Ultra-Radical Surgery for Ovarian Cancer

Why might ultra-radical surgery be needed?

Ovarian cancer can spread across the lining of the abdomen and onto or around other organs.

For some women with advanced ovarian cancer, standard surgery alone may not be sufficient to remove all visible disease.

Cytoreductive surgery, also known as debulking surgery, aims to remove as much visible cancer as possible. When the cancer involves several areas of the abdomen or requires surgery involving additional organs, the operation may be described as ultra-radical or maximal-effort cytoreductive surgery.

The aim is to achieve complete cytoreduction, meaning no visible cancer remains at the end of surgery, where this can be achieved safely.

The extent of surgery is carefully considered because more extensive surgery also carries greater risks.

What organs may be involved?

The exact procedures vary from patient to patient.

Depending on where the cancer has spread, ultra-radical surgery may involve treatment of:

• The bowel
• The peritoneum, which is the lining of the abdominal cavity
• The diaphragm
• The spleen
• The liver or its surface
• The gallbladder
• The appendix
• The pancreas
• The stomach or surrounding tissues
• Lymph nodes
• Other areas of the abdomen or pelvis affected by cancer.

You may therefore hear your operation described as involving several different procedures rather than one single operation.

Specialist teams from other surgical disciplines may be involved when required, including colorectal, hepatobiliary or upper gastrointestinal surgeons.

Bowel surgery

Ovarian cancer can grow onto or into the bowel.

If this happens, it may be necessary to remove a section of affected bowel to achieve complete or optimal removal of the cancer.

The healthy ends of the bowel may then be joined together. This is called an anastomosis.

Sometimes it is safer not to reconnect the bowel immediately. In these circumstances, the bowel may be brought through the abdominal wall to create a stoma.

A stoma may be temporary or permanent, depending on the circumstances and the type and location of bowel surgery required.

If there is a possibility that bowel surgery or a stoma will be required, this should be discussed with you before your operation.

What is a stoma?

A stoma is an opening created through the abdominal wall so that bowel contents can leave the body into a specially designed bag.

Having a stoma can initially feel daunting, but specialist stoma nurses provide advice and practical support before and after surgery.

Whether a stoma can subsequently be reversed depends on the type of bowel surgery you have had and how safely the bowel can be reconnected.

Surgery involving the diaphragm

The diaphragm is a large muscle separating the chest from the abdomen.

Ovarian cancer can spread onto the surface of the diaphragm.

If this happens, the surgeon may remove affected areas of tissue from the diaphragm or carefully strip the involved surface to remove cancer.

In some circumstances, more extensive diaphragm surgery may be required.

Your surgical team will monitor you carefully afterwards because surgery in this area can affect the lungs and breathing.

Surgery involving the spleen

The spleen is situated in the upper left side of the abdomen and plays an important role in the immune system.

If ovarian cancer has spread to the spleen or surrounding tissues, removing the spleen may sometimes be necessary to achieve complete removal of visible disease.

This is called a splenectomy.

If your spleen is removed, you will need appropriate vaccinations and may need antibiotic protection because your risk of certain serious infections is increased.

Your specialist team will explain the precautions you need to take following splenectomy.

Surgery involving the liver

Cancer can sometimes involve the surface of the liver or, less commonly, deeper liver tissue.

Depending on the location and extent of disease, the surgeon may remove cancer from the surface of the liver or perform a more extensive liver procedure.

The exact approach depends on whether the cancer can be safely removed and whether doing so would contribute to achieving complete cytoreduction.

Where specialist liver surgery is required, a hepatobiliary surgeon may be involved in your operation.

Peritoneal surgery

The peritoneum is the thin membrane lining the abdominal cavity and covering many of the abdominal organs.

Ovarian cancer frequently spreads across the peritoneal surfaces.

The surgeon may therefore need to remove areas of affected peritoneum. This can involve a procedure called a peritonectomy.

The extent of peritoneal surgery depends on how widely the cancer has spread.

Removal of the appendix or gallbladder

If cancer has spread to or around the appendix or gallbladder, these organs may occasionally need to be removed as part of the overall cytoreductive procedure.

These decisions are made according to the location of the cancer and the aim of removing all visible disease.

Is ultra-radical surgery always possible?

No.

Although the aim may be to remove all visible cancer, this cannot always be achieved safely.

The full extent of the disease may also only become clear once surgery has started.

NICE recognises that the extent of ovarian cancer may not be completely apparent before surgery and that maximal cytoreductive surgery may not always be possible.

If removing every area of cancer would cause unacceptable harm, your surgeon may decide that further extensive surgery would not be in your best interests.

The priority is to balance cancer control with your safety and quality of life.

How is the decision made?

Your treatment should be discussed by a specialist gynaecological oncology multidisciplinary team (MDT).

The team may consider:

• Your type of ovarian cancer
• The stage of your cancer
• Where the cancer has spread
• Your CT or other imaging
• Your response to chemotherapy
• Your general health and fitness
• Your nutritional status
• Previous surgery
• Whether complete cytoreduction appears achievable
• The complexity and risks of the proposed operation
• Your own wishes and priorities.

For patients being considered for maximal-effort cytoreductive surgery, NICE highlights the importance of detailed pre-operative assessment and appropriate postoperative facilities, including access to intensive care where required.

Surgery before or after chemotherapy

There are different ways in which surgery and chemotherapy can be combined.

Some patients are suitable for primary cytoreductive surgery, where surgery is performed first and chemotherapy follows.

For others, chemotherapy is given first. This is called neoadjuvant chemotherapy.

If the cancer responds appropriately, surgery can then be performed. This is known as interval cytoreductive surgery or interval debulking surgery.

Further chemotherapy is usually given following surgery.

The appropriate sequence depends on the individual cancer and the patient's overall health and fitness.

What happens during ultra-radical surgery?

Ultra-radical ovarian cancer surgery is usually performed under a general anaesthetic.

Because the surgeon may need to examine and treat several areas of the abdomen, the operation is generally performed through an abdominal incision.

The surgeon carefully assesses the distribution of the cancer and removes visible tumour wherever this can be done safely.

Depending on your individual circumstances, this may involve:

• Hysterectomy
• Removal of both ovaries and fallopian tubes
• Removal of the omentum
• Removal of affected peritoneum
• Bowel resection
• Diaphragm surgery
• Spleen removal
• Liver surgery
• Removal of affected lymph nodes
• Appendix removal
• Other procedures required to remove tumour deposits.

Not every patient will require all of these procedures.

How long does the operation take?

Ultra-radical surgery is considerably more extensive than routine gynaecological surgery and can take many hours.

The length of the operation depends on:

• The amount of cancer present
• Where the cancer is located
• The number of organs or structures involved
• Whether bowel surgery is required
• Whether upper abdominal surgery is required
• Whether additional surgical specialists need to be involved.

Your surgeon will discuss the expected extent of your operation before surgery.

What are the benefits?

The principal aim of ultra-radical surgery is to remove as much visible cancer as possible and, where safely achievable, to leave no visible residual disease.

Complete removal of visible cancer is an important goal in advanced ovarian cancer surgery and is associated with better outcomes.

However, it is important to understand that the potential benefit has to be balanced against the increased complexity and risks of extensive surgery.

Ultra-radical surgery is therefore not automatically the best option for every patient. The decision is individualised according to whether the cancer can be removed safely and whether the potential benefits justify the risks.

What are the risks?

Because ultra-radical surgery may involve several organs, it carries a higher risk of complications than less extensive operations.

Possible complications include:

• Bleeding and the need for a blood transfusion
• Infection
• Blood clots in the legs or lungs
• Chest infection or breathing difficulties
• Injury to the bowel, bladder or ureters
• Bowel leakage following bowel surgery
• Abdominal infection or sepsis
• Bowel obstruction
• Wound infection or breakdown
• Formation of a fistula
• Kidney problems
• Complications affecting the liver, spleen or pancreas
• Problems related to a stoma
• Fluid collections within the abdomen
• Need for further surgery
• Prolonged hospital admission
• Intensive care treatment
• Rarely, life-threatening complications.

NICE specifically recognises that maximal cytoreductive surgery is extensive surgery associated with significant complications, including a risk of death.

Your individual risk will depend on your health, the extent of the cancer and the procedures required.

What is a bowel leak?

If a section of bowel is removed and the remaining bowel is joined together, there is a risk that the join may leak.

A bowel leak can cause serious infection within the abdomen and may require antibiotics, drainage procedures or further surgery.

Your surgical team will monitor you closely for signs of this complication following surgery.

What is a fistula?

A fistula is an abnormal connection between two organs or between an organ and the skin.

Fistulas can occasionally occur following complex abdominal surgery, particularly when surgery involves the bowel or urinary tract.

If you develop symptoms such as unusual discharge, persistent abdominal pain, fever or changes in bowel or urinary function, you should contact your medical team promptly.

What should I expect after surgery?

Recovery from ultra-radical surgery is likely to take longer than recovery from a straightforward gynaecological operation.

You may initially require close monitoring in a high-dependency or intensive care environment.

Your recovery will focus on:

• Pain control
• Preventing blood clots
• Monitoring your heart, lungs and kidney function
• Monitoring bowel function
• Maintaining nutrition and hydration
• Managing drains and wounds
• Encouraging gradual mobilisation
• Identifying complications early
• Preparing you for further cancer treatment.

Your hospital stay will depend on the extent of your surgery and how quickly you recover.

Getting your strength back

It is normal to feel tired and weak after major cancer surgery.

Your body needs time to recover, particularly if you have also received chemotherapy.

Nutrition, gentle physical activity and gradually increasing your daily activities are important parts of recovery.

You may be referred to physiotherapy, dietetics or other members of the specialist team to help you regain strength.

A period of prehabilitation before surgery may also be recommended where there is time to improve fitness, nutrition and overall readiness for a major operation. NICE has highlighted the potential value of prehabilitation for people undergoing maximal cytoreductive surgery.

When should I seek medical advice?

After major surgery, you should contact your medical team urgently if you develop:

• A high temperature or chills
• Increasing or severe abdominal pain
• Persistent vomiting
• Increasing abdominal swelling
• Difficulty breathing or chest pain
• Heavy vaginal or wound bleeding
• Redness, swelling or discharge from your wound
• Foul-smelling discharge
• Difficulty passing urine
• Severe diarrhoea or constipation
• No bowel function when you have been advised to expect it
• Sudden swelling or pain in a leg
• Any other symptoms that concern you.

If you feel seriously unwell, seek urgent medical attention.

Will I need further chemotherapy?

Surgery is usually only one part of treatment for advanced ovarian cancer.

Depending on your treatment pathway, chemotherapy may be given before surgery, after surgery or both.

Your final pathology results will also help your oncology team determine the most appropriate next steps.

Your treatment plan will be discussed by your multidisciplinary team and may include further chemotherapy or other systemic treatments where appropriate.

What happens to the tissue removed?

Any tissue or organs removed during surgery are sent to a specialist pathology laboratory.

The pathologist examines the tissue under a microscope to determine:

• The type of cancer
• Where cancer is present
• How extensively it has spread
• Whether the surgical margins are clear where relevant
• The response of the cancer to previous chemotherapy where applicable.

These results help your oncology team understand your cancer more fully and plan any further treatment.

What does complete cytoreduction mean?

You may hear your surgeon use the term complete cytoreduction.

This means that, at the end of surgery, there is no visible cancer remaining.

This is an important surgical goal in advanced ovarian cancer.

However, even when no visible cancer remains, microscopic cancer cells may still be present. This is why surgery is generally combined with other cancer treatments such as chemotherapy.

Does ultra-radical surgery mean my cancer is more advanced?

Ultra-radical surgery is generally considered when ovarian cancer has spread extensively within the abdomen or pelvis and removing it requires more complex procedures.

However, the term describes the extent and complexity of the surgery, rather than being a separate stage or type of ovarian cancer.

Your cancer stage and prognosis depend on your individual diagnosis, pathology and pattern of spread.

Is ultra-radical surgery suitable for everyone?

No.

This is a major operation and careful selection is essential.

The potential benefits need to be weighed against the risks of extensive surgery.

For some patients, surgery may offer an important opportunity to remove extensive disease. For others, chemotherapy or other systemic treatment may be more appropriate, particularly if the cancer cannot be safely removed or the risks of surgery are too high.

Your specialist team will explain the alternatives and help you understand why a particular approach has been recommended.

Specialist ultra-radical ovarian cancer surgery

Ultra-radical surgery requires considerable surgical expertise and close collaboration between different specialist teams.

Depending on the procedures required, a gynaecological oncologist may work alongside colorectal, hepatobiliary, upper gastrointestinal, urological and other surgical specialists.

This multidisciplinary approach allows the team to plan complex surgery around the distribution of your cancer and to provide appropriate support before, during and after your operation.

Mr Jafaru Abu has a specialist interest in gynaecological oncology and complex ovarian cancer surgery, including surgery for advanced ovarian cancer.

At Gynae Solution, the focus is on carefully assessing each patient's cancer and health, explaining the available treatment options clearly and developing an individualised treatment plan.

Your recovery and ongoing care

Recovering from ultra-radical surgery is a process rather than a single event.

You will continue to be supported by your specialist team as you recover and move on to the next stage of your cancer treatment.

Your follow-up may include:

• Review of your surgical recovery
• Pathology results
• Further chemotherapy or other treatment where appropriate
• Imaging and blood tests
• Monitoring for recurrence
• Management of any longer-term effects of surgery
• Support with nutrition, activity and wellbeing.

If you have had bowel surgery, a stoma or removal of an organ such as the spleen, you will also receive specific advice and follow-up relating to that procedure.

A personalised approach to advanced ovarian cancer

Ultra-radical surgery is one of the most extensive forms of surgery used in the treatment of advanced ovarian cancer.

Its purpose is not simply to perform more surgery. The aim is to remove as much visible cancer as possible when this can be achieved safely and is likely to provide meaningful benefit.

Every patient's cancer is different.

Your specialist team will consider your scans, response to treatment, general health, the location of your cancer and the likely benefits and risks before recommending surgery.

At Gynae Solution, we believe you should have the information you need to make informed decisions about your care, with your treatment explained in clear and understandable language.

Arrange a specialist consultation

If you have been diagnosed with advanced ovarian cancer and have been advised that extensive or ultra-radical surgery may be required, a specialist consultation can provide an opportunity to discuss your diagnosis, proposed surgery and treatment options.

We can help you understand what the surgery may involve, why particular procedures may be necessary and what you can expect during your recovery.

Patient leaflets

Written for patients, relatives and hospital personnel, to read before your operation and to keep afterwards.

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Related services

• Ovarian cancer
• Debulking, advanced ovarian cancer surgery
• ICRS and HIPEC
• Lymphadenectomy
• Ovarian cysts
• Gynaecological ultrasounds

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