Cervical Cancer: Surgery

Precancer vs. cancer

Precancer cells of the cervix may not be treated in the same way as invasive cancer. Precancer cells are abnormal cells. But they are not considered cancer. Precancer is also called cervical dysplasia or cervical intraepithelial neoplasia. These types of abnormal cells are only in the surface layers of the cervix. They have not grown into deeper tissues. Invasive cancer has grown through the surface of the cervix. Both can be treated with surgery. But different types of surgery may be used.

Surgery for precancer

Treatment for precancer depends on how severely abnormal the cervical cells look, the size of the area of abnormal cells, any other treatments you may have had for precancer, and your personal health. Some precancer may be treated without major surgery. These treatments may include cryosurgery, laser surgery, or conization. Removing the uterus and cervix (hysterectomy) is another choice. This is seldom needed to treat precancer.

The most common types of surgery for cervical precancers include:

Cryosurgery

A very cold, metal probe is touched to the part of your cervix with the abnormal cells. This freezes and kills the precancer cells on the cervix. Cryosurgery may be done in your healthcare provider's office or clinic. It doesn't need anesthesia.

Laser surgery (laser ablation)

This type of surgery uses a narrow beam of light to create heat. The heat vaporizes (burns off) and destroys the abnormal cells. You may have this procedure in your healthcare provider's office. Or it can be done in a clinic using local, numbing anesthesia or in an outpatient operating room with general anesthesia.

Conization

This is a type of procedure used to biopsy the abnormal cells and used as treatment. It can be done in your healthcare provider's office, a clinic, or outpatient surgery room. You can usually go home the same day. The type of anesthesia used depends on how much tissue is removed and how conization is done. Talk with your healthcare provider about the type of anesthesia that is best for you. You may be given a local anesthesia with medicines to make part of your cervix numb. Or a regional anesthesia (epidural or spinal injection) may be used so you don't feel pain below the waist. Or general anesthesia may be given to put you to sleep during the procedure. A laser, knife, or an electric wire is then used to remove the abnormal cells in a cone-shaped piece of tissue taken from the outer part of the cervix. The removed tissue is sent to a lab and tested to make sure there are no cancer cells in it. When the electric wire is used, this procedure is also known as loop electrosurgical excision procedure.

Simple hysterectomy (total or extrafacial hysterectomy)

This may be done to treat moderately to severely abnormal cervical cells or other abnormal types of cervical cells. This is a major surgery. A surgeon removes your uterus and cervix through a cut (incision) made in your belly (abdomen) or through your vagina. A hysterectomy can also be done as a laparoscopic or robot-assisted surgery. This usually has a faster recovery because a few small cuts are made instead of one big cut. This surgery uses regional anesthesia (epidural or spinal) to make you numb below the waist. Or you might be given general anesthesia. This way you’re asleep and don't feel pain. You may stay in the hospital for a night or so after surgery. The length of your stay in hospital depends on which method of hysterectomy is performed. A hysterectomy might be used for women who've had more than one treatment and still have precancer cervical cells. 

Surgery for invasive cervical cancer

Invasive cancer means the cancer has spread beyond the surface of the cervix into the deeper layers. Women with invasive cancer may be treated with some of the same types of surgery used for precancer. The type used depends on the size and stage (extent) of the cancer. And on whether you want to have children. The most common types of surgery for invasive cervical cancer include:

Conization

Your healthcare provider may use this procedure instead of a hysterectomy to treat some early stage cancers, such as a stage IA cancer (5 millimeters or less invasion), if you want to get pregnant in the future. The type of anesthesia used depends on the amount of tissue removed and the conization method used. It can be done in the healthcare provider's office or clinic under local anesthetic. It can also be done in an outpatient surgical room using regional or general anesthetic. A laser, knife, or an electric wire is used to remove a cone-shaped piece of tissue from the outer part of the cervix that contains the cancer. Using the cold knife method is preferred. This procedure is also known as loop electrosurgical excision procedure when the electric wire is used. The tissue is sent to a lab and tested to make sure no cancer cells are near the edges (negative margins) of the cone. The goal is to remove all the cancer cells in one procedure. Still, when using this treatment, there's a small chance that the cancer will come back. It's important to keep all follow-up appointments to watch for signs that the cancer is back. Talk with your surgeon about the type of conization method and type of anesthesia that is best for you.

Simple hysterectomy (total or extrafascial hysterectomy)

This is the standard treatment for low-risk stage IA1 (cancers 3 mm or smaller) invasive cancer in women who don’t want to get pregnant in the future. Only your uterus and cervix are removed through your abdomen or vagina. Either regional or general anesthesia is needed to keep you from feeling pain during the surgery. Regional anesthesia makes you numb below the waist so you don't feel the surgery. General anesthesia means you are given medicines that make you sleep and not feel pain while surgery is done. You may stay at least 1 night in the hospital. This depends on the type of surgery. Women often recover faster when the hysterectomy is done through the vagina. Laparoscopic or robot-assisted surgery also tends to have a faster recovery. This is when the surgery is done through a few small cuts instead of 1 big cut. Your ovaries and fallopian tubes don’t need to be removed to cure cervical cancer. Talk about this with your surgeon before the surgery. Removing your ovaries causes menopause.

Radical hysterectomy

This type of hysterectomy surgery can be used to treat stage IA2, IB1 (larger than 5 mm but smaller than 2 cm), IB2 (between 2 and 4 cm), and sometimes small IIA cancers. These have grown beyond the cervix into the vagina. Your uterus, cervix, the upper part of your vagina, and much of the connective tissue that holds your uterus in place are removed. The lymph nodes in the pelvic area might also be taken out to test them for cancer. This surgery is often done through an incision in your abdomen. Laparoscopic or robotic surgery may be used, too. But studies have shown that there's a higher chance of the cancer coming back when the surgery is done this way. Your ovaries don't need to be removed in a radical hysterectomy. This is important for younger women because removing ovaries causes menopause.

Modified radical hysterectomy

This type of surgery can be used to treat high-risk stage IA1 and IA2 (larger than 3 mm and not larger than 5 mm) cancers. The uterus (including the cervix) is a part of the connective tissue that holds your uterus in place. It along with a small part of the upper vagina are removed through an incision in your abdomen. Laparoscopic or robotic surgery may be used, too. Pelvic lymph nodes may be removed to test them for cancer. Your ovaries don't need to be removed. This is important for younger women because removing ovaries causes menopause.

Radical trachelectomy

This surgery can be used to treat high-risk stage IA and some stage IB cancers. It's a choice that may be used if you are young and want to get pregnant in the future. Your cervix, a small part of your upper vagina, and nearby tissues are removed through the abdomen or vagina. Your uterus is then reattached to the remaining vagina. A band is put around the bottom of your uterus to work like the cervix would. Pelvic lymph nodes are often removed. This is to see if cancer has spread beyond the cervix. The uterus and ovaries are not removed. For some women, this procedure is as likely as a radical hysterectomy to cure cervical cancer. But this surgery is complex. It should only be done by a gynecologic oncologist who has experience doing it. After this surgery, there's an increased risk of infertility and pregnancy-related complications. For a future pregnancy, you may need fertility treatments and high-risk pregnancy care, and you will need to deliver by cesarean section.

Getting ready for your surgery

Your healthcare team will talk with you about the surgery choices that are best for you. You may want to bring a family member or close friend with you to appointments. Write down questions you want to ask about your surgery. Make sure to ask about:

• What type of surgery will be done

• What type of anesthesia will be used to keep you from feeling pain

• What will be done during surgery (what organs and type of tissue will be removed)

• If you'll go into menopause after surgery (if your ovaries will be removed)

• The risks and possible side effects of the surgery

• What you can expect sex to be like after surgery 

• If you will be able to get pregnant after surgery

• When you can return to your normal activities

• If the surgery will leave scars and what they will look like

• What you should do to get ready for surgery

Before surgery, tell your healthcare team if you are taking any medicines. This includes prescription and over-the-counter medicines, vitamins, herbs, and other supplements. Also tell them if you use marijuana, tobacco, alcohol, or street drugs. This information should also be shared with your anesthesiologist. This is to make sure you’re not taking anything that could affect the surgery. You'll sign a consent form that says that the healthcare provider can do the surgery after you've discussed all the details with the surgeon.

You’ll also meet the anesthesiologist or nurse anesthetist and can ask questions about the anesthesia that will be used and how it will affect you. Let them know if you ever had difficulty with any type of anesthesia This specialist will give you the anesthesia so that you fall asleep, don’t feel pain, or both just before your surgery.

Common side effects after surgery

The side effects you have depend mostly on the type of surgery you have.

For cryosurgery or laser therapy, you may have:

• Pain

• Tiredness

• Vaginal bleeding or watery discharge

• Cramps that might seem like those you get with your period

For conization, you may have side effects, such as:

• Tiredness

• Pain

• Vaginal bleeding, cramps, or watery discharge

• Infection

• Increased risk for fertility problems due to narrowing of the cervical canal

• Leg swelling (called lymphedema) if lymph nodes are removed

For a hysterectomy, it will take you up to 6 weeks to feel better. You'll no longer have periods. You may have a lot of emotions about not being able to get pregnant in the future. You may have side effects, such as:

• Pain

• Vaginal bleeding, cramps, or watery discharge

• Trouble passing urine or having a bowel movement

• Tiredness

• Risk of blood clots

• Risk of infections, such as pneumonia or at the incision(s)

• Dehydration

• Damage to nearby organs, like the bladder, ureters, or rectum

• Leg swelling (called lymphedema) if lymph nodes are removed

For a radical trachelectomy, you may have an increased risk for infertility. You may have a higher risk for miscarriage, pregnancy loss, and preterm delivery if you do become pregnant. You may have these side effects right after surgery:

• Pain

• Vaginal bleeding, cramps, or watery discharge

• Trouble passing urine or having a bowel movement

• Tiredness

• Risk for blood clots

• Risk for infections, such as pneumonia or at the incision

• Injury to nearby organs, like the bladder, ureters, or rectum

• Leg swelling (called lymphedema) if lymph nodes are removed

Most of these side effects go away as you heal and recover. Irregular bleeding may continue. Your healthcare provider or nurse can help you learn how to cope with these problems. For instance, you can control pain with medicine. Talk with your healthcare provider about how to recognize and manage problems before you go home. Most women who have had surgery get back to their normal activities within 6 weeks or so. Your provider will tell you when it's OK to have sex.

Recovering at home

You may get back to light activity when you go home. Stay away from strenuous activity for 6 weeks. Limits will depend on the type of surgery you had. Your healthcare team will tell you what kinds of activities are safe for you while you recover. Be sure to ask your healthcare team when it is safe for you to have sex.

When to call your healthcare provider

Talk to your healthcare provider about problems you should watch for. Call right away if you have any of the following:

• Any unusual bleeding or bleeding that soaks the bandage

• Redness, swelling, or fluid leaking from the incision or vagina

• Incision opens up or the edges pull apart

• Fever of 100.4°F (38°C) or higher, or as advised by your healthcare provider

• Chills

• Cough, chest pain, or trouble breathing

• Redness, warmth, swelling, or pain in a leg or arm

• Trouble or pain when passing urine or changes in how your urine looks or smells

You may be given medicines, like pain pills, to take after surgery. It's important to know which medicines you're taking. Write down the names of your medicines. Ask your healthcare team how they work, what they're for, what dose you should take, when you should take them, and what side effects they might cause.

Talk with your healthcare providers about what signs to look for and when you need to call them. Know what number to call with problems or questions, even on evenings, weekends, and holidays.