Friday, March 22, 2013

Surgery for Vaginal Cancer

My surgeon is a friendly, short Syrian who is constantly moving at an almost-run. He is very busy, but he always stops to talk if I flag him down in the hall. He answers his cell phone often, sometimes it is a patient who needs comforting, sometimes it is his boss asking where he is, they need to meet with another patient. But he always takes the time, even when he can't. The only time he doesn't answer his phone is when he's in the operating room.

His English is touched by both a Syrian and a German accent and all the things he says sound lyrical like Arabic at the same time as they are truncated like German.

"This might be, a little bit, not the most comfortable thing."

At first he and the head of the department gave me a dual examination and took more biopsies, to make sure it was not cervical cancer that had spread to the vaginal wall - much more common.

"If this is only a vaginal carcinom, it is like a skin cancer, we remove the cells and it is good."

"Yes, I see you after Monday, on Thursday - no? - Tuesday, yes Tuesday."

After the results came back again as vaginal carcinoma, nothing on the cervix, we made a plan for surgery. He said that it would be important to do it soon and he hoped that it would only be surgery. But there was the chance that I would need some adjuvant radiation afterwards.

"Normally, the surgery would be radical hysterectomy and the cervix and vagina would be removed... But you are so young."

"With an older patient, over 50 or 60, after menopause, we do radical hysterectomy."

"Also, the lymph nodes. I will do this laparoscopically and take about four-uh-fifteen lymph nodes from each side. It is possible to have some edema, this is pooling of fluid, in the legs, but maybe not. Maybe it is painful or maybe you are okay."

He had some other surprises in store. Sentinal node testing, where radioactive isotopes are injected directly into the tumor. A few hours later, they take some images to see if the isotopes have moved into the lymph nodes. If yes, the cancer has linked into the lymph system. If no, maybe it's still stationary.

"Before, we do a Nuklearmedizin to see if there is a movement to the lymph system. This is Monday. Then on Thursday - no, Tuesday you must have a colonoscopy to see if there is any irregularities in the colon. I am sorry, we must do this."

"Yes, you will of course be asleep. You will talk to the anesthesiologist, she will tell you about everything."

Here's a weird thing that has happened as doctors have gotten better at curing individual cases of cancer: they have to consider what will happen to the rest of their patient's life. Until very, very recently, women with gynecological cancers were not even told that the treatment they would undergo would almost certainly make them infertile. And with diseases like vaginal cancer, it's not unusual for the entire vagina, a tubular muscle, also called the birth canal because it stretches and allows a baby to pass through during childbirth, to be removed entirely. My doctor decided not to do that, because I'm only 32, married, and probably still interested in being able to have sex. He was right about that, but his approach is not standard, it's new.

However, the surgery would make the vagina smaller and vaginal birth would be out of the question.

"After, you must, if you want to, get pregnant right away. I will do the C-section, you will come here and I will do it."

"Also, just in case of the radiation after surgery, I will move the ovaries up to here. This is also laparoscopically, so in the belly button and small incisions in the abdomen."

Often in the US, surgery for vaginal cancer is done as outpatient surgery. Even a hysterectomy can be outpatient. Not here in Germany. I have the normal public insurance plan and pay the minimum monthly amount, but I have no co-payments or deductibles and I stayed in the hospital for 10 days after surgery.

It was just like he said. On Monday I checked in and had the sentinel node testing. I stayed at the hospital that night and had a colonoscopy the next morning. Everything looked good so far. On Wednesday morning, early, I was rolled into the surgical area and promptly put to sleep. My favorite part is the fast-acting anesthetic that makes you pass out. I woke up, barely, and Joshua was there and I was in the ICU, which was planned. The night there was very loud, and I woke up once an hour, pressed the button and said "schmerzen", which means "hurts" in German, and they injected more pain killers right into my neck. I wasn't in much pain, really. But I had a hard time sleeping. The ICU is a place of alarms and buzzers and more alarms.

Then, maybe a day or two later, the doctor came by and told me everything went as well as possible. He didn't tell me much then, but he did take 27 lymph nodes and he moved my ovaries. I had two drainage bags hanging off me as well as a catheter - surprise! After a few days I was strong enough to do a bit of walking - all the way to the bathroom. The nurses took great care of me. Slowly the tubes and bags and injections were fewer and fewer, but I was taking pain killers, anti-nausea meds, and other pain killers. I probably took more medication in those 10 days than I had over the course of my entire life. 

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