Radical trachelectomy

What is radical trachelectomy?

A radical trachelectomy with pelvic lymphadenectomy is an operation whereby the cervix, the upper part of the vagina (the tissue from around the cervix) and the pelvic lymph nodes are removed.

The uterus (the womb) and the ovaries are not removed and so it is still possible to have children. A large permanent stitch is inserted around the opening to the uterus, strong enough to withhold a pregnancy.

This operation can be performed laparoscopically or robotically. A laparoscopic operation, also known as keyhole surgery, is carried out using several small incisions (keyholes). Robotically assisted surgery is a laparoscopic technique that uses a robotic console to help your surgeon during the operation. Your surgeon will be in the same room and will control the robotic arms to perform the operation. It is important to understand that the robot is not performing the operation. The aim of this operation is to remove all cancer tissue leaving an area of normal tissue around the tumour (cancer-free margin).

All tissue removed is sent to the laboratory for examination. It will take about 2 weeks before the results are received. These will be discussed by the multidisciplinary team who will then plan for your treatment or follow up appointments.

If cancer cells are found in either the margins or the lymph glands then the need for further surgery to remove the womb or chemoradiotherapy is very likely.

Is everyone suitable for this operation?

To be considered for this operation the cancer must be small and confined to the cervix and you must have a strong desire to preserve your fertility. An assessment will be carried out to see if you are suitable for this surgery which may involve:

• MRI, CT, or PET scan
• Examination under general anaesthetic
• Review of the biopsies performed at your local hospital.

Before the surgery

You should carry on taking your usual medications, unless told otherwise. We strongly advise that you stop smoking before your operation. If you develop an illness before your operation or have any questions, please contact your consultant’s secretary.

Pre-operative assessment

You will be invited to the hospital before your surgery for a pre-operative assessment. During this assessment we will check your fitness for general anaesthetic and surgery. This will include recording a full medical history, any current medication and arranging any investigations needed. Please tell the nurse practitioner or doctor if you have had problems with any previous operation, anaesthetic or if you have any allergies – this is very important.

At this visit you will have the opportunity to discuss what to expect before, during and after your operation. We will also tell you what you will be able to do during your recovery time. Your admission details should be confirmed with you at this visit.

Will I have to sign a consent form?

You will be asked to sign a form giving your consent to the surgery. The consent form gives your gynaecologist the right to do only what is written on this form.

The only exception to this is if during the surgery there is an unforeseen problem, you have then consented to have this corrected. Please feel free to ask any questions about the surgery that you do not understand before signing the consent form.

The medical terms commonly used on the consent form are:

Trachelectomy: removal of the cervix and vaginal tissue around the cervix.

Lymphadenectomy: removal of pelvic lymph nodes.

During the surgery

Trachelectomy is normally carried out under a general anaesthetic (while you are asleep). A narrow plastic tube called a cannula is inserted into a vein in your arm or hand using a needle; this is used to give you fluids and medications. After you have been given a general anaesthetic and you are asleep, a catheter (a tube for urine drainage) is inserted into your bladder.

Your abdomen is then filled with gas and an optical instrument, called a laparoscope, is inserted to allow the internal organs to be viewed before 4 further small cuts, about 1 cm each, are made on your abdomen at about the level of the umbilicus (bellybutton). These cuts are for other instruments to be inserted. The surgeon will remove your cervix and vaginal tissue around the cervix and leave behind the uterus (womb). This is stitched to the remaining vaginal tissue, leaving a small opening to allow blood to escape during your period. The stich is strong enough to support a growing baby in the future.

During the operation the surgeon will remove the lymph nodes near your cervix and womb. The lymph nodes will be sent to the laboratory to check if the cancer has spread. Your ovaries, fallopian tubes and womb will not be removed.

The wounds are closed with dissolvable stitches and surgical glue. The procedure takes about 2 to 3 hours, but you can expect to be in theatre and recovery for 3 to 4 hours.

After the surgery

You will normally wake up in the recovery area of the operating theatre, but you may not remember much until you are back on the ward. You will be given medication during your surgery to help reduce the pain when you wake up. You may have some discomfort following your surgery but we will try to control this in the best way possible using a variety of pain relief.

Risks

Minor risks

• Infections (such as chest, wound or bladder)
• Bruising to any wound on the abdomen or in the vagina
• Haematoma (blood collecting in the wound or pelvis)
• Hernia
• Adhesion (tissue sticking together)
• Ileus (temporary slowing of the bowel movements)
• Bladder dysfunction
• Need for intermittent catheterisation
• Risk of miscarriage or premature birth
• Constipation

More serious risks

• Bleeding
• Blood loss can sometimes be heavy during the surgery and this may mean that you need a blood transfusion
• Blood clots (chest pulmonary embolism (PE) or Deep Vein Thrombosis (DVT) of the legs). Preventative treatment will be discussed
• Injuries to the bladder, ureters (narrow tubes between the bladder and the kidneys), bowel or blood vessels, requiring further surgery
• Anaesthetics carry a small risk and you will be asked by your doctors about any medical problems that might increase those risks

Will I need a catheter?

You will be discharged home with a catheter (plastic tube in your bladder); the nurses on the ward will teach you how to care for your catheter before you go home. The catheter will keep your bladder empty while you are recovering. You will have the catheter in for 7 days after the surgery and will need to attend the Gynaecology Outpatient Department, Gloucestershire Royal Hospital to have a ‘trail without catheter’. During this appointment the catheter will be removed and you will be asked to drink water. Once you have emptied your bladder the nurse will scan your bladder to see how much urine is left.

This is to check if you are able to empty your bladder properly. If you can empty your bladder properly you will be discharged home later the same day without a catheter.

If after several attempts your bladder has not emptied properly, another catheter will be inserted. This will allow the bladder to rest for a further week. You will then be discharged home.

Unfortunately for some patients their bladder does not fully recover. This can cause them to experience difficulty in fully emptying their bladder. These patients will receive further support from the continence team.

When can I resume my normal diet?

You may be able to drink a few hours after your surgery, until then you will be given extra fluid via your cannula. You will usually be eating and drinking normally within a day of the surgery.

How long will I be in hospital?

You may be discharged 2 to 3 days after your surgery.

At home

• You may still have some discomfort when you leave hospital but you will be given a supply of pain relief medication which you should take regularly for the best effect. You may also be given some laxatives to take home as minor bowel problems are common after a trachelectomy operation.
• You may feel weak or tired when you go home, this may last for a few weeks.
• You may feel you need to rest more than usual.
• Slowly increase your activity and avoid heavy chores, such as vacuuming for the first few weeks.
• You are asked not to have full penetrative intercourse for 6 weeks following the surgery. This to allow the top of the vagina to heal.
• You should avoid swimming and the use of tampons for 6 weeks; to prevent infection to the healing area.
• Avoid baths for the first 2 to 3 weeks. If you feel that you must take a bath during this time please do not soak. You should also avoid soaking for the next 6 weeks.
• At first you may have a brownish discharge from your vagina, this is normal. If the discharge gets heavier, foul smelling or if you have bright red bleeding you should contact your GP or specialist nurse.
• Your next period may be early or late as surgery can upset your normal cycle. It can take a while for your cycle to settle back into a normal pattern. Periods are often heavier and more painful to start with after having this surgery.
• You are advised to use contraception for 12 months after the trachelectomy. At this point you will have an MRI scan to check that there are no signs of cancer.

Returning to normal

You may feel more tired in the weeks following your surgery if you do too much. You may also experience a slight aching discomfort at the wound sites.

In some cases this can carry on for some months after the surgery, but most women are able to resume normal activity in terms of exercise and daily tasks within 4 to 8 weeks. It is advisable not to swim until all the wounds have healed and any vaginal discharge has cleared up.

When can I go back to work?

We suggest that you stay off work for 4 to 8 weeks; this depends on the nature of your job. Please talk about this with your consultant or GP.

Follow-up

• After your surgery you will be seen every 3 to 4 months for 2 years. This will alternate between the Gynaecological-Oncology Clinic and the Colposcopy Clinic. You will need a cervical smear test at 6 monthly intervals.
• You will require annual smears for 10 years after your diagnosis.
• An MRI scan will be performed 1 year after your surgery.

What about my sex life?

The area at the top of the vagina where the cervix was will have stitches will need about 6 weeks to heal before intercourse is resumed. You will tend to know when you feel ready to resume intercourse, you should find that there is no alteration in the sensation, but there may be slight discomfort if you are over enthusiastic.

Future pregnancy

As soon as you discover that you are pregnant you must see your GP to be referred to a local specialist maternity service as you may need closer monitoring during your pregnancy.

Women who have had this type of surgery will have their baby delivered by a planned caesarean section at 38 weeks, although it is possible that your waters may break before.

Contact information

If you need any more information, or would like to talk to a member of the team please telephone one of the numbers listed below.

Gynaecological Cancer Nurse Specialists

Tel: 0300 422 4047 or

Tel: 0300 422 3181

Monday to Friday, 8:30am to 4:30pm

If we cannot take your call, please leave a short message with your name, date of birth and contact number and someone will get back to you as soon as possible.

Acknowledgement

We would like to thank Cancer Research UK for kindly letting us use the diagram within the PDF below.