Surgical treatment is the best possible option for early-stage cervical cancer cure. In advanced-stage and even recurrent cancer specific interventions also provide beneficial results. Modern surgical techniques don`t restrict their aims to removing cancer cells from the human body. Advanced methods are minimally invasive, leave virtually invisible cosmetic defects instead of large scars and even save ability to give birth to child in the future. Choosing correct surgical technique and performing the most intricate interventions provide excellent results in fighting cervical cancer.
General principles of surgical treatment choice
Surgical treatment of cervical cancer is the first ever known treatment method, which came to the medical practice in the middle of the 19th century. As time went by, great advance has been made and surgical techniques have evolved from open traumatic surgeries to laparoscopic minimally invasive manipulations. Nevertheless, today surgery is still considered to be the golden standard for early-stage and low-risk cervical cancer treatment.
A number of surgical techniques is available now, so doctors should choose wise in order to reach the best result.
Choice of the certain surgical method considerably depends on few aspects:
- Size of the tumor
- Degree of stromal invasion (extension of the tumor inside the cervix)
- Degree of tumor differentiation (maturity of cells and intensity of mutation process)
- Lymphatic nodes invasion
- Spreading to pelvic organs, metastasizing
As this features finally determine stage of cervical cancer, types of surgical interventions can be connected to certain cancer stages.
First we will take a look of surgical treatment options at each stage and after that we will proceed to more profound investigation and peculiarities of different techniques:
- Stage 0 (carcinoma in situ). This is the most favorable form of cervical cancer and some healthcare specialists even don`t consider it to be cancer at all. At this stage atypical cells are found only on the surface of the cervix, deeper structures are totally normal. In case squamous cell carcinoma in situ is diagnosed a doctor chooses between cryosurgery (including cold knife conization), laser surgery, loop electrosurgical excision procedure (LEEP/LEETZ), and simple (total) hysterectomy. Possible for adenocarcinoma in situ interventions include cone biopsy with active follow-up and simple (total) hysterectomy.
- Stage IA1 treatment options include cone biopsy with active follow-up (in case a woman wants to have children in the future), simple (total) hysterectomy or, in more complicated cases, radical hysterectomy. When this stage of cervical cancer is diagnosed during pregnancy, most doctors choose watchful waiting, as it is safer for mother and child to have treatment several weeks after delivery.
- Stage IA2 and more advanced stages usually require complex treatment. Surgical interventions at this stage include cone biopsy, radical trachelectomy or radical hysterectomy with lymphatic nodes removing.
- Stages IB1 and IIA1 imply radical trachelectomy with lymphatic nodes removing for those who are concerned about fertility. Otherwise radical hysterectomy with lymphatic nodes removing is performed.
- Stages IB2 and IIA2 require only radical hysterectomy with affected lymphatic nodes (pelvic, para-aortic) dissection. Surgery is no more intervention of first choice at this stage.
- Stages IIB, III, IVA, and IVB doesn`t require any type of surgical intervention at all.
Recurrent cervical cancer is a special condition. Term “recurrent” means that cancer came back after previous successful treatment. New tumor may be detected in cervix, uterus or other pelvic organs.
In such case surgical treatment includes pelvic exenteration – during the procedure doctor removes all affected organs and tissues. When recurrent tumors arise in distant organs (e.g. bones, lungs) other types of surgical interventions are considered.
Surgical treatment at early stages
Generally speaking, total or radical hysterectomy with additional removing of lymphatic nodes is considered to be the most comprehensive and effective surgery in women with cervical cancer. Nevertheless, in young women, who want to maintain fertility and are planning pregnancy, less radical types of surgery may be beneficial, as well.
Timely diagnosis and early beginning of treatment allow saving the uterus and reproductive ability. The surgeon needs to be accurate enough and find optimal balance between removing all oncological cells and preserving reproductive function.
Squamous cell carcinoma in situ and adenocarcinoma in situ affect only the superficial layer of cervical cells. Treatment of these conditions consists rather in destroying pathologically changed cells than in their removing.
There are few safe and effective options of providing this:
- Cryosurgery (other names are cryotherapy and cryoablation) is an outpatient intervention. Principle of freezing cold temperatures application lies in the basis of this procedure that destroys pathological cells or even small tumors. The manipulation is performed under the local anesthesia or even without administering anesthetic drugs. During the procedure surgeon applies liquid nitrogen or argon gas directly on the affected region of cervix. As only “bad” cells are exposed to cold, surrounding tissues remain undamaged. Surgeon may repeat the procedure few times, if necessary.
- Laser surgery is also an outpatient procedure, but it requires local anesthesia performing. Basic principle of this intervention consists in influence of high temperatures and high-energy light. With the help of focused laser beam a doctor burns off (vaporizes) abnormal cells from your cervix. In addition, he may take a tissue sample for further laboratory examination – histological study.
Conization is a more traumatic group of methods, as it implies removing a cone-shaped piece of tissue from the cervix. This procedure pursues few goals: removing oncological or suspicious for oncology locus and receiving sufficient amount of the material for comprehensive histological examination.
There are few technical ways of performing conization:
- Cold knife cone biopsy is usually an outpatient procedure; it lasts no more than an hour. This intervention is performed under a general or regional anesthesia. During the procedure cervix is damaged, and this organ has intensive blood supply. That is why surgeon uses special tool to seal blood vessels and stop bleeding or places few stitches on damaged area. You will need to stay in the clinic until bleeding stops and anesthesia action is over, but you will go home the same day.
- Loop Electrosurgical Excision Procedure or Large Loops Excision of the Transformation Zone (LEEP or LEETZ procedure) is highly similar to cold knife cone biopsy. The only difference is the mechanism of tissue sample taking – LEEP/LEETZ uses low-voltage electrical current. Such technique provides the same result, namely, good quality tissue sample for histological examination, but causes less bleeding. LEEP/LEETZ is also used for microinvasive cervical cancer removing.
Histological examination of the removed tissue is extremely significant. This study establishes the nature of the tissue – benign or malignant. Other important moment is presence of oncological cells on the outer edges of the sample (“negative or positive margins”). Revealing “positive margins” means that some abnormal cells may have been left in the cervix. In such situation doctor will recommend you additional treatment.
Treatment of early-stage cervical cancer with cryosurgery, laser surgery cold knife cone biopsy or LEEP/LEETZ cures up to 90% of women, which is a quite good result. Interventions have certain side effects, like pain in the pelvis, bleeding or watery discharge, but all of these reactions are not life threatening and usually don`t require additional treatment.
Surgical treatment of advanced cervical cancer
When cervical cancer is diagnosed at stages from IA1 to IIA2 the most appropriate treatment option is hysterectomy. During hysterectomy a surgeon removes the uterus with its cervix and other parts of the reproductive system (optionally, depending on the results of preoperative examination).
Hysterectomy is a more serious surgical intervention, so you will need to stay at the hospital for few days. General anesthesia will help to avoid pain during the procedure. In case the hospital is properly equipped, surgeons perform hysterectomy with the help of different techniques.
Diversity of approaches makes surgical interventions more individual and helps in avoiding cosmetic defects:
- Abdominal hysterectomy, when the uterus is removed through the incision in the lower part of abdomen or down from the belly button.
- Vaginal hysterectomy, when the uterus is removed through the vagina.
- Laparoscopic hysterectomy, when the uterus is removed through tiny cuts in the abdomen with the help of special instruments. No large cut in the abdomen is required in such case.
- Robotic-assisted hysterectomy is a kind of laparoscopic hysterectomy, when the uterus is removed through minimally traumatic laparoscopic approach with the help of special tools connected with robotic arms.
As it was mentioned before, treatment of cervical cancer may require removing not only the uterus, but also ovaries, fallopian tubes and lymphatic nodes.
Based on the volume of surgical intervention there are two main types of hysterectomy:
- Simple (total) hysterectomy. This type of surgery affects only the uterus and its cervix. The ovaries and fallopian tubes are usually preserved unless there are other medical indications for removing them. Surgeon usually removes not the sole tumor, but certain amount of healthy tissues, as well. If the incisions are done close to the visible tumor edge, there will be a chance of leaving certain amount of cancer cells in the organism.
- Radical hysterectomy is a more extensive intervention. In this case surgeon removes uterus and its cervix, upper part of the vagina, tissues next to the uterus and pelvic lymphatic nodes. The ovaries and fallopian tubes are removed in presence of clinical indications. Surgeons prefer to preserve hormone-producing function of the ovaries in women of childbearing age, as this will prevent a number of side effects. As radical hysterectomy is usually performed in women with more advanced cancer it is usually a part of complex treatment scheme (e.g. in combination with chemotherapy, radiation therapy).
After the surgery you will need to stay at the hospital for few days in order to undergo postoperative examination and be sure that you don`t have any complications of treatment.
Possible complications include the following:
- Lower abdominal pain due to tissue trauma during the surgery, skin incisions, etc.
- Difficulty with urination due to removing of certain nerves
- Bleeding, as uterus has good blood supply
- Wound infection, which is actually a rare complication
- Swelling of arms and legs due to excessive water retention
- Damage to the intestinal system due to scar tissue formation
After hysterectomy women are no longer able to menstruate and have children. Nevertheless, the surgery doesn`t influence quality of sexual life, as women don`t need uterus for reaching orgasm.
Quite the contrary, avoiding cervical cancer symptoms (e.g. pain, bleedings) with the help of surgery actually improves a woman's sensitivity and sexual life.
Alternative options for women of childbearing age
Treatment approaches in patients with “intermediate” stages of cancer are highly individual. For example, at stages IA2, IB1 and IIA1 cancer is already not superficial, the tumor invades inner part of the cervix and can even affect nearby lymphatic nodes. On the other hand, risk of distant metastases presence is not significant and total removing of the tumor is possible. In such circumstances doctors take into consideration age of a woman and her wish to plan pregnancy in the future. In older women total or radical hysterectomy is usually performed, as it is simple and comprehensive intervention. The most preferable technique for younger women is radical trachelectomy.
It should be noted that radical trachelectomy is not a common intervention, it can be performed in limited number of hospitals worldwide. Usually radical trachelectomy is performed through the vagina; other options are abdominal approach and laparoscopy. Of course, it is an inpatient surgery, so you`ll need to stay at the hospital for few days. The intervention is painless, as general anesthesia is provided to all patients. During the procedure surgeon removes affected cervix, nearby tissues and upper part of the vagina. This means that uterus stays undamaged and preserves its function. After removing obviously affected tissues surgeon proceeds to examination and removing of lymphatic nodes. Usually lymphatic nodes near cervix and uterus are removed in order to prevent relapse of the disease.
Final part of radical trachelectomy includes reconstruction of uterus opening, as the cervix has been already removed. The surgeon places a "purse-string" stitch or a band to create new artificial opening in the uterus. This gives chance for both getting pregnant and carrying pregnancy to a term. It should be noted, that radical trachelectomy increases risk of miscarriage, as fixing stitch may change its properties during a pregnancy. Natural childbirth becomes impossible, as well; the baby will need to be delivered by caesarean section.
Nevertheless, radical trachelectomy is a decent chance for preserving fertility and getting rid of cancer the same time. Risk of relapse after this intervention is very low.
Surgical treatment of recurrent cervical cancer
When cancer symptoms arise again after the period of remission and medical examination confirms returning of the disease, we speak about recurrent cervical cancer. Relapse of the disease may arise in the cervix or uterus, in any pelvic organ or in remote organs (in the form of metastases). Comprehensive surgical treatment, namely, pelvic exenteration, is offered if the cancer hasn`t spread beyond the pelvis.
Pelvic exenteration is an extensive surgery, performed under the general anesthesia. If you are planning to undergo this type of surgery, you will need to stay at the hospital for 5-10 days. During the pelvic exenteration surgeon removes all affected by oncological process organs – cervix, vagina, uterus, surrounding tissues and lymphatic nodes; bladder and intestines are also removed if they have signs of the disease.
Thus, surgery involves two stages. The first one is removing of organs and tissues and the second one is reconstructive surgery.
During the reconstructive stage surgeon restores function of removed organs and makes all the efforts for improving quality of patient`s life:
- If the bladder is removed the surgeon creates new way for storing and removing urine. A small part of your intestine may serve as a new bladder and this is the most widespread technique. New bladder is connected directly to the abdominal wall, so the patient may drain urine through the urostomy (small hole in the abdominal wall). Other option is draining urine into a small plastic bag, which is always connected to the abdomen. Before discharge from the hospital a patient receives all the information about living with new bladder. This requires certain skills, but finally appears to be not that complicated.
- If a part of intestine is removed the surgeon creates new way for defecation. The technique is similar to abovementioned – intestine is attached to the abdominal wall so that excrements pass through a hole in it (colostomy) to a small plastic bag, connected to the abdomen. If possible, organ-saving treatment is provided and a surgeon removes affected part of the intestine with reconnecting ends of healthy parts.
- If the vagina is removed the surgeon creates new vagina out of patient`s own tissues. This type of plastic surgery requires specific skills and should be performed only by trained professionals.
It takes about 6 months to recover from pelvic exenteration completely. During this period you will be followed up by the multidisciplinary team of healthcare professionals, which usually includes surgeon, clinical or medical oncologist, pathologist, radiologist, gynecologist, psychologist and social worker. You should tell your doctor about any unpleasant feelings or disturbing symptoms without any hesitation. Also you should feel free to ask all important for you questions.
Choosing a right hospital for fighting the disease
Next logical step after establishing the diagnosis and determining volume of the operation is choosing hospital and, which is even more important, appropriate personally for you surgeon. Actually, result of each surgical intervention can`t be predicted for sure and considerably depends exactly on skills and clinical experience of the surgeon. The doctor should perform delicate work on organ-saving intervention and removing all cancer cells at the same time, as this significantly influences further quality of life. If we are talking about more extensive surgeries, doctor should have additional experience in surgical vagina reconstruction.
Each healthcare professional has its own success rate, which reflect general number of surgeries per year, number of excellent surgeries, and frequency and types of postoperative complications. You may check this information along with data on doctor`s scientific achievements, participation in medical societies, attending conferences and workshops, and so on. Beyond all doubt, you may choose the doctor not only in your native country, but all over the world, as well. In this situation you should be prepared in advance, as international patients have special conditions of receiving treatment – long queues for non-citizens, additional fees for insurance, problems in communication with administrative staff and the doctor himself.
The most appropriate option of arranging treatment abroad is using help of company Booking Health. Booking Health is the medical tourism company, which annually helps thousands of patients with cervical cancer in receiving surgical treatment abroad. The company has international quality control ISO certificate in this field of work, which ensures reliability and correspondence to the highest international demands.
Booking Health offers help in such significant aspects, as:
- Recommending the best doctor and clinic for your case
- Booking an appointment on the convenient date
- Organizing comprehensive preoperative examination
- Organizing surgical intervention and staying in hospital as long, as you need
- Providing you with transfer, interpreter and medical coordinator, if necessary
- Preparing for you all the medical reports and further recommendations
- Providing help in further treatment or rehabilitation, if necessary
- Providing help in further communication with your treating physician, if necessary
To start planning your surgery abroad you should leave the request on the web-site of Booking Health. Our patient case manager or medical advisor will contact you the same day to discuss all the details. Aim of our work is to help you in restoring and maintaining health.
Choose treatment abroad and you will for sure get the best results!
Author: Dr. Nadezhda Ivanisova