A Radical Hysterectomy or Wertheim's Hysterectomy is an operation performed to treat cancer affecting the uterine cervix.
The cervix is the lower one-third of the uterus or womb. When cells in the cervix grow abnormally, a tissue mass called a tumor forms. Tumors can be benign or malignant. Benign tumors are localized to one place and are not capable of spreading into surrounding tissues. Malignant tumors can spread or metastasize and interfere with normal tissue function.
Malignant tumor cells can spread directly into nearby tissues, through lymphatic (drainage) channels, or through the bloodstream. When cancer of the cervix spreads, it is usually by direct extension into nearby tissues, such as the uterus, or through the lymphatic system.
More tissue is removed in radical hysterectomy than in a standard hysterectomy because this surgery is designed to treat not only the malignant tumor in the cervix, but also the adjacent areas into which the tumor may have spread.
The uterus and cervix, nearby supporting tissues, the innermost part of the vagina, and pelvic lymph nodes are removed in radical hysterectomy. All tissues are examined carefully under a microscope to determine precisely the extent of the disease. The ovaries may or may not be removed at the time of surgery and this should be discussed clearly with your attending doctor when planning the surgery.
When you are referred to the Gynecological Cancer Centre (GCC) at KK Women's and Children's Hospital (KKH), your care is coordinated by one of our attending doctors. They are all specialists in gynecological oncology and staff members of the Gynaecological Oncology Unit.
Your attending doctor will review your medical history and do a physical examination. He or she will review your laboratory results, as well as pertinent past medical records.
You may be asked to have a chest X-ray and CT scan to determine if the cancer has spread to other organs. Your attending doctor will discuss the findings and alternative methods of treatment with you. Your family are welcome and encouraged to join you for any of these discussions. When all your questions are answered, admission to the hospital will be planned.
Our GCC staff as well as ward nurses are trained in caring for women with gynecological cancer. They will look after you throughout your hospitalization and recovery from surgery.
Our social worker is available to meet with you to discuss a variety of topics, including social and psychological support and financial concerns.
You will become acquainted with several doctors during your hospital stay. In addition to your attending doctor, who will perform the surgery, the resident medical offers (doctors receiving advanced training), house officers, anaesthetists, physiotherapists and medical students will comprise the team involved in your care.
The day before surgery, our resident doctors will meet with you to review the plans initiated by your attending doctor and answer any questions. You may have routine urine and blood studies, as well as a chest X-ray and ECG (electrocardiogram), at this time.
The anaesthetist will examine you and discuss the surgical anaesthetic. He or she will order medications for sedation before surgery, including sleeping medicines for the night before, if you wish.
You may be prescribed a drink to clear you bowels the day before surgery. This is to avoid contamination during surgery. You may have a regular dinner (unless special instructions are given), but nothing to eat or drink after midnight, not even water.
If you usually take important medicines (for example, heart, blood pressure, or diabetic medications) in the morning, ask your doctor whether or not you are to take them (with a sip of water) on the morning of your surgery.
The physiotherapist will teach you breathing exercises that prevent lung congestion and leg exercises that improve blood circulation while you are less active. You will be encouraged to walk soon after surgery because activity stimulates the body's return to normal function.
Your family and close friends are welcome and encouraged to visit you during visiting hours. During your surgery, they will be directed to the waiting area in the ward.
With any surgery there are risks of bleeding, infection and unusual anaesthetic reactions. You may require blood transfusions during or after radical hysterectomy.
In radical hysterectomy, there may be additional risks related to the area of the surgery. There may be damage to the organs next to the surgical site - bowel, bladder, ureters (tubes that drain urine from the kidneys to the bladder) - or to the large blood vessels and nerves. Blood clot formation, nerve damage, prolonged leg swelling and damage to the urinary tract, with resultant urine drainage through the vagina, may occur, but are rare.
A radical hysterectomy usually takes about 3 hours, followed by 2 or 3 hours for recovery from the anaesthetic. Patients after radical hysterectomy are routinely transferred to the intensive care ward or post-operative area for the first one or two days for close monitoring.
As you awaken, you will become aware of the nurse checking your condition frequently. Your blood pressure, pulse, and temperature will be monitored, and you will have an intravenous (IV) line until you are able to drink and eat normally.
One or two tubes may be placed on either side of the incision to drain excess fluid from the surgical site. These will be attached to suction bottles. You may also have a catheter in your bladder to drain urine. Do not be alarmed if you have a nasal tube or are receiving oxygen or a blood transfusion upon awakening. These therapies are common following major surgery. Antibiotics are generally given before and sometimes following surgery to prevent post-operative infection.
You will be encouraged to take deep breaths and to cough deeply every two or three hours to prevent lung congestion. Nurses will help you to turn periodically in bed and to exercise your feet and legs gently to maintain good circulation.
Special compression leg covers or periodic injections of a blood-thinning medicine (heparin) are used to prevent the formation of blood clots. These are discontinued when you are able to walk. You will be urged to sit on the edge of the bed within 24 hours after your surgery and to begin walking as soon as possible.
Your doctors will order pain relief medications for you, as these activities may be uncomfortable after surgery. Your nurse will work with you to schedule medications for adequate pain control, balanced with rest and increasing activity.
After abdominal surgery bowel function normally is sluggish, due to the anaesthetic and surgical exploration. As bowel function returns, you can begin to drink and eat. When your diet advances to regular meals, intravenous fluids will be discontinued.
Persistent slowed bowel function following radical hysterectomy may be caused by the unavoidable cutting of tiny nerves at the surgical site. Dietary management (daily prune juice, high fiber or high bulk diets) or other bowel programs (stool softener medications or mild laxatives) may help prevent difficulties. Increased fluid intake also helps improve bowel function. Once your normal diet and activity are resumed, bowel function usually returns to normal.
A suprapubic bladder catheter (inserted just above your pubic area) may be left in place for approximately two to six weeks after surgery. This relieves pressure on the surgical site and also allows for greater healing of the tiny nerves to the bladder. These nerves help you sense when your bladder is full and help you empty your bladder as well. The catheter is necessary to prevent your bladder from becoming too full until you can urinate on your own.
Typically after radical hysterectomy, bladder healing requires keeping the catheter in place for about 10 days after surgery. On the tenth day, you will be taught "bladder training" which involves periodic closure of the catheter, enabling you to pass urine through the normal route. The periodic clamping of the catheter is to allow your bladder to gradually regain its previous normal tone. Do not be discouraged if you are unable to pass urine normally at first - it is a function of how fast nerve function returns, which varies from person to person. The ward nurses will teach you how to measure and chart the residual urine in your bladder (RU) and your progress will be monitored. When you are able to void normally, the suprapubic catheter will be removed.
Even after the catheter is removed, there may be a continued loss of the sensation of bladder fullness. You may have to empty your bladder "by the clock" every two to three hours, rather than waiting for the sensation of fullness. Your doctor will discuss this with you.
Drinking plenty of fluids - six to eight glass a day - is important to prevent bladder infection while the catheter is in place. Once the surgical incision has healed, you may take tub baths or showers.
Drainage tubes. The drainage catheter(s) sometimes left in or near the surgical site will be there for a few days.
Incision - Absorbable stitches are usually used, but sometimes staples to close the surgical incision used will be removed seven to ten days after the operation. There may be a reddish to brown discharge from the vagina for several days. This is part of the normal healing process.
Emotions - Any major surgical procedure consumes a great deal of physical and emotional energy. Increased fatigue, hospital confinement, and temporary physical limitations may lead to feelings of nervousness or frustration and even anger. Although these reactions are normal and temporary, they may distress you. It often helps to share your concerns with a close family member, friend, or one of our staff.
The final pathology report is usually known about one to two weeks after surgery. The pathology slides will be reviewed by a panel of gynaecological cancer experts including radiation oncologists at the KK Gynaecological Cancer Centre (GCC) weekly Tumor Board Meeting and recommendations for any further treatment, if felt necessary, will be made. Your attending doctor will discuss this with you and your family.
If further treatment by radiotherapy or chemoradiation is recommended, arrangements will be made for you to see the Radiation Oncologist and Medical Oncologist. Your family members are encouraged to accompany you to discuss the treatment. Your attending doctor will continue coordinating your care with the radiation oncologists with whom the unit works very closely.
Radiation works by affecting cells that divide rapidly within the radiation area or "field." It can be given in two ways:
Side effects of radiation therapy may include nausea or diarrhoea, decreased blood counts, or in external radiation therapy, possible skin irritation at the treatment site. Your doctor and radiation oncologist will discuss radiation treatment in more depth if this is an option for you.
These medicines kill cancer cells regardless of their location in the body. The intravenous route is the most common way to give chemotherapy for ovarian cancer.
Once in the blood, the drug is distributed to all parts of the body. The cells that divide most rapidly, such as cancer cells, take up most of the drug. Chemotherapy drugs act by interfering with growth and duplication of the cell, and the cell is eventually destroyed.
Chemotherapy can also affect normal, actively dividing cells. Normal cells, however, have a tremendous capacity to repair themselves. Such normal cells that might be affected include those in the bone marrow (where blood cells are formed), gastrointestinal tract (lining of mouth, stomach and bowels), and hair follicles.
Chemotherapy is usually given in cycles. This allows normal cells to recover from the effects of the medication. The cancer cells cannot repair themselves.
Drug frequency and dose are determined by the body's response to, and recovery from, the chemotherapy. You will have periodic blood counts to determine the recovery create of blood cells (red blood cells, white blood cells, and platelets) in the bone marrow. Examinations are done to determine if any remaining tumor is shrinking. Your doctor will discuss with you over what period chemotherapy treatments will be given.
Before leaving the hospital, you will be told what to expect in the coming days. Although it is unusual to encounter complications after hospital discharge, do inform your doctor if you experience any of the following :
We recommend that you get adequate rest and nutrition, as well as mild physical activities, during your recovery from surgery. A balanced diet with an emphasis on high protein foods like meat and fish will help to build your strength and aid healing.
Light activity is encouraged in the first two weeks after surgery or until you are seen in the GCC for the first time following your surgery.
Delay driving or prolonged sitting for three or four weeks. You may begin isometric (tightening) exercises of the abdomen after three or four weeks. Avoid heavy lifting and strenuous exercise for two to three months after surgery.
Each woman reacts to radical hysterectomy in her own way. You may temporarily feel anxious or insecure about the surgery's effect on you, your partner, or on the way you live.
The idea of having cancer is stressful, and radical hysterectomy is a complicated treatment. Do not expect your emotional stress to resolve instantly. Talking with someone close to you or with one of our staff may help you to adjust physically and emotionally. Most women, however, do feel comfortable resuming their normal activities over time, often within a few weeks to several months.
Many women believe that a hysterectomy will cause menopausal (change of life) symptoms such as hot flashes, night sweating, or mood changes. However, it is removal of the ovaries, not the uterus, which produces these symptoms in younger women, and removal of the ovaries at the time of radical hysterectomy should be discussed with your attending doctor. Removing the uterus does cause cessation of menstrual periods and loss of childbearing function.
Sexual feeling need not be altered as a result of this surgery. However, sexual intercourse, as well as vaginal douching or use of tampons, should be delayed for three to six weeks after surgery, depending on wound healing. Do not be afraid to discuss concerns you or your partner may have about sexual activity with your doctors and nurses at any time.
Follow-up examinations are recommended every three months for the first year and then at four to six-month intervals during subsequent years.
Despite treatment, there is a risk that cancer may recur and further treatment may be required. Our staff and facilities at the Gynaecological Cancer Centre in KK Women's and Children's Hospital are always available as a resource to you.