Irradiation after surgery to remove the uterus. Methods for the treatment of uterine cancer in the early and late stages of development. Where can recurrence occur?

Content

In modern gynecology, the issues of treatment of malignant tumors, including uterine cancer, are topical. He constantly searches for and implements effective methods that would significantly extend the life of patients. One of these methods is radiation therapy. Operations in various volumes are actively used.

Cancer of the uterus or endometrium is a tumor of a malignant nature, which is localized in the internal cavity. According to statistics, it occupies a leading position in terms of prevalence, second only to breast cancer.

Uterine cancer is usually detected in women after menopause. However, today there is a rejuvenation of many malignant neoplasms. Endometrial cancer has also become increasingly common in younger patients.

The uterus is an unpaired organ that belongs to the reproductive system. For many, the uterus is, first of all, an organ that performs a reproductive function. The uterus is also a kind of symbol of the feminine.

The uterus is small in size, which depends on whether the woman had childbirth or not. The average size of the uterus is:

• thickness up to 3 cm;
• length 8 cm.

The uterus includes:

• body;
• neck.

The structure of the uterine body is heterogeneous. The wall of the uterus consists of the following layers:

• endometrium;
• myometrium;
• parameters.

The parametrium is a serous membrane that covers the outside of the uterus. The myometrium is also called the muscular layer. It allows the uterus to stretch and expand during pregnancy. Due to the contraction of the uterus, childbirth is carried out and the endometrium is rejected during menstruation.

The endometrium is the inner layer or lining of the uterus. The endometrium is represented by:

• functional surface layer;
• basal growth layer.

The functional layer during the cycle changes under the influence of female sex steroids. In particular, by the middle of the cycle, it grows, thus preparing for the upcoming pregnancy. If pregnancy does not occur in a particular cycle, under the influence of other sex hormones, the endometrium is rejected and excreted from the body in the form of bloody menstrual flow. The mucous layer is restored due to the basal component of the endometrium, which is practically unchanged.

For the adequate functioning of the reproductive system, the correct ratio of sex hormones is extremely important. With hormonal fluctuations and various disorders, the ratio of sex steroids changes. This leads to functional and then structural changes.

Often there is an overgrowth of the endometrium. This condition is dangerous because when several negative factors are combined, malignancy of the inner layer of the uterus can occur, which is called cancer.

Causes and negative factors

It is known that uterine cancer is based on hyperplastic processes leading to excessive growth of the endometrium. Hyperplasia is observed in the case of a hormone-dependent type of cancer, which is caused by excessive production of estrogens.

Factors that can provoke a hormone-dependent type of uterine cancer:

• elderly age;
• PCOS and other ovarian pathologies;
• obesity;
• infertility;
• the presence of one birth in history;
• difficulties with conception;
• late onset of the extinction of hormonal function;
• HRT during menopause;
• long-term use of Tamoxifen;
• liver pathology.

In women with hyperestrogenism, the following symptoms are observed:

• anovulation;
• violation of the cycle;
• acyclic bleeding;
• an increase in the duration and amount of menstrual flow.

In a small number of cases, uterine cancer is caused by non-hormonal causes. This uterine cancer is autonomous in nature and occurs in women with low body weight. The prognosis for autonomous uterine cancer is less favorable than for the hormone-dependent form.

Experts consider different hypotheses as the causes of uterine cancer. In particular, some scientists are of the opinion that pathology is hereditary. The genetic theory of uterine cancer is currently being developed.

Smoking reduces the risk of uterine cancer due to early menopause. Nevertheless, smoking contributes to the development of a malignant tumor of another localization.

Symptoms

Uterine cancer has no characteristic symptoms. In addition, in the early stages, the disease does not have a clinical picture. It is possible to identify a dangerous pathology only if you undergo an examination and exclude other diseases.

Usually, signs appear with advanced forms of uterine cancer and include:

• leucorrhea of ​​a watery nature;
• pathological discharge when an infection is attached;
• discharge of the color of meat slops with an unpleasant odor, indicating the decay of the tumor;
• pyometra;
• stenosis of the cervical part of the uterus;
• compression of the neoplasm of the bladder and rectum, which is manifested by painful frequent urination and defecation, constipation, blood in the urine and feces;
• edema;
• pains of varying intensity, which are localized in the lower abdomen, sacrum, lower back and rectum;
• discomfort and discharge during intercourse.

The symptoms of uterine cancer should be especially attentive to women after menopause. If bleeding occurs after a long absence, you should immediately consult a doctor.

Forms and stages

It is known that uterine cancer can be both hormone-dependent and autonomous. In addition, a malignant tumor is differentiated depending on the tissue that forms it:

• adenocarcinoma;
• squamous variety;
• glandular-squamous form.

The determination of the degree of cell differentiation has a significant impact on the choice of treatment tactics and on the prognosis in general.

• Highly differentiated tumors grow slowly and rarely form metastases. Such cancer is successfully treated and has a good prognosis.
• Moderately differentiated neoplasms occur in most cases. The appearance of metastases is typical for stages 3-4.
• Low differentiated formations are the worst option. This type of uterine cancer progresses rapidly and metastasizes early. The course and prognosis are unfavorable.

Tumors of the uterus have a different direction of growth:

• into the uterine cavity - exophytic;
• in the thickness of the uterine wall - endophytic;
• mixed.

There are also rare types of uterine cancer, for example, clear cell.

The severity of uterine cancer is determined by four stages.

1. Damage to the endometrium. A - a tumor within the inner layer of the uterus. B - the neoplasm grows up to half of the myometrium. C - malignant cells germinate to the serous cover.
2. Cervical involvement. A - coverage of the cervical glands by the pathological process. B - damage to the tissue of the cervical canal.
3. Spread of uterine cancer outside the uterus. A - germination in the serous membrane, ovaries. B - the appearance of metastases in the vagina. C - the occurrence of malignant cells in the lymph nodes.
4. Damage to surrounding and distant organs. A - Involvement of the bladder or bowel. B - the formation of distant metastases.

The prognosis and treatment depends on the diagnosed stage. The earlier treatment is started, the higher the chances of its success.

Diagnostic methods

Detection of uterine cancer is a difficult task. This is largely due to the lack of a clinical picture at an early stage. In order to detect endometrial cancer in gynecology, several main methods are used.

Cytological examination

A special syringe is inserted into the uterine cavity and its contents are taken. The biological material is then examined under a microscope to detect cancerous elements.

The method has significant errors. In particular, in the early stages of the oncological process, such an aspiration biopsy can give false-negative results. In the later stages, the reliability is more than 90%. Nevertheless, it is not possible to obtain complete information about the nature of the malignant neoplasm.

Gynecological examination

Inspection by palpation is informative in advanced forms of the disease. The doctor determines the enlarged painful uterus, probes the infiltrates.

ultrasound

Ultrasound examination is an inexpensive and informative method in the diagnosis of cancer. Using the transvaginal and abdominal method of research, it is possible to identify neoplasms, assess the condition of the organs of the reproductive system. Doppler ultrasound detects changes in blood flow during the development of cancer.

Hysteroscopy and biopsy

The study is carried out by introducing a hysteroscope into the uterine cavity, which transmits the image to the screen. In the process of manipulation, the doctor performs a biopsy, and then carries out curettage. The material obtained in this way is examined histologically in the laboratory.

Hormonal examination

Since tumors in uterine cancer can be both autonomous and hormone-dependent, it is necessary to determine their type. To detect sensitivity to hormonal treatment, it is necessary to perform an immunochemical analysis.

Detection of distant metastases performed using chest X-ray, CT and MRI.

Treatment

Therapy is prescribed based on the results of the diagnosis and depends on the severity of the oncological process, the prevalence of malignant cells and the individual characteristics of the patient.

For the treatment of uterine cancer are used:

• operations;
• radiation therapy;
• chemotherapy.

Treatment tactics can be used both in combination and as an independent method of therapy.

Operation

This is one of the main ways to treat cancer. The volume of operations depends on the stage of the cancer process.

1. subtotal hysterectomy. Treatment is used in the early stages of cancer. The operation involves the amputation of the uterine body with the preservation of the tubes.
2. Total hysterectomy or extirpation. Surgeons perform removal of the uterine body along with appendages, cervix, regional lymph nodes, and surrounding tissues. In some cases, part of the vagina is removed.
3. Ablation of the endometrium. The operation is suitable for the treatment of pre-invasive and micro-invasive cancer. The inner layer and part of the myometrium is removed, which excludes the possibility of a subsequent pregnancy.

Surgery is often combined with other treatments, such as radiation therapy and chemotherapy.

Radiation therapy

Irradiation or radiation therapy, like surgery, is the main treatment. Often, radiation therapy is used after surgery to destroy the remnants of malignant cells.

In some cases, radiation therapy is given before surgery. Radiation therapy helps shrink the tumor and reduces the amount of surgery. It is possible to use radiation therapy as an independent treatment tactic. Radiation therapy is considered to be a more gentle treatment than surgery.

Radiation therapy can be used at any stage of the cancer process. If you use radiation therapy after surgery, you can reduce the risk of metastases.

There are contraindications to radiation therapy:

• anemia;
• thrombocytopenia;
• radiation sickness;
• bleeding due to disintegration of the formation;
• increased body temperature;
• heart attack;
• diabetes;
• tuberculosis;
• liver pathology;
• kidney failure;
• leukopenia;
• multiple metastases;
• advanced cancer.

Radiation therapy can be carried out:

• contact;
• remotely.

With contact radiation therapy, internal exposure occurs by inserting a catheter into the vagina. Such radiation therapy does not have a significant effect on healthy surrounding tissues.

External beam or external beam radiation therapy is delivered through unaffected tissue. This radiation therapy is prescribed for deep lesions. The disadvantages of external beam radiation therapy include the harmful effects on healthy tissues.

With an advanced form of cancer, combined radiation therapy is possible when both contact and remote treatment methods are used. After radiation therapy, nausea and vomiting, diarrhea, weakness, skin flushing, and baldness of the pubic area may occur.

Chemotherapy

The treatment can be used both before and after surgery. When chemotherapy is used before surgery, it is possible to achieve a reduction in the size of the tumor and slow its progression.

As the main treatment, chemotherapy is prescribed in the second to fourth stages. If chemotherapy is used after surgery, metastases can be prevented. Typically, treatment tactics are used in conjunction with surgery and radiation therapy.

If the cancer is hormone-dependent, chemotherapy and hormonal treatment are used.

After the treatment, which includes surgery, chemotherapy, hormonal and radiation therapy, it is necessary to pay close attention to good nutrition and foods that have an anti-cancer effect. These foods include vegetables, herbs, cereals, legumes and fruits. Smoked meats, semi-finished products, canned foods should be excluded from the diet.

Which is found mainly in 40-60-year-old ladies.

In fact, the uterus is an organ with walls of three layers: epithelial, muscular and connective tissue. In the uterus, a malignant oncoprocess develops on the walls, and in the absence of proper therapy, it passes to other organic structures.

This multi-layered uterus explains the presence of many different types of tumors, caused by localization.

Can uterine cancer be cured?

Of all oncological pathologies, uterine cancer is the second most common after malignant oncology.

Approximately 20-40 women out of 100 thousand suffer from oncopathology of this organ.

Unfortunately, in recent years, cases of uterine cancer have begun to occur in younger women, which gynecologists attribute to the early onset of regular sexual relations among today's youth.

Timely access to specialists at an early stage of development of uterine oncoformations in combination with an adequate therapeutic approach can completely save a woman from the disease without further consequences and relapses.

If oncology is detected in the later stages, then it will not be possible to cure the cancer completely, however, following all the oncologist's prescriptions and undergoing the prescribed procedures will help to significantly extend the patient's life.

In general, experts assure that uterine cancer is successfully treatable, and about 90% of patients after surgery live for another 5 years or more. Therefore, today the diagnosis of uterine cancer should not be treated as a death sentence.

Methods for the treatment of uterine cancer in the early and late stages

The choice of a therapeutic approach is determined by the stage and extent of the tumor process, the rate of its spread and the depth of germination into tissue structures.

In addition, age and general health, future pregnancy planning and other factors are very important.

Anti-cancer treatment is usually based on:

1. Surgical intervention;
2. Methodology;

These techniques are fundamental, and as additional methods are:

• Hormonal treatment;
• diet therapy, etc.

Each of the methods is unique and effective in its own way, therefore, it requires a more detailed study.

Surgery

Surgical intervention for uterine cancer is justified only at the initial stages of the development of the pathological process.

In general, there are several surgical methods of treatment:

1. laser treatment. The essence of the technique is to influence the area of ​​the uterus affected by the tumor process with a beam of laser beams. For such an intervention, local anesthesia is sufficient, however, the procedure is effective only in precancerous or very early stages of the uterine oncological process;
2. Cryodestruction. Such a procedure involves treating the tumor with liquid nitrogen, under the influence of which malignant abnormal cellular structures die. The technique is also effective only at the stage of incipient uterine cancer;
3. Extraction of the uterus and appendages. The procedure involves the removal of an organ and is carried out if the prognosis for oncology is favorable. If there are any risk factors, then the patient undergoes an extended hysterectomy, in which, in addition to the uterus and appendages, the tubes, cervix, lymph nodes and fiber, part of the vagina are removed;
4. Endoscopic hysterectomy allows for removal without large tissue incisions, which significantly reduces the invasiveness of the method, minimizes the likelihood of postoperative complications, and reduces the duration of rehabilitation;
5. Hysteroresectoscopic ablation. This is an organ-preserving surgical technique that involves cutting off the endometrial layer along with the tumor. A similar method is applicable with a low prevalence of the tumor process.

Most often, surgical treatment is the main therapeutic method of oncology of the uterine body.

Refusal of such treatment is appropriate only if there is no risk of further progression of the oncological process or if there is a high probability of death on the operating table or after the intervention.

Radiation therapy

If the uterine cancer process is actively progressing, surgical treatment is ineffective. In such cases, radiation therapy is taken as the basis of treatment, which is considered more gentle than surgical treatment.

Such treatment is used at any stage of the oncological process. In addition, radiation therapy for uterine cancer is indicated in the postoperative period in order to prevent metastasis of abnormally malignant cell structures.

Radiation therapy is contraindicated in women with uterine cancer if:

• anemia;
• radiation sickness;
• thrombocytopenia;
• The collapse of the tumor, which led to bleeding;
• fever;
• Concomitant pathological conditions such as tuberculosis, diabetes, liver or kidney failure, etc .;
• Leukopenia;
• plural character;
• Final grades of malignant lesions, etc.

Various radiotherapy techniques can be used: contact, remote or combined.

Contact radiotherapy involves internal exposure, when a catheter that emits radio waves is inserted into the vagina. With this treatment option, the surrounding healthy tissue is least exposed to the harmful effects of radiation.

With remote (or external) radiation therapy, the irradiation procedure is carried out through tissues that are not affected by cancer, usually this technique is used if the lesion is of a deep nature. A serious disadvantage of such treatment is damage to healthy areas during the treatment.

If uterine cancer is neglected and treatment is started already at the later stages of the oncological process, then combined radiotherapy is used, that is, contact and remote irradiation methods are used.

Among the adverse reactions of such therapy, the appearance of a nausea-vomiting syndrome, weakness, diarrhea, hyperemia and peeling of the skin surface, pubic baldness, etc.

Chemotherapy for endometrial tumors

The main goal of chemotherapy treatment is to reduce tumor parameters and slow down its further growth as much as possible in the future.

Typically, this technique is chosen as the main therapy for stage 2, 3 and 4 cancer.

Chemotherapy is not always taken as the basis of anticancer treatment; it is often combined with other methods in order to increase the survival of patients.

Usually, chemotherapy is used after surgery to prevent possible metastasis and recurrence of the oncological process.

The most commonly used chemotherapy drugs are:

Chemotherapy is used mainly when the use of other drugs does not provide the desired results, which is caused by a considerable number of adverse reactions of anticancer drugs such as:

1. Osteoporosis. A similar reaction usually occurs as a result of taking drugs like, or Cyclophosphamide and is a rarefaction and weakness of the bones;
2. Alopecia. Usually, after chemotherapy sessions, partial hair loss is observed, however, baldness can be more widespread. When the use of antitumor agents ends, the hairline begins to recover;
3. Anemic signs and excessive weakness of a permanent nature;
4. Nausea-vomiting syndrome, diarrhea- such manifestations occur due to violations of the activity of the digestive tract, however, after treatment, all signs disappear;
5. infectious processes- chemotherapeutic effects have a detrimental effect on the immune defense, depriving it of resistance to viruses and infectious agents.

If the oncoprocess has developed to stage 4, then the effectiveness of chemotherapy does not exceed 9%, since the lesions are rapidly spreading to the pelvic organs.

How to treat with hormone therapy?

Hormonal anti-cancer treatment consists of taking drugs containing antiestrogen and progestin. Such treatment is effective in cases where the tumor contains progesterone receptors.

If such receptors are absent, then chemotherapy treatment will be most effective.

Immunotherapy

At the initial stages of the oncoprocess in the uterus, it can be prescribed using drugs based on interferon.

This substance, in addition to the strongest effect, also has antitumor properties.

The drugs administered to the patient activate the protective organic forces and direct their power to resist the tumor process.

Also, medicines of biological origin, such as monoclonal antibodies or cytokines, are introduced into the body, which block the system that feeds the formation.

When the tumor stops growing, the malignant cancer process is also blocked. Such treatment absolutely does not cause adverse reactions and does not harm healthy tissues.

Diet

The basis of the nutrition of patients with uterine cancer is products endowed with anti-cancer effects:

• Potato;
• Cabbage of all varieties;
• Greens, spices;
• Sprouted cereal dishes or whole grains;
• Asparagus;
• Peas;
• Beet;
• Beans;
• Carrot;
• Fresh fruits.

The above products must be consumed fresh or cooked in a double boiler. And it is recommended to change the meat to fish. You also need to eat sour-milk low-fat products. It is strictly forbidden: alcohol and strong tea, smoked meats, pickles and marinades, chocolate, semi-finished products, fast food, etc.

Prevention

To detect the cancerous process of the uterine body, in its infancy, is possible only with systematic gynecological preventive medical examinations and regular visits to the gynecologist.

After the start of regular sexual relations, a woman needs to visit an antenatal clinic every year. Only with an annual gynecological examination, vaginal smear studies, ultrasound examination of the pelvic organs, it will be possible to timely detect the presence of precancerous processes.

Their timely therapy will avoid the formation of a malignant tumor.

Video about laparoscopic treatment of uterine cancer:

Radiation therapy after removal of the uterus with appendages is prescribed if the malignant process has not stopped. This method is more gentle for the body, and it can be used at different stages of the development of female diseases. The decision on the need to use this therapy is made by the attending physician or even a council, and only after a thorough diagnosis.

Types of exposure

Radiation therapy is used to deliver a dose of radiation to points in the body where there is suspicion of possible metastases. This type of postoperative treatment allows the destruction of malignant cells while maintaining the viability of intact tissues. The method can be used both independently and in combination with other methods of treatment.

Irradiation is prescribed in such cases:

• if the tumor begins to spread to regional lymph nodes;
• with stage 1-2 cancer, when tumor cells remain after the operation to remove the uterus;
• during the period of palliative care;
• when a woman underwent surgery due to stage 4 cancer, but it did not bring the desired result.

This method gives the highest efficiency in combination with chemotherapy. But this approach is used infrequently, as it is a strong blow to the body.

There are several types of radiation:

The main task of irradiation is the destruction of damaged tissues, as well as the activation of regenerative processes in the body. But while this treatment will last, it is important for a woman to follow all the doctor's prescriptions, including adhering to the developed diet.

Preparation for the procedure

Radiation therapy may be prescribed if tumor cells remain in the body, other abnormal structures in the structure of cells that can lead to relapse.

After the operation, the woman will have to retake tests:

• biopsy;
• general analysis of blood and urine;
• smear;
• examination for the presence of inflammation in the body.

The results will allow you to identify the presence of cancer cells and track how the body is recovering.

If the surgical operation did not bring the expected result, then irradiation is prescribed. Preparation for it includes:

The procedure itself takes no more than half an hour. The woman enters a special room, where she has to undress and put on special protective pads for the body. All the time while the equipment is working, the patient will be on the couch.

Effects

The uterus with appendages is part of the endocrine system. Therefore, after their removal, hormonal failure occurs. In younger patients, menopause may occur earlier.

At first, a woman may experience the following symptoms:

• causeless mood swings;
• increased fatigue, even without physical activity;
• in more severe cases, depression.

After the operation, not only the reproductive function is lost, but menstruation also stops.

There is also a decrease in libido, and pain may occur during intercourse. You should tell your doctor about the last two conditions.

As for radiation therapy, it can have the following consequences:

All these states are kept only in the first sessions and should gradually pass.

To reduce the risk of complications, it is recommended to pay a lot of attention to rest - get enough sleep, take walks, adjust your diet so that a sufficient amount of minerals and vitamins enters the body. For the healing of wounds on the mucous membranes, the patient is prescribed special plant-based ointments. At first, a woman should refrain from taking a hot bath, visiting saunas, pools and baths, otherwise irritation can be provoked.

Recovery period

It is important to start treatment immediately after surgery. The patient is prescribed painkillers, special vaginal suppositories and droppers, hormone replacement therapy.

An important factor is the age of the patient, because the older the body, the more time and effort it will take to fully return to normal. During the rehabilitation period, it is worth paying attention to such points:

Some patients are prescribed a visit to a psychologist, especially if the surgery took place in a young woman. These sessions will help restore peace of mind and eliminate signs of stress or depression.

In many ways, recovery depends on how clearly a woman will follow the instructions of her doctor. The body is weakened not only by the operation, because it is stressful for him, but also by the full course of radiation therapy.

Successful rehabilitation requires:

• after the end of each procedure, give yourself a rest for at least 3 hours;
• carry out daily treatment of the vagina with prescribed drugs;
• avoid thermal procedures - overheating in the sun, hot baths, saunas, etc.;
• do not skip examinations;
• control your diet
• during the period of radiation therapy, do not use perfumes for intimate hygiene;
• walk a lot and do physical exercises;
• if there are no contraindications, include phytotherapy in the course of rehabilitation.

The success of recovery largely depends on the stage of the disease at which radiation therapy was started. All these recommendations will help you quickly bounce back and restore health.

In gynecology, in the treatment of uterine bleeding in recent years, various conservative methods of influencing the uterus have been used, for example, hysteroscopic removal of the myomatous node and endometrial ablation, thermal ablation of the endometrium, and hormonal suppression of bleeding. However, they are often ineffective. In this regard, the operation to remove the uterus (hysterectomy), performed both on a planned and emergency basis, remains one of the most common abdominal interventions and ranks second after appendectomy.

The frequency of this operation in the total number of gynecological surgical interventions on the abdominal cavity is 25-38% with an average age of operated women for gynecological diseases of 40.5 years and for obstetric complications - 35 years. Unfortunately, instead of trying conservative treatment, there is a tendency among many gynecologists to recommend removal of the uterus to a woman with fibroids after 40 years, citing the fact that her reproductive function has already been realized and the organ no longer performs any function.

Indications for removal of the uterus

Hysterectomy indications are:

• Multiple uterine fibroids or a single size of more than 12 weeks with a tendency to rapid growth, accompanied by repeated, profuse, prolonged uterine bleeding.
• The presence of fibroids in women over 50 years of age. Although they are not prone to malignancy, cancer develops much more often against their background. Therefore, the removal of the uterus after 50 years, according to many authors, is desirable in order to prevent the development of cancer. However, such an operation at approximately this age is almost always associated with subsequent pronounced psycho-emotional and vegetative-vascular disorders as a manifestation of post-hysterectomy syndrome.
• Necrosis of the myomatous node.
• with a high risk of pedunculated torsion.
• growing into the myometrium.
• Widespread polyposis and constant profuse menstruation, complicated by anemia.
• and 3-4 degrees.
• , or ovaries and related radiation therapy. Most often, the removal of the uterus and ovaries after 60 years is carried out precisely for cancer. In this age period, the operation contributes to a more pronounced development of osteoporosis and a more severe course of somatic pathology.
• Omission of the uterus of 3-4 degrees or its complete prolapse.
• Chronic pelvic pain, not amenable to therapy by other methods.
• Uterine rupture during pregnancy and childbirth, placenta accreta, development of consumption coagulopathy during childbirth, purulent.
• Uncompensated hypotension of the uterus during childbirth or in the immediate postpartum period, accompanied by profuse bleeding.
• Sex change.

Despite the fact that the technical performance of hysterectomy has been improved in many respects, this method of treatment still remains technically complex and is characterized by frequent complications during and after the operation. Complications are damage to the intestines, bladder, ureters, the formation of extensive hematomas in the parametric region, bleeding, and others.

In addition, the consequences of hysterectomy for the body are not uncommon, such as:

• long-term recovery of bowel function after surgery;
• development (menopause after removal of the uterus) - the most common negative consequence;
• development or more severe course of endocrine and metabolic and immune disorders, coronary heart disease, hypertension, neuropsychiatric disorders, osteoporosis.

In this regard, an individual approach in choosing the volume and type of surgical intervention is of great importance.

Types and methods of removal of the uterus

Depending on the volume of the operation, the following types are distinguished:

1. Subtotal, or amputation - removal of the uterus without appendages or with them, but with the preservation of the cervix.
2. Total, or extirpation of the uterus - removal of the body and cervix with or without appendages.
3. Panhysterectomy - removal of the uterus and ovaries with fallopian tubes.
4. Radical - panhysterectomy combined with resection of the upper 1/3 of the vagina, with the removal of part of the omentum, as well as the surrounding pelvic tissue and regional lymph nodes.

Currently, abdominal surgery to remove the uterus is carried out, depending on the access option, in the following ways:

• abdominal, or laparotomic (median incision of the tissues of the anterior abdominal wall from the umbilical to the suprapubic region or a transverse incision above the womb);
• vaginal (removal of the uterus through the vagina);
• laparoscopic (through punctures);
• combined.

Laparotomy (a) and laparoscopic (b) access options for surgery to remove the uterus

Abdominal access

Used most often and for a very long time. It is about 65% when performing operations of this type, in Sweden - 95%, in the USA - 70%, in the UK - 95%. The main advantage of the method is the possibility of performing surgical intervention under any conditions - both in planned and in case of emergency surgery, as well as in the presence of another (extragenital) pathology.

At the same time, the laparotomy method also has a large number of disadvantages. The main ones are a serious injury directly to the operation itself, a long stay in the hospital after the operation (up to 1 - 2 weeks), long-term rehabilitation and unsatisfactory cosmetic consequences.

The postoperative period, both immediate and long-term, is also characterized by a high frequency of complications:

• long physical and psychological recovery after removal of the uterus;
• adhesive disease develops more often;
• bowel function is restored for a long time and the lower abdomen hurts;
• high, compared with other types of access, the likelihood of infection and elevated temperature;

Mortality with laparotomy access per 10,000 operations averages 6.7-8.6 people.

Vaginal removal

It is another traditional access used when removing the uterus. It is carried out by means of a small radial dissection of the vaginal mucosa in its upper sections (at the level of the arches) - posterior and, possibly, anterior colpotomy.

The undeniable advantages of this access are:

• significantly less trauma and the number of complications during surgery, compared with the abdominal method;
• minimal blood loss;
• short duration of pain and better health after surgery;
• rapid activation of a woman and rapid restoration of bowel function;
• short period of stay in the hospital (3-5 days);
• a good cosmetic result, due to the absence of an incision in the skin of the anterior abdominal wall, which allows a woman to hide the fact of surgical intervention from her partner.

The terms of the rehabilitation period with the vaginal method are much shorter. In addition, the frequency of complications in the immediate and their absence in the late postoperative periods is low, and mortality is on average 3 times less than with abdominal access.

At the same time, vaginal hysterectomy also has a number of significant disadvantages:

• the lack of a sufficient area of ​​the surgical field for visual revision of the abdominal cavity and manipulations, which greatly complicates the complete removal of the uterus in endometriosis and cancer, due to the technical difficulty of detecting endometrioid foci and tumor boundaries;
• high risk of intraoperative complications in terms of injury to blood vessels, bladder and rectum;
• difficulty in stopping bleeding;
• the presence of relative contraindications, which include, in addition to endometriosis and cancer, a significant size of the tumor-like formation and previous operations on the abdominal organs, especially on the organs of the lower floor, which can lead to changes in the anatomical location of the pelvic organs;
• technical difficulties associated with lowering the uterus in obesity, adhesions and nulliparous women.

Due to such limitations, in Russia, vaginal access is used mainly in operations for omission or prolapse of an organ, as well as in case of a sex change.

Laparoscopic access

In recent years, it has become increasingly popular for any gynecological operations in the small pelvis, including hysterectomy. Its benefits are largely identical to the vaginal access. These include a low degree of trauma with a satisfactory cosmetic effect, the possibility of dissecting adhesions under visual control, a short recovery period in a hospital (no more than 5 days), a low incidence of complications in the immediate and their absence in the long-term postoperative period.

However, the risks of such intraoperative complications as the possibility of damage to the ureters and bladder, blood vessels and large intestine remain. The disadvantage is the limitations associated with the oncological process and the large size of the tumor formation, as well as extragenital pathology in the form of even compensated heart and respiratory failure.

Combined or assisted vaginal hysterectomy

It consists in the simultaneous use of vaginal and laparoscopic accesses. The method allows to eliminate the important disadvantages of each of these two methods and to perform surgical intervention in women with the presence of:

• endometriosis;
• adhesions in the pelvis;
• pathological processes in the fallopian tubes and ovaries;
• myoma nodes of considerable size;
• in the anamnesis of surgical interventions on the abdominal organs, especially the small pelvis;
• difficulty bringing down the uterus, including nulliparous women.

The main relative contraindications that force preference for laparotomy access are:

1. Common foci of endometriosis, especially retrocervical with germination in the wall of the rectum.
2. Pronounced adhesive process, causing difficulties in dissection of adhesions when using a laparoscopic technique.
3. Volumetric formations of the ovaries, the malignant nature of which cannot be reliably excluded.

Preparing for the operation

The preparatory period for a planned surgical intervention consists in conducting possible examinations at the prehospital stage - clinical and biochemical blood tests, urinalysis, coagulogram, determination of the blood group and Rh factor, tests for the presence of antibodies to hepatitis viruses and sexually transmitted infectious agents, including including syphilis and HIV infection, ultrasound, chest fluorography and ECG, bacteriological and cytological examination of smears from the genital tract, extended colposcopy.

In the hospital, if necessary, additionally carried out with a separate, repeated ultrasound, MRI, sigmoidoscopy and other studies.

1-2 weeks before the operation, if there is a risk of complications in the form of thrombosis and thromboembolism (varicose veins, pulmonary and cardiovascular diseases, overweight, etc.), a consultation of specialized specialists and the administration of appropriate drugs, as well as rheological agents and antiplatelet agents.

In addition, in order to prevent or reduce the severity of symptoms of post-hysterectomy syndrome, which develops after removal of the uterus in an average of 90% of women under 60 years of age (mostly) and has varying degrees of severity, surgery is planned for the first phase of the menstrual cycle (if any) .

1-2 weeks before the removal of the uterus, psychotherapeutic procedures are carried out in the form of 5-6 conversations with a psychotherapist or psychologist, aimed at reducing the feeling of uncertainty, uncertainty and fear of the operation and its consequences. Phytotherapeutic, homeopathic and other sedatives are prescribed, concomitant gynecological pathology is treated, and it is recommended to stop smoking and taking alcoholic beverages.

These measures can significantly facilitate the course of the postoperative period and reduce the severity of psychosomatic and vegetative manifestations provoked by the operation.

In the hospital on the evening before the operation, food should be excluded, only liquids are allowed - loosely brewed tea and still water. In the evening, a laxative and a cleansing enema are prescribed, before going to bed - a sedative. On the morning of the operation, it is forbidden to take any liquid, the intake of any drugs is canceled and the cleansing enema is repeated.

Before the operation, compression tights, stockings are put on or the lower extremities are bandaged with elastic bandages, which remain until the woman is fully activated after the operation. This is necessary in order to improve the outflow of venous blood from the veins of the lower extremities and prevent thrombophlebitis and thromboembolism.

Equally important is the provision of adequate anesthesia during the operation. The choice of the type of anesthesia is carried out by the anesthesiologist, depending on the expected volume of the operation, its duration, concomitant diseases, the possibility of bleeding, etc., as well as in agreement with the operating surgeon and taking into account the wishes of the patient.

Anesthesia during removal of the uterus can be general endotracheal combined with the use of muscle relaxants, as well as its combination (at the discretion of the anesthesiologist) with epidural analgesia. In addition, it is possible to use epidural anesthesia (without general anesthesia) in combination with intravenous medical sedation. Insertion of a catheter into the epidural space can be prolonged and used for postoperative analgesia and faster recovery of bowel function.

The principle of the operation technique

Preference is given to laparoscopic or assisted vaginal subtotal or total hysterectomy with preservation of the appendages on at least one side (if possible), which, among other advantages, helps to reduce the severity of post-hysterectomy syndrome.

How is the operation going?

Surgical intervention with combined access consists of 3 stages - two laparoscopic and vaginal.

The first stage is:

• introduction into the abdominal cavity (after gas insufflation into it) through small incisions of manipulators and a laparoscope containing a lighting system and a video camera;
• carrying out laparoscopic diagnostics;
• separation of existing adhesions and isolation of the ureters, if necessary;
• the imposition of ligatures and the intersection of round uterine ligaments;
• mobilization (isolation) of the bladder;
• the imposition of ligatures and the intersection of the fallopian tubes and own ligaments of the uterus or in the removal of the ovaries and fallopian tubes.

The second stage consists of:

• dissection of the anterior wall of the vagina;
• intersection of the vesicouterine ligaments after displacement of the bladder;
• an incision in the mucous membrane of the posterior wall of the vagina and the imposition of hemostatic sutures on it and on the peritoneum;
• the imposition of ligatures on the sacro-uterine and cardinal ligaments, as well as on the vessels of the uterus, followed by the intersection of these structures;
• removing the uterus to the wound area and cutting it off or dividing it into fragments (with a large volume) and removing them.
• suturing on the stump and on the mucous membrane of the vagina.

At the third stage, laparoscopic control is again carried out, during which small bleeding vessels (if any) are ligated and the pelvic cavity is drained.

How long does a uterus removal surgery take?

It depends on the access method, the type of hysterectomy and the extent of the surgical intervention, the presence of adhesions, the size of the uterus, and many other factors. But the average duration of the entire operation is usually 1-3 hours.

The main technical principles of hysterectomy for laparotomy and laparoscopic approaches are the same. The main difference is that in the first case, the uterus with or without appendages is removed through an incision in the abdominal wall, and in the second case, the uterus is divided into fragments in the abdominal cavity using an electromechanical instrument (morcellator), which are then removed through a laparoscopic tube (tube). ).

rehabilitation period

Moderate and slight spotting after removal of the uterus is possible for no more than 2 weeks. In order to prevent infectious complications, antibiotics are prescribed.

In the first days after surgery, bowel dysfunction almost always develops, mainly associated with pain and low physical activity. Therefore, the fight against pain is of great importance, especially in the first day. For this purpose, injectable non-narcotic analgesics are regularly administered. Prolonged epidural analgesia has a good analgesic and intestinal motility-improving effect.

In the first 1-1.5 days, physiotherapeutic procedures, physiotherapy exercises and early activation of women are carried out - by the end of the first or at the beginning of the second day they are recommended to get out of bed and move around the department. 3-4 hours after the operation, in the absence of nausea and vomiting, it is allowed to drink non-carbonated water and "weak" tea in a small amount, and from the second day - to eat.

The diet should include easily digestible foods and dishes - soups with chopped vegetables and grated cereals, dairy products, boiled low-fat varieties of fish and meat. Foods and dishes rich in fiber, fatty fish and meat (pork, lamb), flour and confectionery products, including rye bread (wheat bread is allowed on the 3rd - 4th day in limited quantities), chocolate are excluded. From the 5th - 6th day, the 15th (general) table is allowed.

One of the negative consequences of any operation on the abdominal cavity is the adhesive process. It most often proceeds without any clinical manifestations, but sometimes it can cause serious complications. The main pathological symptoms of adhesion formation after hysterectomy are chronic pelvic pain and, more seriously, adhesive disease.

The latter can occur in the form of chronic or acute adhesive intestinal obstruction due to impaired passage of feces through the large intestine. In the first case, it is manifested by periodic cramping pains, gas retention and frequent constipation, moderate bloating. This condition can be resolved conservatively, but often requires surgical treatment in a planned manner.

Acute intestinal obstruction is accompanied by cramping pain and bloating, lack of stool and flatus, nausea and repeated vomiting, dehydration, tachycardia and, first, an increase and then a decrease in blood pressure, a decrease in the amount of urine, etc. In acute adhesive intestinal obstruction, its urgent resolution is necessary through surgical treatment and intensive care. Surgical treatment consists in dissection of adhesions and, often, in resection of the intestine.

Due to the weakening of the muscles of the anterior abdominal wall after any surgical intervention on the abdominal cavity, the use of a special gynecological bandage is recommended.

How long to wear a bandage after removal of the uterus?

Wearing a bandage at a young age is necessary for 2-3 weeks, and after 45-50 years and with poorly developed abdominal muscles - up to 2 months.

It contributes to faster healing of wounds, reducing pain, improving bowel function, and reducing the likelihood of hernia formation. The bandage is used only in the daytime, and in the future - with long walking or moderate physical exertion.

Since the anatomical location of the pelvic organs changes after the operation, and the tone and elasticity of the pelvic floor muscles are lost, consequences such as prolapse of the pelvic organs are possible. This leads to constant constipation, urinary incontinence, deterioration of sexual life, vaginal prolapse and also to the development of adhesions.

In order to prevent these phenomena, it is recommended to strengthen and increase the tone of the muscles of the pelvic floor. You can feel them by stopping the started urination or the act of defecation, or by trying to squeeze the finger inserted into the vagina with its walls. The exercises are based on a similar contraction of the pelvic floor muscles for 5-30 seconds, followed by relaxation for the same duration. Each of the exercises is repeated in 3 sets of 10 times each.

A set of exercises is performed in different starting positions:

1. The legs are set shoulder-width apart, and the hands are on the buttocks, as if supporting the latter.
2. In the kneeling position, tilt the body to the floor and put the head on the arms bent at the elbows.
3. Lie on your stomach, put your head on bent arms and bend one leg at the knee joint.
4. Lie on your back, bend your legs at the knee joints and spread your knees to the sides so that the heels rest on the floor. Put one hand under the buttock, the other - on the lower abdomen. While compressing the pelvic floor muscles, pull the arms up a little.
5. Position - sitting on the floor with crossed legs.
6. Put your feet slightly wider than your shoulders and rest your knees with straightened arms. The back is straight.

The muscles of the pelvic floor in all starting positions are compressed inward and upward with their subsequent relaxation.

Sex life after hysterectomy

In the first two months, abstinence from sexual intercourse is recommended to avoid infection and other postoperative complications. At the same time, regardless of them, removal of the uterus, especially at reproductive age, in itself very often causes a significant decrease in the quality of life due to the development of hormonal, metabolic, psychoneurotic, vegetative and vascular disorders. They are interconnected, exacerbate each other and are reflected directly in the sexual life, which, in turn, increases the degree of their severity.

The frequency of these disorders especially depends on the volume of the operation performed and, last but not least, on the quality of the preparation for it, the management of the postoperative period and treatment in a longer period. Anxiety-depressive syndrome, which proceeds in stages, was noted in every third woman who underwent hysterectomy. The terms of its maximum manifestation are the early postoperative period, the next 3 months after it and 12 months after the operation.

Removal of the uterus, especially total with unilateral, and even more so with bilateral removal of the appendages, as well as carried out in the second phase of the menstrual cycle, leads to a significant and rapid decrease in the content of progesterone and estradiol in the blood in more than 65% of women. The most pronounced disorders of the synthesis and secretion of sex hormones are detected by the seventh day after the operation. The restoration of these disorders, if at least one ovary was preserved, is noted only after 3 or more months.

In addition, due to hormonal disorders, not only libido decreases, but many women (every 4-6th) develop atrophy processes in the vaginal mucosa, which leads to their dryness and urogenital disorders. It also adversely affects sexual life.

What drugs should be taken to reduce the severity of negative consequences and improve the quality of life?

Given the staging nature of the disorders, it is advisable to use sedative and antipsychotic drugs, antidepressants in the first six months. In the future, their reception should be continued, but in intermittent courses.

With a preventive purpose, they must be prescribed during the most likely periods of the year of exacerbations of the course of the pathological process - in autumn and spring. In addition, in order to prevent manifestations or reduce the severity of post-hysterectomy syndrome, in many cases, especially after hysterectomy with the ovaries, it is necessary to use hormone replacement therapy.

All drugs, their dosages and duration of treatment courses should be determined only by a doctor of the appropriate profile (gynecologist, psychotherapist, therapist) or together with other specialists.

The impact on the tumor of ionizing rays allows you to achieve a positive effect, since the tumor cells are quite sensitive. For healthy cells, radiation therapy, even after removal of the uterus with appendages, practically does not cause damage. This is the most sparing method, unlike surgery, which is carried out today everywhere and the consequences are minimal. Radiation therapy after removal of the uterus is by far one of the most effective.

Irradiation is often carried out in combination with chemotherapy and is indicated for use at any stage of the development of the oncological process. The method of radiation therapy can be prescribed after the removal of the uterus and appendage. While surgery may be completely ineffective.

Radiation hysterectomy is just basically carried out after surgery in order to eliminate the remaining, other abnormal structures in the structure of cells in uterine cancer in women. The method of radiation therapy is based on a therapeutic effect, despite the training with ionizing rays, the harm from which is insignificant. Although this exposure is contraindicated if women have:

• radiation sickness;
• thrombocytopenia;
• feverish state;
• tumor breakdown;
• severe bleeding against the background of the collapse of the tumor;
• myocardial infarction;
• tuberculosis;
• diabetes mellitus;
• hepatic, renal failure;
• stage 4 cancer;
• anemia;
• multiple metastases.

How Radiation is Performed

Radiation is usually assigned:

• at 1-2 stages of cancer after surgery to remove the uterus;
• when the tumor spreads to regional lymph nodes;
• at the time of palliative care;
• at 4 stages of cancer, if the operation did not bring significant results;
• in order to prevent recurrence.

Types of radiation therapy

It is possible to carry out remote, intracavitary, contact or internal radiation therapy.

1. Remote therapy is carried out by exposure of the rays to the lesion, but at a certain distance from the skin without contact with it.
2. Intracavitary therapy is carried out in order to destroy the tumor, for which a special device is inserted into the uterine cavity.
3. Contact therapy is carried out by contact of a radioactive drug with the skin. Before the procedure, the doctor will tell you in detail about this technique and what a woman may feel at the time of the procedure.
4. Internal therapy consists in the introduction of initially defined drugs into the uterine cavity, followed by the supply of ionizing rays in order to suppress a malignant tumor.

The main goal of therapy is to maximize the effect on the site of the lesion, to reduce the recovery period for the body. When irradiation is performed, it is important for women:

• normalize nutrition;
• walk more in the fresh air;
• comply with all doctor's instructions.

How to prepare

Preparatory procedures for radiological treatment are:

• referring the patient to an MRI to clarify the location of the tumor;
• doctor prescribing the necessary doses for irradiation, taking into account the results of the tests.

The duration of the procedure is no more than 35 minutes. It is held in a specially designated room in compliance with all technological requirements for safety purposes. Women are invited to lie down on the couch, to remain motionless at the moment of bringing the ionization source.

Nothing should prevent the free penetration of x-rays. For convenience and separation from the site of injury, healthy areas of the body are covered with protective material.

What are the consequences after exposure?

Many patients after radiation therapy complain of the following consequences:

• nausea, vomiting;
• severe intoxication of the body;
• indigestion;
• stool disorder;
• signs of dyspepsia;
• the appearance of burning and itching on the integument of the skin in part;
• dryness in the vaginal mucosa and on the genitals.

Doctors say that such consequences take place and recommend that women somehow survive this period, pay more attention to rest, do what they love. It is important to get enough sleep and gain strength after the course of radiotherapy. In addition, at home, you need to treat the affected area with herbal preparations to avoid burns at the time of treatment. At the same time, do not use cosmetics and perfumes until the wounds are completely healed after the operation.

Possible consequences in the form of allergic reactions after the procedure. Therefore, you should not take thermal hot baths during the week. From visiting the bath, sauna is better to give up for a while.

What is the forecast

After removal of the uterus with appendages, a woman, of course, will have to forget about childbearing, but radiation therapy at an early 1-2 stage of cancer gives quite positive forecasts. Perhaps even a complete healing from the supply of radio waves and carrying out in stages up to 5 sessions.

But, unfortunately, it is no longer possible to stop the uterine tumor process at stages 3-4. All such efforts can be directed only to remove unpleasant in patients, to stabilize the growth of a malignant tumor.

After the treatment process, in order to quickly survive the consequences of radiation exposure to the body, women are shown sanatorium treatment during the rehabilitation period, as well as a course of massage, physiotherapy, balneotherapy, acupuncture, radon baths.

If radiation is carried out and serious complications arise, then, most likely, a disability group will be assigned if the operation has led to a significant loss of working capacity.

In addition, it will be possible to begin sexual activity no earlier than 8 weeks after radiation therapy. Still, at first, women need to take care, gain strength, heal the wounds left in the postoperative period. Although doctors say that radiation therapy after removal of the uterus, along with appendages, the operation does not affect the sexuality and psychological activity of a woman.

Having sex is not at all contraindicated, but first it is advisable to visit a gynecologist for an examination, which will tell you when you can start having sex and how long you need to wait for wounds and scars to heal.

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