Types of Gynecologic Cancer Surgery

The following are some of the common types of gynecological surgery:

• Hysterectomy - A hysterectomy is when the uterus and the cervix (the cervix is the bottom portion of the uterus) are surgically removed. This is often done through an incision (cut) in the abdomen. A hysterectomy is performed when a doctor thinks a woman has a gynecological cancer, especially endometrial or ovarian. Depending on the diagnosis and the woman's risk factors, a hysterectomy may also be done through the vagina.
• Total Abdominal Hysterectomy (TAH) - This type of hysterectomy is usually done for cancer of the uterus or ovaries. It usually involves an abdominal incision (cut) from the bikini line up past the belly button. The purpose of the large incision is for the surgeon to look at and study all signs of disease. Abdominal scars and surgical incisions can interfere with how a woman feels about her body, making her uncomfortable in an intimate situation. Depending on the reason for surgery, an abdominal incision can be vertical (up and down) or transverse (horizontal or across the abdomen in the bikini line). Most surgeries for suspected gynecological cancer will use the vertical incision for better assessment at the time of surgery.
• Laparoscopic Vaginal Assisted Hysterectomy (LAVH) - In this type of surgery, the uterus is removed using a laparoscope (a small instrument inserted through the belly button and on either side of the abdomen) to allow the surgeon the see the pelvis and remove the uterus from the vagina. A hysterectomy does not commonly interfere with sexual function, although a woman may experience temporary fatigue and pain from the incision. If infection or other problems occur, it may take longer to heal and sexual desire may be decreased due to concern about the incision. Post-operative pain is usually temporary but may be the focus of concern rather than sexual desire. Pain medication is necessary during this time, but it may also cause constipation. In addition, medicines may be needed to ease the symptoms from the surgery (i.e. pain) in order for a woman to feel intimate.
• Radical Hysterectomy – A radical hysterectomy is often done for cancer of the cervix. In addition to removing the uterus and cervix, the upper part of the vagina may also be removed. A radical hysterectomy may include removing surrounding tissue inside the pelvis. This may cause temporary inflammation making it hard for the woman to empty her bladder. Some women may require a urinary catheter for up to 10 days after surgery until the inflammation resolves. A radical hysterectomy often requires an abdominal incision.

The vaginal canal may be shorter after a hysterectomy causing discomfort with sexual intercourse. However, the vagina can stretch during sex so sexual functioning and pleasure can be maintained. Since the uterus contracts during orgasm, some women have said the intensity of their orgasm is decreased after a hysterectomy, while other women have reported no difference.

Similarly, some women have reported a decrease in vaginal lubrication with the cervix removed, while others have reported no difference. Learning how your body responds after surgery will help you discover what is pleasurable. Some women fantasize or touch themselves to know how their body responds again.

For women under the age of 40, who are diagnosed with early stage endometrial or cervix cancer, the removal of the ovaries may not be necessary. The removal of both ovaries in a premenopausal woman will cause menopause or the lack of ovarian function. If estrogen is not prescribed, vaginal dryness and vaginal atrophy (thinning) may occur over time, causing discomfort with intercourse and pelvic examinations. The use of water-soluble vaginal lubricants and moisturizers (non-prescription) are often used to improve comfort for vaginal entry. Your health care team may also prescribe a vaginal estrogen to help with vaginal atrophy.

• Bilateral salpingo-oophorectomy (BSO) - This is the removal of the fallopian tubes and ovaries and may be done with the hysterectomy during ovarian and endometrial staging, or as a single procedure. When a BSO is performed as a single procedure it may be done with a laparoscope through three small incisions in the abdomen.

Long-term effects on sexual functioning may include vaginal dryness due to decreased vaginal lubrication and decreased sexual desire due to the lack of estrogen. However, decreased sexual desire can be affected by life style factors such as stress and fatigue. If the surgery causes menopause, hot flashes may result. Hot flashes can cause discomfort during the day and evening and interrupt sleep patterns, leading to fatigue and moodiness. Talk to your health care team about treatment options that help reduce menopause symptoms that can impact quality of life and sexual desire. Common recommendations may be estrogen-based products, testosterone-based products, and non-medical products such as soy or black cohash. There is data to support the use of low does anti-depressant medication to reduce hot flashes.

• Vulvectomy - This is the partial or complete removal of the vulva or surrounding area of the vagina. In early stage disease, surgery will not include the labia and clitoris. For early stage cancer of the vulva, resuming sexual practice should not be a problem. The woman may have concerns about the physical appearance of her vulva due to the surgical scars. In more advanced stage disease, there may be more surgical removal of the vulva and the labia. If lymph nodes of the groin are removed, there may be swelling or edema of the vulva and labia, or in the area of the inner thigh. This may be temporary or permanent. Further treatment with radiation may be needed depending on the spread of disease. The need for radiation following surgery may cause swelling, delayed wound healing and vaginal discharge. There may be discomfort with vaginal intercourse following radiation and the need for vaginal lubricants and vaginal dilators may be necessary.
• Vaginectomy – This procedure involves the removal of all or a part of the vagina due to vaginal cancer, or disease spread from the cervix or uterus. In most situations, the upper top of the vagina is removed and intercourse and sexual pleasure remains intact. For advanced or recurrent disease, it may be necessary to remove the entire vagina and reconstruct a new one from skin grafts. The reconstruction of a new vagina will limit sexual pleasure but will allow for sexual intercourse for the woman and her partner.

Radiation treatment to the vagina may result in vaginal discharge, burning with urination and rectal inflammation. Vaginal stenosis or narrowing may occur after radiation. Interventions include the use of frequent intercourse if the woman has a partner or vaginal dilators. If there is initial discomfort with intercourse, the woman may want to use dilators as a means to keep the canal open, and also to determine when discomfort has decreased enough for intercourse. Vaginal estrogen creams are often prescribed to keep the vagina moist and elastic.

• Ostomies - These are surgical diversions of the bladder or the bowel, which empty outside of the abdomen usually due to obstruction of the bowel or ureter (the canal that leads to the bladder). A colostomy (the colon is surgically diverted through the abdomen) is used in rare situations for advanced cancer. A colostomy may be temporary or permanent depending on the situation and amount of disease. This will not interfere with the woman’s sexual functioning but may affect her body image, and make her feel self-conscious if uncontrolled sounds or odors are produced from the colostomy.

Feeling comfortable with one’s body is part of feeling sexual. Some women use sexy clothing to cover areas that makes them feel unattractive. The site of the colostomy will be selected so that the stoma bag can be applied without difficulty.

A urinary diversion outside the abdomen is called an ileal conduit and is created from part of the bowel to form a bladder, but the opening (ostomy) is through the abdomen. Depending on the type of conduit, a woman may have an ostomy that she need not wear an appliance bag but drains her urine by self-catheterization. Again, this will not interfere with sexual functioning but may require her to get used to her new body.