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Surgery is the main treatment for most ovarian cancers. How much surgery you have depends on how far your cancer has spread and on your general health. For women of childbearing age who have certain kinds of tumors and whose cancer is in the earliest stage, it may be possible to treat the disease without removing both ovaries and the uterus.

Surgery for epithelial ovarian cancer

For epithelial ovarian cancer, surgery has 2 main goals: staging and debulking. If your cancer isn’t properly staged and debulked, you may need to have more surgery later, so it’s important that this surgery is done by a specialist who’s trained and experienced in ovarian cancer surgery, like a gynecologic oncologist.

Staging epithelial ovarian cancer

The first goal of ovarian cancer surgery is to stage the cancer ? to see how far the cancer has spread from the ovary. Usually this means removing the uterus (this operation is called a hysterectomy), along with both ovaries and fallopian tubes (this is called a bilateral salpingo-oophorectomy or BSO). In addition, the omentum is also removed (an omentectomy). The omentum is a layer of fatty tissue that covers the abdominal contents like an apron, and ovarian cancer sometimes spreads to this area. Some lymph nodes in the pelvis and abdomen might also be biopsied (taken out to see if the cancer has spread from the ovary).

If there is fluid in the pelvis or abdominal cavity, it will be removed for testing. The surgeon may "wash" the abdominal cavity with salt water (saline) and send that fluid to the lab for testing. Biopsies may also be taken from different areas inside the abdomen and pelvis. All the tissue and fluid samples taken during the operation are sent to a lab to look for cancer cells. Staging is very important because ovarian cancers at different stages are treated differently. If the staging isn't done correctly, the doctor may not be able to decide on the best treatment.

Debulking epithelial ovarian cancer

The other important goal of ovarian cancer surgery is to remove as much of the tumor as possible ? this is called debulking. Debulking is very important when ovarian cancer has already spread throughout the abdomen (belly) at the time of surgery. The aim of debulking surgery is to leave behind no visible cancer or no tumors larger than 1 cm (less than 1/2 an inch). This is called optimally debulked. Patients whose tumors have been optimally debulked, have a better outlook (prognosis) than those left with larger tumors after surgery (called sub-optimally debulked).

In some cases, other organs might be affected by debulking:

• Sometimes the surgeon will need to remove a piece of colon to debulk the cancer properly. In some cases, a piece of colon is removed and then the 2 ends that remain are sewn back together. In other cases, though, the ends can’t be sewn back together right away. Instead, the top end of the colon is attached to an opening (stoma) in the skin of the abdomen to allow body wastes to get out. This is known as a colostomy. Most often, this is only temporary, and the ends of the colon can be reattached later in another operation. For more information, see Colostomy Guide.
• Sometimes, a part of the small intestine may need to be removed. Just like with the colon, the small intestine can either be reconnected (which is most common) or an ileostomy might be made. This is usually temporary, but will need special care, so ask your doctor if this is a possibility before having surgery. See Ileostomy Guide to learn more.
• Debulking surgery might also mean removing a piece of the bladder. If this happens, a catheter (to empty the bladder) will be placed during surgery. This will be left in place until the bladder recovers enough to be able to empty on its own. Then, the catheter can be removed.
• Debulking might also require removing the spleen and/or the gallbladder, as well as part of the stomach, liver, and/or pancreas.

If both ovaries and/or the uterus are removed, you will not be able to become pregnant. It also means that you will go into menopause if you haven’t done so already. Most women will stay in the hospital for 3 to 7 days after the operation and can resume their usual activities within 4 to 6 weeks.

Intraoperative imaging

To know where the ovarian cancer is in your body to remove it, the surgeon typically uses the imaging tests done before surgery as well as a bright light and feeling for the tumors during the operation. Still, some tumors that are not easily seen or felt by hand might be missed. To help find these tumors, intraoperative imaging might be used.

This approach uses a special imaging system in the operating room during the surgery. A fluorescent drug called pafolacianine (Cytalux) will be injected into your blood a few hours before surgery. The drug travels through the body and attaches to a specific protein found on ovarian cancer cells. During surgery, the imaging system gives off near-infrared fluorescent light that will cause the drug to light up so the surgeon can see which areas need to be removed.

The most common side effects from pafolacianine (Cytalux) are belly pain, heartburn, itching, chest pain, nausea, vomiting, and flushing.

Your doctor will probably ask you to avoid taking any supplements that have folic acid in them for a few days before the procedure so they don’t disturb the test.

Surgery for ovarian germ cell tumors and ovarian stromal tumors

For germ cell tumors and stromal tumors, the main goal of surgery is to remove the cancer.

Most ovarian germ cell tumors are treated with a hysterectomy and bilateral salpingo-oophorectomy. If the cancer is in only one ovary and you still want to be able to have children, only the ovary containing the cancer and the fallopian tube on the same side are removed (leaving behind the other ovary and fallopian tube and the uterus).

Ovarian stromal tumors are often confined to just one ovary, so surgery may just remove that ovary. If the cancer has spread, more tissue may need to be removed. This could mean a hysterectomy and bilateral salpingo-oophorectomy and even debulking surgery.

Sometimes, after child bearing is finished, surgery to remove the other ovary, the other fallopian tube, and the uterus may be recommended, for both germ cell and stromal ovarian tumors.