[Gynecology Special Topic]New therapy improves cure rate and reduces number of hysterectomies

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Text: Yang Qianni Compiled by: Liang Yingxiu

(Kuala Lumpur News) Endometriosis is one of the common benign diseases that requires hysterectomy. In other situations where hysterectomy cannot be avoided, including severe bleeding during delivery, and the bleeding cannot be stopped after taking various methods, it is a last resort. Emergency surgery is required to remove the uterus to save the mother’s life.

The uterus is located in the center of the pelvic cavity, and the opening connected to the vagina is called the cervix. It is one of the most important reproductive organs of women, and its main function is to give birth to life. Normally, the lining of the uterus will peel off every month, which is menstruation. Removing the uterus means that a woman cannot continue to have children.

Patients undergoing hysterectomy can be divided into two broad categories, benign tumors or cancer. Non-cancerous causes are usually due to tumors in the uterus, such as fibroids, sarcomas, ovarian tumors, or endometriosis. Common cancers that require hysterectomy are cervical cancer, uterine cancer (endometrial cancer), ovarian cancer, or vaginal cancer.

Early treatment does not require hysterectomy

Dr Chua Peng Teng, consultant in minimally invasive obstetrics and gynecology surgery, pointed out that in developed countries such as the United States, Germany and Denmark, the most frequently performed gynecological surgery is caesarean section, followed by hysterectomy, with approximately 100 per 100,000 people. to 500 cases.

In recent years, with the advancement of science and technology and the advent of new treatments, many diseases can be treated while preserving the uterus. Therefore, the implementation rate of hysterectomy has been on a downward trend.

“I have to mention here that ‘stage zero cancer’ is also called carcinoma in situ. Simply put, this is a cancer that is localized in situ and has not invaded structures such as blood vessels or lymph glands. Surgery is acceptable at this time Complete resection has good curative effect and few sequelae, and usually does not require follow-up treatment. Because carcinoma in situ is ‘silent’, patients in many countries, including Malaysia, have already developed advanced cancer by the time they seek medical treatment. The later the stage of the cancer, the more challenging it is to treat it. Depending on the condition, patients may also require additional treatments such as chemotherapy and radiation therapy.”

“Can carcinoma in situ avoid hysterectomy? Indeed, it can, but not entirely. The first consideration is of course age. If the patient is young and has not yet married, of course he will not decide to remove the uterus easily. Furthermore, it depends on the type of disease. .”

He took cervical cancer in situ, Cervical Intraepithelial Neoplasia (CIN), as an example. The cervix only needs to be removed through cone biopsy, and the cure rate is 98%.

“If the condition recurs or becomes more serious, it will usually be discovered within two to three years after surgery. Generally, no abnormalities for two to three years are considered good news. Therefore, if CIN is discovered, hysterectomy is not required as long as it is treated early.”

“However, endometrial carcinoma in situ cannot be removed like CIN. Because abnormal cells are present in the uterus, it is usually difficult to avoid hysterectomy. If the patient is young and wants to preserve fertility, oral progesterone drugs can be tried. Or then insert an intrauterine device (uterine ring) containing levonorgestrel (levonorgestrel) to make the endometrium thinner, and retest after a few months. Usually early stage carcinoma in situ of the endometrium can be cured.”

40% of endometriosis turns into cancer

In addition, gonadotropin-releasing hormone agonist (GnRHa) and endometrial ablation can also achieve the effect of thinning the endometrium, but the former can cause menopausal symptoms in women, while the latter can destroy The endometrium causes infertility.

In addition, patients with endometrial carcinoma in situ usually have excess fat, diabetes, high blood pressure, or high cholesterol, which are all risk factors for uterine cancer. Because fat cells themselves secrete estrogen, weight loss may be difficult for patients to achieve. If you choose non-surgical treatment, but the risk factors cannot be reduced, the chance of recurrence or cancer of uterine carcinoma in situ will still exist in the future, which may become more difficult.

He said that if cancer has been diagnosed, whether it is cervical cancer or uterine cancer, it is generally difficult to avoid hysterectomy. Nowadays, cancer also has a trend of getting younger. There used to be uterine cancer patients in their 30s. They always faced a dilemma. If they wanted to preserve the uterus, the treatment would use chemotherapy or radiotherapy, but there are still risks and side effects. If cancer cells are left in the body, the disease is likely to spread from Stage I to Stage III or IV, making treatment more challenging.

“Endometriosis is one of the most common benign diseases that requires removal of the uterus. It is very strange because it ‘behaves’ like cancer, often eroding the ureters, bladder or large intestine, causing severe adhesions.”

“Patients will experience pelvic pain, severe dysmenorrhea, painful intercourse, and even bleeding during urination or defecation. Although it is not cancer, about 20% to 40% of endometriosis will develop into ovarian cancer. The medical community has not yet truly understood The mechanism.”

“Drugs or GnRHa injections can only relieve the symptoms of endometriosis. If you want to cure it once and for all, you can only consider removing the uterus and ovaries. After all, hormonal secretion mainly comes from the ovaries, and patients can usually get real relief only after complete removal. “

Hemorrhage during childbirth may require hysterectomy

Other situations in which hysterectomy cannot be avoided include severe hemorrhagic collapse during childbirth, in which the bleeding cannot be stopped after taking various methods. Emergency surgery is required as a last resort, i.e., hysterectomy is required to save the mother’s life. This type of surgery is usually a subtotal hysterectomy, which involves removing only the uterus above the cervix, leaving the cervix intact. This is to minimize the physical and mental harm of the removal to the mother, because after all, it is an emergency life-saving operation.

He pointed out that from a medical perspective, losing the ovaries would not bring much benefit to the uterus. Because the “original factory” that produces estrogen has disappeared, a woman’s menstruation will also stop. In addition, the human body is very mysterious. No one can be sure whether the uterus remaining in the body will cause other problems in 10 or 20 years, such as causing discomfort or cancer.

Generally, both ovaries are removed, and the uterus is also routinely removed. If the patient wants to retain the uterus, the patient can also discuss it with the doctor. Usually the doctor will analyze the risks and consequences of retention and removal and respect the patient’s choice.

The arm feels like an insect bite

Minimally invasive wound, quick recovery

What factors determine whether a patient can choose minimally invasive or laparotomy to remove the uterus?

Dr. Cai Pengcheng, consultant in minimally invasive obstetrics and gynecology surgery, pointed out that this is a complex issue, many people have different opinions, and the medical community is often deadlocked. Why?

Patients who undergo traditional laparotomy surgery usually need to stay in the hospital for 3 to 7 days. When the surgical wound is relatively large, patients may also be afraid of getting out of bed and moving, which may increase the risk of deep vein thrombosis and pulmonary embolism.

The advantages of minimally invasive laparoscopic hysterectomy are small wounds, low risk of blood transfusion, and fast recovery. Even older or heavier patients can usually be discharged from the hospital in one or two days.

Minimal damage and good curative effect

In terms of methods, hysterectomy can be divided into three categories. The first is a traditional laparotomy, where a transverse or vertical incision is made in the lower abdomen. Vertical incision was a very early practice because at that time there was not much emphasis on scarring and recovery speed.

With the advancement of the times, even caesarean section will choose transverse incision (pfannenstiel incision), which is also the so-called “bikini line”.

The second category is minimally invasive surgery, in which doctors insert endoscopes and various tiny and delicate instruments into the body through tiny incisions to perform surgery. As the name suggests, minimally invasive surgery allows patients to get the maximum therapeutic effect with minimal harm. Although the incision of minimally invasive surgery is small, it can be “competent” for large and small surgeries, ranging from tumor to organ removal.

Natural entry through vagina

Dr. Cai Pengcheng, consultant of minimally invasive obstetrics and gynecology surgery, said that you can think of minimally invasive surgery as using ‘chopsticks’ to perform major surgery. It can be subdivided into multiple port laparoscopy, and single-port laparoscopy (single port laparoscopy) or transvaginal natural orifice endoscopic surgery (vNOTES).

He pointed out that traditional multiport laparoscopic surgery involves making several holes of one to two centimeters in size in the abdomen. Later, medicine evolved to allow surgery to be performed through just a single hole, usually in the belly button. Single-port surgery is also constantly improving. It is entered through the natural vaginal canal, and vNOTES, a minimally invasive surgery that does not require “drilling”, has been developed. This method only makes a small incision at the top of the vagina, so the patient’s abdomen will not be left with any scars.

He said that there are also robotic arm assisted surgeries. After hearing this, many people mistakenly thought it was a “robot” performing surgery and were frightened, but this was not the case. From start to finish, these robotic arms and instruments are controlled by computers by the surgical team.

Finally, the third major category of hysterectomy is the traditional vaginal resection method, which is suitable for the elderly, those with multiple parities, or those with uterine prolapse, and can be subdivided into pendulous and non-drug hysterectomies. The pendulous technique is mostly used when the uterus prolapses to the point where the vaginal entrance is visible. Generally, patients will need surgery due to the pulling of the uterus and pain when touching the lower body.

“The non-drooping method may require surgery because the patient is in the early stages of prolapse and causes discomfort. The non-drooping method is generally used for uterine prolapse, but the lowest point is at least half or more of the vaginal diameter from the vaginal entrance.”

Most instruments are disposable

He said that the advantages of minimally invasive laparoscopic hysterectomy include small wound (about 1 to 2 centimeters), low risk of blood transfusion, and fast recovery. Even older or heavier patients can usually be discharged from the hospital in one or two days.

Patients who undergo traditional laparotomy surgery usually need to stay in the hospital for 3 to 7 days. Patient confidence also improves due to smaller wounds. Just imagine being bitten by an insect on the arm. Most people will think it is a trivial matter; if there is a cut, they will be more worried. When the surgical wound is relatively large, patients may also be afraid of getting out of bed and moving, which may increase the risk of deep vein thrombosis and pulmonary embolism.

“Due to research and development costs and strict control, the cost of minimally invasive surgery is generally higher than that of traditional conventional surgery. However, the cost of laparotomy and minimally invasive laparoscopic uterine removal is actually only a few thousand ringgits apart.”

If a robotic arm is used, the cost will be higher, but Cai Pengcheng believes that as robotic arms gradually become more popular, the cost of treatment should decrease in the future.

He said that for skilled doctors, the time spent in minimally invasive surgery is not much different from that of laparotomy, except that the preoperative and postoperative preparations are more time-consuming. This is because most of the instruments used in minimally invasive surgery are disposable and need to be carried into the operating room or opened one by one. However, the advantage is that it is cleaner and sanitary, and there is no need to worry about cross-infection. However, it is also more expensive than traditional surgery. Surgery comes high.

“In addition, the risks of laparoscopy and laparotomy are similar, which mainly depends on the patient’s personal factors. If you have ‘three highs’, heart disease or respiratory disease, the risk of minimally invasive surgery is higher, otherwise there is generally not much difference. “

Stage I cervical cancer survival rate 90%

Taking cervical cancer as an example, patients with carcinoma in situ (stage zero) and stage I have a very low risk of cancer recurrence after the cervix is ​​removed. Some patients with early-stage cervical cancer who underwent minimally invasive surgery had a 5-year survival rate of 100%.

What factors determine whether a patient can choose minimally invasive or laparotomy to remove the uterus? Dr. Cai Pengcheng, consultant in minimally invasive obstetrics and gynecology surgery, pointed out that this is a complex issue, many people have different opinions, and the medical community is often deadlocked.

“Take cervical cancer as an example. Patients with carcinoma in situ (stage zero) and stage I have a very low risk of cancer recurrence after the cervix is ​​removed. Some studies in the United States believe that laparotomy to remove the cervix has a better survival rate; According to data from Linkou Chang Gung Memorial Hospital in Taiwan, the five-year survival rate for early-stage cervical cancer patients who undergo minimally invasive surgery is 100%.”

High risk for heart and lung problems

In any case, the medical community has not yet reached a definite conclusion, but the stage of the disease is an important consideration. For cervical cancer in stages II to IV, laparotomy is generally preferred. Because when cervical cancer gradually spreads, doctors need to remove the surrounding involved tissue.

When it comes to stage I uterine cancer, the curative effects of minimally invasive and laparotomy are similar, with the survival rate exceeding 90%. Patients with uterine cancer are often obese, and laparotomy surgery can sometimes be a challenge.

“Some time ago, I performed a multiport laparoscopic hysterectomy on a 60-year-old patient with uterine cancer. She was referred by my colleague because she weighed 130 kilograms. If the uterus was removed by laparotomy, it would cost money first. It takes a lot of effort to lift the fat layer, and when the fat layer is too thick, it is difficult for the doctor to see clearly.

Therefore, these patients are more suitable for minimally invasive surgery, because only a small camera needs to be inserted into the abdomen through the incision, and the surgery can be performed at a glance. “

In addition to the condition and stage, the ability to undergo minimally invasive surgery mostly depends on the patient’s personal circumstances.

He noted that people with heart or respiratory problems are less candidates for minimally invasive hysterectomies. Above the human body’s diaphragm are the heart and lungs, and below is the abdominal cavity. Typically, minimally invasive surgery involves injecting carbon dioxide into the abdomen to expand it so there is more room for operations. Be aware that carbon dioxide may also push the diaphragm upward, putting slight pressure on the heart or lungs. If the patient already has heart and lung problems, he or she will be further affected, so the risk is higher.

“In addition, patients who have undergone multiple laparotomy surgeries will face greater technical challenges in minimally invasive surgery. Whenever there is a wound, there is a risk of adhesion, which means that between the originally separated organs, due to the wound healing process The exuded fluid is connected together. Therefore, doctors need to be particularly careful when making holes. Sometimes the peritoneum is adherent to the intestines, bladder or uterus, or the belly becomes thicker, and there may be no place to start.”

“Usually doctors will recommend that such patients undergo laparotomy to remove the uterus. Although the risk of intra-abdominal organ damage caused by adhesion is similar to that of minimally invasive surgery, at least the incision is larger, and the doctor can directly ‘get his hands on’ to get the touch without having to worry about going through the small hole. Whether the ‘chopsticks’ are enough to solve the problem. In any case, this depends on the experience and skills of the individual doctor.”

He said that in Taiwan, the implementation rate of minimally invasive surgery has greatly surpassed laparotomy. However, this does not mean that the emergence of minimally invasive surgery is to replace laparotomy. We should have a consensus of ‘taking others’ strengths and making up for one’s own shortcomings’ . Although many doctors in our country are performing minimally invasive surgery, not many people understand its benefits. “

Hysterectomy improves sexual life of patients

Question 1: Will sexual life be affected after hysterectomy?

Answer 1: This is also an issue that many patients worry about but are too shy to talk about. Studies have found that within one or two years after hysterectomy, patients’ sex life improves, becomes more frequent, and becomes less painful during intercourse.

This is because the “source of the disease” is solved and the discomfort or pain is eliminated, so the willingness and quality of sexual life are improved.

Also, unless a patient gets a rare form of vaginal cancer, a hysterectomy will preserve the vagina. Even cervical cancer that is located quite close to the vagina will “retain” the vagina, so it will not have much impact on sexual life. The length of the vagina is about 7 to 10 centimeters. If uterine cancer spreads to the vagina, removal of 3 centimeters is usually enough. Otherwise, the entire vagina is rarely removed.

Unless the cancer unfortunately spreads throughout the vagina, it will be completely removed.

Removing the ovaries stops the production of estrogen

Question 2: Will people age faster after hysterectomy?

Answer 2: The impact of hysterectomy alone is not significant, it is mainly related to the ovaries. The ovaries are where estrogen is produced. After removing the ovaries, women will directly enter a state of menopause, which increases the risk of brain degeneration, heart disease, stroke and osteoporosis. Therefore, patients need to start hormone supplementation (hormone replacement therapy) in the long term.

If possible, a hysterectomy can preserve the ovaries. The advantage is that the ovaries can still produce estrogen, and there is no need to take additional hormonal drugs. The disadvantage is that when the uterus is removed, many connected blood vessels will be blocked, affecting the blood supply to the ovaries. Therefore, the ovaries will degenerate prematurely.

For example, Malaysian women generally stop menstruating at the age of 51. If a patient has a hysterectomy at the age of 40, she will undergo degeneration 3 to 5 years earlier. Therefore, her ovarian function will stop at about the age of 45, which means that the production of hormones will completely stop and the woman will experience menopause.

In summary, the effects of physical aging depend on whether the ovaries are removed. If conditions permit, doctors usually recommend preserving the ovaries. However, again, no one can predict whether patients will need another surgery in the future due to ovarian tumors or other problems.

Tumor retrieval bag “power crushing”

Question 3: The incision of minimally invasive surgery is so small, how to remove the tumor from the uterus?

Answer 3: In this case, the tissue is cut into small pieces using a tissue morcellation machine or manually, and then taken out of the body through the vagina or laparoscopic hole. The process can be performed in a closed or non-closed system.

The doctor can implant the specimen bag or endobag into the abdominal cavity through an incision of 1 cm and 2 mm, open the bag and put the tumor or tissue into it. The isolated tumor will be “dynamically crushed” and finally removed. The bag is removed from the body through the incision together, and the surgical site will be very clean.

Answer◇Dr. Cai Pengcheng, consultant in minimally invasive surgery for obstetrics and gynecology

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