bowel, bladder or nearby lymph nodes.

Pelvic exenteration :
Pelvic exenteration is a major operation that includes vaginectomy, removing the pelvic lymph nodes, and removing one or more of the following:

  • The lower colon

  • Rectum

  • Bladder

  • Uterus and/or

  • Cervix

If the bladder is removed, a new way to store and get rid of urine is needed. Usually a short piece of intestine is used to function as a new bladder. This may be connected to the abdominal (belly) wall with a small opening called a urostomy. If the rectum and part of the colon are removed, a new way to remove solid waste is needed. This is done by attaching the remaining intestine to the abdominal wall so that stool can pass through a small opening (called a colostomy) into a small plastic bag that sticks to the abdomen.

 

VULVAR CANCER

Cancer of the vulva is relatively rare. It can start in any part of the external female sex organs. This includes the opening of the vagina, the inner and outer lips (also called labia minora and labia majora), the clitoris and the mons pubis (soft, fatty mound of tissue, above the labia). It is also sometimes diagnosed in the perineum (the skin between the vulva and the anus). Less often, vulval cancer may involve the clitoris or two small glands each side of the vagina, called the Bartholin's glands.

Types of surgery :

The different types of surgery depend on where the cancer is. These include:

Wide local excision :
A wide local excision means surgery to remove a wide area of skin that is affected by VIN or cancer. The surgeon also removes a border of healthy tissue, called a margin. It may be called a simple partial vulvectomy.

Skinning vulvectomy :
If the VIN is very widespread, the surgeon may need to do an operation called a skinning vulvectomy. This means removing the skin over a large area. Since, the affected cells are only on the vulval surface, it is possible to take away only the skin and leave the healthy tissue underneath.

Partial vulvectomy :
When the surgeon removes part of the vulva, this is called a partial vulvectomy. A partial or modified radical vulvectomy removes part of the vulva, including the deep tissue.

Radical vulvectomy :
Surgery to remove the whole vulva is called vulvectomy or radical vulvectomy. The whole vulva is removed, including the inner and outer lips of the vagina. The clitoris is removed as well. In a Complete radical vulvectomy, the entire vulva and deep tissues, including the clitoris, are removed.

Checking the lymph nodes :
If the cancer is stage 1B or greater, the doctor will check the lymph nodes near the vulva to see if they contain cancer.

Pelvic exenteration :
Pelvic exenteration is an extensive operation that when used to treat vulvar cancer includes vulvectomy and often removal of the pelvic lymph nodes, as well as removal of one or more of the following structures: the lower colon, rectum, bladder, uterus, cervix, and vagina. How much has to be removed depends on how far the cancer has spread into nearby organs.