Cervical Cancer Surgery
Surgery for cervical cancer encompasses a spectrum of procedures that includes minor operations, minimally invasive procedures using the robot, and open surgeries with a vertical incision. Unlike the situation with ovarian cancer where a Gynecologic Oncologist will operate on all stages of the disease, surgical procedures for cervical cancer are primarily reserved for diagnostic purposes and for treating early stage cancers that have not spread beyond the cervix (i.e., mainly Stage I cancers).
Large loop excision of the transformation zone (aka LEEP) and Cold knife cervical conization
Both of these are outpatient procedures that are performed in the operating room oftentimes with just some sedation and local anesthesia. Patients who undergo these procedures typically have had cervical biopsies that are concerning for severely pre-cancerous changes of the cervix (aka severe cervical dysplasia or CIN3 or CIS) or for invasive cervical cancer. The purpose of the LEEP or cone biopsy is to obtain a larger piece of tissue to:
A) Completely treat the pre-cancerous changes by obtaining a clear margin around the abnormal cells
B) Determine the extent of invasive cancer if present
Patients are discharged to their home on the day of surgery and can return to work in 1 or 2 days. They remain on pelvic rest for a period of 6 weeks.
Robotic radical trachelectomy with bilateral pelvic lymphadenectomy (fertility-preserving surgery)
For patients with small cervical cancers (<2 cm in tumor diameter) who have never had children and strongly desire to bear children, a fertility-preserving surgery that involves only removing the cervix (with upper vagina and parametria) can be performed robotically. This is called a radical trachelectomy and is considered the standard of care for patients with very early cervical cancers that wish to preserve fertility. The parametria are the ligaments which support and surround the cervix and removal of these tissues (along with the upper vagina) and cervix is important to ensure a clear tumor-free margin around the cervical cancer. This procedure often is performed together with a robotic pelvic lymph node dissection and the Gynecologic Oncologist typically sutures a cerclage tightly around the uterine stump to help keep a subsequent pregnancy inside the uterus. It is very important that patients have no clinical or radiographic signs of cervical cancer that has spread past the cervix to other parts of the body. It is also very crucial that patients undergoing this type of operation remain compliant with a very careful and frequent follow-up schedule with the Gynecologic Oncologist for the next several years. Patients can typically be discharged to their home one day following surgery and can expect normal menstrual and sexual function after a period of several weeks. Pregnancy should not be attempted for at least six months. Studies have shown that this procedure is safe from a cancer standpoint in women with small cervical cancers. However, there is a risk of preterm birth in pregnancies following radical trachelectomy procedures and this needs to be carefully discussed by both a Gynecologic Oncologist and a Maternal-Fetal Medicine specialist with the patient.
Robotic radical hysterectomy with bilateral pelvic lymphadenectomy
Similar to endometrial cancer, early stage cervix cancers can be cured using minimally invasive surgical techniques that employ the DaVinci robot. However, unlike a regular hysterectomy performed for endometrial cancer, a radical hysterectomy involves removing the upper vagina and ligaments that surround and support the cervix (aka the parametria). This is a very complex operation that can only be performed by Gynecologic Oncologists and the goal of the surgery is to get a clear margin uninvolved by cancer around the cervix. Lymph nodes are also dissected along the pelvic blood vessels where they drain cells from the cervix and may harbor hidden cancer cells. Robotic radical hysterectomies are believed to be best suited for patients with cervical cancers less than 4 cm in diameter (i.e., stage IB1 and lower). Although hospital discharge typically occurs after one day, patients may require a week to have normal return of bladder function due to the type of dissection required to surgically cure a cervical cancer. Although the vagina is shortened with radical hysterectomy, it is not appreciably shortened so as to interfere significantly with sexual functioning once the healing process has been completed in 6 weeks. The ovaries are not typically removed during this operation for women under 50 year s of age.
Open radical abdominal hysterectomy with bilateral pelvic lymphadenectomy
For women diagnosed with large, bulky early stage cervical cancer (i.e., those with tumors >4 cm involving the cervix – aka stage IB2), an open radical hysterectomy is typically recommended in order to obtain satisfactory surgical margins which may not be as easily accomplished without the surgeon being able to lay his/her hands on the cervix. Aside from the midline, vertical incision which extends from just above the pubic bone to just below the naval, the operation is very similar to what is performed robotically for smaller cervical cancers. Lymph nodes are also removed during this surgery and patients may be in the hospital for 2 to 3 days. The bladder may not return to normal for 2-3 weeks due to the extensive dissection required to surgically cure these cancers. Once again, following 6 weeks of pelvic rest, most patients do not find the vagina significantly shortened. For women under 50 years of age, the ovaries are usually not removed.