Surgery to remove cervical preparation, implementation, rehabilitation, consequences
Worldwide cervical cancer the standard treatment is removal of the uterus, chemotherapy and radiotherapy. However, for young women who want to retain the ability to birth of child, developed an alternative operation, trachelectomy, or the removal of the cervix.
What is a trachelectomy and can you get pregnant after the conference?
To the consequences of the removal of the cervix was favorable, critical selection of patients for this procedure. During the operation the cervix is removed, the upper 2 cm of the vagina and surrounding tissue. The body and the body of the uterus remain intact. The intervention can be performed through the abdomen, laparoscopically, robotically-assisted surgery. Possible removal of the cervix through the vagina.
The first successful operation was performed in 1994. Since that time, there were at least 1000 of these interventions, after which at least 250 women were able to conceive.
There are two types of surgery:
- Simple with removal of the cervix and vagina.
- With additional radical excision of lymph nodes in the pelvis, where there may be cancer cells, and parametrial (tissue around the uterus).
Treatment method is accompanied by low risk of complications. The frequency of relapse does not exceed 5%.
Surgery is indicated not only in cancer of the cervix. It is performed under such pathological conditions:
- recurrent cysts and polyps of the cervix, chronic endocervicitis;
- cervical endometriosis;
- a small knot of fibroids in the cervix;
- deformation of the cervix and ectropion, caused by the unfavorable period of the previous birth;
- prolapse or uterine prolapse, which caused thickening and deformation of the neck;
- severe leukoplakia or pseudo, not amenable to treatment in other ways.
Is often removal of the cervix with dysplasia, 2 and 3 degrees – of precancerous processes of the cervix. Conservative methods at this stage is usually ineffective, and need for complex surgical intervention no.
In 1998 formulated the following indications for removal of the cervix:
- the patient’s desire to preserve the possibility of having a baby;
- tumor size less than 2 cm;
- stage according to FIGO 1A1, 1A2 and 1B1;
- uninvolved upper part of the cervical canal, as evidenced on MRI;
- the absence of metastases in the lymph nodes.
If at least one of these conditions is not met, partial removal of the cervix with preservation of the organ impossible.
Tumors larger than 2 cm are usually accompanied by involvement of the lymphatic vessels and nodes, and the cervical canal. This increases the frequency of recurrence of tumors and the likelihood of metastases.
The operation is not performed, patients with these histological forms of tumors of the neck:
- neuroendocrine tumors;
- papillary-serous education;
Before performing the removal of the cervix is important to exclude metastatic involvement of lymph nodes. To do this, before the main surgery is performed removal of lymph nodes laparoscopically, through small incisions in the abdominal wall. If they discovered cancer cells, removes the whole uterus.
See also: Methods of removing the uterus
Preparing for surgery
Studies the blood, its biochemical composition and state of the coagulation system. Conducted x-rays of the lungs. For the evaluation of metastases in the lymph nodes is performed CT, MRI or positron emission tomography. In the diagnosis of inflammatory diseases treatment of infection until complete recovery.
Before to remove part of the cervix, the doctors determine the suitability of the patient for this intervention. Then she explained in detail that during operation can cause damage to the blood vessels, ureters and other organs that may require immediate laparotomy.
Discusses alternative methods for the treatment of: conization of the cervix, removal of cervix, chemoradiation.
Some patients directly during the intervention have to expand its volume and to remove the uterus if found to have lymph node metastases.
A woman hospitalized on the day of surgery or the night before. 6 hours before the intervention, she should not eat or drink. Doctor’s prescription can be administered some medications.
The patient signs the consent form, in which there is information about possible complications.
Before surgery to prevent infection we recommend the use of antibiotics. Sometimes done enema or patient in advance takes a substance cleansing the intestines. It depends on the type of the intended intervention.
The woman should take hygienic shower. Sometimes required the removal of hair from pubis. Removable jewelry, glasses, contact lenses, piercings.
The patient is placed on surgical gynecological chair. Use General or local anesthesia. Often performed epidural anesthesia.
Trachelectomy is performed in one of three ways:
- Removal of part of the cervix in a cone.
- Wedge resection.
- Amputation with a change of the vaginal vault.
To perform the operation can apply a variety of tools: a scalpel, laser, electric current, cryodestruction or radiono. The selection is made by the doctor depending on the capabilities of the clinic and the characteristics of the patient.
How long is surgery to remove the cervix?
Depending on the type of intervention, from 30 minutes to 4 hours.
First, using laparoscopy to remove multiple pelvic lymph nodes. They are examined for the presence of malignant cells. If no metastasis, carry out the removal of the cervix. The probability of detection of malignant cells in the lymph nodes at an early stage is 6%.
Radical vaginal trachelectomy is performed most often and consists of 5 stages. First, under the mucous injected local anesthetic with a vasoconstrictor effect and make a circular incision 2 cm below the cervix. The front and rear edges of the mucosa are taken on the clamps.
They are then processed and the space between the uterus and rectum. Then open the tissue between the uterus and bladder.
Highlighted in the ureters and the uterine vessels, is removed okolomatocnah fiber. In simple trachelectomy parameters is not incising. The blood supply of the uterus is trying to preserve. Bind artery, reaching to the cervix. The neck is cut at 1 cm below the internal uterine OS.
Remote urgently the abnormal area and examined under a microscope. If cancer cells are found closer than 5 mm from its edge – the operation is inefficient, its volume expands and the uterus removed.
At the final stage, the cervix trying to repair using non-absorbable materials. In this subsequent stitch, partially covering the cervical canal, helping to preserve and to make pregnancy. In the cervical canal leaving rubber catheter, which is subsequently removed. The edges of the vaginal mucosa attached to the neck.
Body cavity removal
Abdominal surgery to remove the cervix is done with a low horizontal or vertical incision in the abdominal wall.
Opened the abdominal cavity is thoroughly inspected in search of metastases. Removes all the lymph nodes of the pelvis on both sides. They immediately evaluated by the method of frozen sections. If they are found malignant cells requires an advanced operation.
Allocate ligament of the uterus and the ureters. Through the rear open surface of the uterus vaginal portion is removed and the outer surface of the cervix. Suture.
Using thin instruments in the form of tubes, and optical devices. The surgeon makes short incisions in the abdominal wall. A laparoscope is inserted through these small openings and under video control and remove the cervix and the surrounding tissue. Such operation of the least traumatic for the patient. After it swept aside a quick recovery.
What happens after surgery?
The patient is in the recovery room for several hours or overnight, then transferred to the Department. She can stand up, walk, take food and water on the same day after doctor’s permission. Especially useful protein and dairy products.
If the patient for some reason has to constantly lie, she needed to do breathing exercises and lift the leg to improve venous blood flow and preventing blood clots.
The urinary catheter is usually removed soon. If the bladder function is not restored, the catheter can be left for a few days. Through it, the urine falls into a special plastic bag – the bag.
If you have used non-absorbable sutures, the sutures will be removed 5-10 days after the intervention.
A woman can be concerned about constipation and bloating, throat pain, discharge of blood from the vagina. It is not dangerous. It is advisable to do a light leg massage and breathing exercises and also use compression stockings. Hospitalization lasts for about 7 days. At this time antibiotics, painkillers and anti-inflammatory drugs.
The ineffectiveness of regular painkillers in the first days can be used 2 options:
- Epidural anesthesia.
- Controlled anesthesia, when the patient, by pressing a button on a special pump regulates the flow of anaesthetic into the vein.
All tissue and lymph nodes removed in surgery shall be examined in the laboratory for 2 weeks. If they are metastatic lesions that need additional consultation. It will decide on radiotherapy or surgery to remove the uterus.
After discharge a woman is concerned about the fatigue and she needs to rest more. She recommended walking, but not Jogging and swimming. Of household loads in the first month after surgery allowed washing dishes, cooking simple meals. Drive the car a month and a half after surgery. Around the same time, you can return to normal work and normal sexual life.
If you did not vaginal and abdominal surgery, the recovery period is extended to 3 months until complete healing of the joints.
The next complication
The postoperative period and the first week after removal of the cervix may be accompanied by complications:
- the inability to completely empty the bladder due to the lowering of its tone;
- pain during intercourse;
- vaginal discharge;
- deep vein thrombosis, pulmonary embolism;
- infectious complications and inflammation of the joints;
- reduction of skin sensitivity in thighs;
- painful or irregular menstruation;
- swelling of the external genitalia, including the labia, clitoris and vagina;
- vaginal candidiasis;
- prolonged absence of menstruation.
Prevention of these complications:
- Sex life is allowed after 6 weeks, when will be performed a control medical examination, and will be the first after the intervention period.
- In the same period, prohibited douching, vaginal swabs, hot baths, swimming, lifting more than 3 kg.
- In the first six months you need protection from pregnancy.
To ease their condition after discharge, the woman is better to take care of the supply of food to discuss with loved ones duties.
If after removal of cervical pain in lower abdomen, discharge with an unpleasant odor, deteriorating health, increases the temperature, you should immediately consult a doctor. Normal discharge may persist for 6 weeks, they spotting, brownish, painless. The appearance of bright red secretions or clots you need to go on consultation to the gynecologist.
The first medical examination is appointed in 2 weeks. While the vaginal examination is not carried out. The woman reported the results of the biopsy of tissue removed. Discussed the plan for further observation and treatment.
PAP test and colposcopy performed every 3-4 months for the first 3 years after the intervention. Then control examinations performed 1 time a year for 2 years.
The doctor draws attention to the emergence of long-term side effects of surgery that can occur even several years after the intervention:
- accumulation of lymph in the vessels of the limbs (lymphedema) or the abdomen (lymphocele) due to the removal of pelvic lymph nodes (especially this complication is typical for a situation when trachelectomy combined with radiation);
- stress incontinence during activities that increase intra-abdominal pressure, for example, when sneezing;
- trouble conceiving and higher risk of complications of pregnancy.
Women who have undergone removal of the cervix, the pregnancy is recommended not earlier than in 6-12 months. Approximately 15% of the patients there are difficulties associated with narrowing of the lower part of the cervical canal. In this case, it shows assisted reproductive technologies such as in vitro fertilization.
During pregnancy the risk of miscarriage is not increased. However, this increases the frequency of premature birth resulting from shorter cervix or the development of chorioamnionitis. This leads to premature rupture of membranes. 4% of women deliveries occur in up to 32 weeks of pregnancy, and 55% in a period of more than 37 weeks. To avoid premature interruption of pregnancy, on the neck impose additional seams or use special restraints – pessary.
Vaginal birth not carried out, the child is born by caesarean section.
Despite the fact that many of the world’s centres successfully used a trachelectomy in young women, is still evidence of its effectiveness do not exist. Therefore, such interference does not apply to standard treatment for cancers and is performed by high qualification only at the insistence of the patient in the future to have a baby, if it fits all other criteria of suitability to be conserving surgery.