Hysterectomy is one of the most common surgeries around the world and is indicated for both benign and malignant conditions. A simple hysterectomy typically involves removal of the uterus and cervix and is performed for benign reasons such as uterine fibroids, as well as for certain early-stage cervical and endometrial malignancies5. A radical hysterectomy entails excision of surrounding structures such as the parametrium, upper vagina, and bilateral pelvic lymph nodes4. Radical hysterectomy is typically performed for more advanced gynecological malignancies5. Due to the differences in complexity, duration, extent of surgical trauma and postoperative pain, there are different anesthesia considerations for simple and radical hysterectomy.
Preoperatively, patients requiring radical hysterectomy may present with more risk factors for anesthesia compared to those needing simple hysterectomy3. For example, 89% of patients with ovarian cancer present with ascites, or malignant fluid in the abdomen that makes them difficult to ventilate; if this fluid accumulates too rapidly, it can be a contraindication for surgery altogether3. Ascites can further cause abnormal shifts in fluid volume, leading to patients being prone to intravascular dehydration but also fluid overload, and swelling in the abdomen, legs, and lungs3. Fluid management in surgery is thus complicated by balancing the need for volume repletion while attempting to avoid volume overload3. Furthermore, patients who have had significant weight loss related to their condition may benefit from optimizing their nutrition preoperatively, which may require a feeding tube or parenteral nutrition3.
Radical hysterectomies are also associated with a higher risk of deep vein thrombosis, or blood clots in the leg3. This is partially due to increased surgical length and complexity, and partially due to the patient’s underlying malignancy3. However, the risk of bleeding during and after surgery is also higher due to the potential for abnormal vascularity with malignant tumors3. Thus, balancing the risks and benefits of anticoagulation can be an important consideration in these patients, as well as preparing blood products prior to surgery3.
Radical hysterectomy is associated with more severe postoperative pain when compared with simple hysterectomy, requiring more potent anesthesia for pain control3. Thus, along with the standardly administered morphine and the transverse abdominis nerve block, additional perioperative pain control agents may be administered such as gabapentin or low thoracic epidural3. Interestingly, epidural anesthesia and analgesia may help to decrease the stress of surgery and preserve immunity; one retrospective study looking at patients with a subtype of ovarian cancer who underwent surgery found that patients who received epidural anesthesia and analgesia had better three-year and five-year outcomes when compared with patients who had general anesthesia with IV analgesia2. While general anesthesia is the standard of care for hysterectomy in the US, combining general anesthesia and epidural anesthesia has been similarly shown to mitigate surgical stress in non-gynecological caners, and thus might be a consideration for use in gynecological cancer surgery and radical hysterectomy1.
Overall, radical hysterectomy is associated with greater surgical and anesthesia challenges compared to simple hysterectomy but can be life-prolonging and life-saving for patients. Pain control, fluid management, thromboembolic prophylaxis, and the ability to adequately ventilate during surgery are a few important considerations for anesthesiologists when devising an anesthetic plan for patients undergoing radical hysterectomy.
References
- Hou, B.-J., et al. (2019). “General anesthesia combined with epidural anesthesia maintaining appropriate anesthesia depth may protect excessive production of inflammatory cytokines and stress hormones in colon cancer patients during and after surgery.” Medicine 98(30): e16610. doi: DOI: 10.1097/MD.0000000000016610
- Lin L, Liu C, Tan H, Ouyang H, Zhang Y, Zeng W. (2011) “Anaesthetic technique may affect prognosis for ovarian serous adenocarcinoma: a retrospective analysis”. Br J Anaesth 106: 814–22. doi: https://doi.org/10.1093/bja/aer055
- Powell L, Garfield JM. (1990). “Anesthetic considerations for gynecologic cancer surgery.” Semin Surg Oncol 6(3):194-8. doi: 10.1002/ssu.2980060312. PMID: 2189200.
- https://www.moffitt.org/treatments/surgical-care/radical-hysterectomy-for-gynecological-cancers/
- https://www.cancer.gov/news-events/cancer-currents-blog/2024/cervical-cancer-simple-hysterectomy