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Surgery is used for uterine cancer for several reasons:

• For staging, to evaluate if and where the cancer has spread outside of the uterus.          
• For treatment, to remove all cancer in the abdomen and pelvis.          
• For symptom management, if the cancer has spread to distant parts of the body.    

Surgery usually includes a total hysterectomy (removal of the uterus and cervix), bilateral salpingo-oophorectomy (removal of both fallopian tubes and ovaries), and lymphadenectomy (assessment and removal of certain lymph nodes).

Typically, peritoneal lavage is also done during surgery.  The abdominal and pelvic cavities are “washed” with salt water (saline) which is then collected and sent to the lab to see if it contains cancer cells. The results of testing the fluid from the peritoneal lavage does not affect the current staging, but both FIGO and the American Joint Committee on Cancer (AJCC) recommend collecting the sample.

During surgery, the surgeon will also inspect the peritoneum (membrane around the abdominal and pelvic cavity) and will biopsy any suspicious areas to check for cancer cells.If endometrial cancer cells are found, the cancer’s surgical stage may change, and the next steps of treatment could be affected.

For surgical treatment, the goal is to remove as much cancer as possible. This is called debulking or cytoreduction.     

If the surgery is being done to manage symptoms, the procedure will target specific symptoms, such as blocked bowels.     

What is a hysterectomy?

Hysterectomy is surgery to remove your uterus (womb).

Depending on the type of cancer you have and whether it has spread to nearby organs, you might also have your ovaries (oophorectomy) and fallopian tubes (salpingectomy) removed. You might also need to have nearby lymph nodes (lymphadenectomy) removed to see if the cancer has spread to them.

Types of hysterectomy

• Total hysterectomy – Removal of the uterus and cervix.
• Subtotal (partial) hysterectomy – Removal of the uterus, leaving the cervix intact.
• Radical hysterectomy – Removal of the uterus, cervix, upper vagina, and surrounding tissues.
• Hysterectomy with bilateral salpingo-oophorectomy – Removal of the uterus, cervix, both ovaries, and fallopian tubes (also called a radical hysterectomy).

The standard type of hysterectomy for uterine cancer is a total hysterectomy. However, if the endometrial cancer is suspected to have spread to the cervix, a radical hysterectomy could be done to make sure all the cancer is removed.

Surgical approaches for hysterectomy

Hysterectomies can be done in different ways (approaches). Your surgeon will talk through options with you and suggest what approach they think is best for you.

Abdominal hysterectomy (laparotomy)

This surgery is done through an incision (cut) in the front of your abdomen (belly). This lets your surgeon look directly at the cancer area. Your uterus and other organs can then be removed through this incision.

 Also called open surgery, this approach helps your surgeon remove as much of your cancer as possible.  It also decreases the risk of injury to organs near the uterus, such as your bladder and bowel. It often takes longer to recover from open surgery than other methods.

Vaginal hysterectomy

This surgery is done through your vagina. An incision is made at the top of your vagina, and your uterus is removed.

 Vaginal hysterectomy is seldom used to treat cancer because it doesn’t let the surgeon clearly see all the cancer.  But it might be an option if you have health problems that make it too risky for you to have other types of hysterectomy.

Laparoscopic hysterectomy (minimally invasive surgery)

This surgery only requires small incisions. A thin tube called a laparoscope is put through an incision. The laparoscope has a tiny video camera at the end, which lets the surgeon look at the inside of your abdomen (belly) and pelvis.

 Small surgical instruments are then inserted through the laparoscope or other incision. The surgeon uses the instruments to cut around the uterus and other organs that need to be removed. Your uterus can often be removed through your vagina.

 Laparoscopic hysterectomy usually causes less pain and blood loss because the incisions are smaller. Recovery time is usually shorter than from an abdominal hysterectomy.

Robotic-assisted laparoscopic hysterectomy

Robotic technology is sometimes used during laparoscopic hysterectomies. For this, the surgeon sits at a control panel in the operating room and operates through special tools attached to robotic arms . This also only requires small incisions.

Pain, blood loss, and recovery are much the same as with laparoscopic hysterectomy. Ask your surgeon how much experience they have with robotic-assisted surgery and how their other patients have done.

Other surgery done with hysterectomy

Bilateral salpingo-oophorectomy

A bilateral salpingo-oophorectomy (BSO) removes both ovaries and fallopian tubes. It is usually done at the same time as the hysterectomy to treat endometrial cancers.      

Having both ovaries removed means that you'll go into menopause if you haven't done so already. If you have endometrial cancer and have not yet gone into menopause it may be safe to keep your ovaries if you have a low-stage, non-aggressive endometrial cancer.  Talk with your surgeon about this decision. When ovaries are removed there might be a lower chance of the cancer coming back, but for patients who keep their ovaries, there doesn’t seem to be an increased risk of dying from endometrial cancer.

Lymph node surgery

Sentinel lymph node dissection (SLND) and lymphatic mapping may be used in early-stage endometrial cancer if imaging tests don't clearly show signs that cancer has spread to the lymph nodes in your pelvis. For this procedure, a blue or green dye is injected into the  cervix. The surgeon then looks for the lymph nodes that turn blue or green (from the dye). This is called lymphatic mapping.  These lymph nodes are the first ones the cancer would drain into and are called sentinel lymph nodes. They are removed and tested to see if they have cancer cells. This is a sentinel lymph node dissection. If they do have cancer cells, more lymph nodes may be taken out.  

If there are no cancer cells in the sentinel nodes, no more nodes are removed. This procedure is usually done at the same time as surgery to remove the uterus (hysterectomy).

If a sentinel lymph node is not identified on both sides, then this is a failure of mapping. In this situation the lymph nodes should be removed from each side that failed to map.       

If imaging tests done before surgery show enlarged lymph nodes (indicating the cancer might have spread) the lymph nodes in specific areas from the pelvis and from the area next to the aorta will be removed during the hysterectomy. They are then tested to see if they contain cancer cells that have spread from the endometrial tumor. This information is part of finding the cancer’s surgical stage.

Omentum biopsy

The omentum is a flat layer of fat on the surface of the abdominal organs. A sample from this structure is taken during surgery for aggressive types of endometrial cancer.

Recovery after a hysterectomy for uterine cancer

Your recovery will depend on the type of hysterectomy you had and what surgical approach was used.

The hospital stay after an abdominal hysterectomy (laparotomy) is usually 2 to 7 days. Complete recovery can take  4 to 6 weeks.

If the hysterectomy is done by a laparoscopic or robotic or vaginal approach, usually you will be able to leave the hospital on the same day or the next day. Full recovery takes about 3 to 4 weeks.

Possible side effects of hysterectomy

Complications of these surgeries are not common and depend on the surgical approach. They can include nerve or vessel damage, excessive bleeding, wound infection, and damage to nearby tissues (the urinary and intestinal systems).

You might also be at higher risk for blood clots. That’s why you will be encouraged to get out of bed as soon as possible. You may also be given stockings or a device to compress your legs and help move blood back out of your legs.

If you have many pelvic lymph nodes removed, you might be at risk for swelling in your legs (lymphedema). This risk is higher if you have radiation after surgery.

A radical hysterectomy can affect the nerves that control the bladder, so a catheter is used to drain urine after surgery. It may be needed for a few days or up to 2 weeks. If the bladder hasn’t recovered completely when the catheter is removed, it may need to be put back in. Or, you can be shown how to put in a catheter several times a day to empty your bladder. Over time, your bladder function should return     .

Long-term side effects of uterine surgery

Any hysterectomy causes infertility (you won't be able to get pregnant).

Removing the ovaries will cause menopause right away. This can lead to symptoms like hot flashes, night sweats, and vaginal dryness. It can lead to osteoporosis and increased risk for heart disease, which impacts all post-menopausal women.

Removing lymph nodes in the pelvis can lead to a build-up of fluid in the legs and genitals. This can become a life-long problem called lymphedema. It's more likely if radiation is given after surgery.

Surgery and menopausal symptoms can also affect your sex life. For more, see How Cancer Surgery Can Affect Sex for Women.

Talk with your treatment team about side effects you might have right after surgery and later on. There might be things you can do to help prevent side effects. Know what to expect so you can get help right away.