A Descriptive Analysis of Occult Gynecologic Malignancy in a Large Series of Supracervical Hysterectomy with Sacrocolpopexy

Abstract

<h3>Study Objective</h3> The incidence of occult malignancy in patients with pelvic organ prolapse (POP) undergoing a supracervical hysterectomy (SCH) at the time of robotic-assisted laparoscopic sacrocolpopexy (RA-SCP) is not well documented in the medical literature. This has clinical implications as discovery would entail further operative management to perform staging, remove oncologic burden, and possibly revise the approach to pelvic reconstructive surgery. This study aims to detect the prevalence of oncologic pathology and ability of diagnostic preoperative work-up to detect such disease. <h3>Design</h3> Retrospective descriptive analysis. <h3>Setting</h3> University-affiliated community hospital. <h3>Patients or Participants</h3> All women undergoing a RA-SCP with SCH by one surgeon between March 2017 and March 2020 without symptoms of abnormal or postmenopausal bleeding. <h3>Interventions</h3> N/A. <h3>Measurements and Main Results</h3> A total of 425 women were included in this study. Of these, 19 (4.2%) patients were found to have uterine pathology of either pre-malignancy (n=14, 3.5%) or malignancy (n=5, 1.2%). Transvaginal ultrasonography (TVUS) had lower cases of missing pathology compared to EMB in the case of endometrial cancer (EC) (0% vs. 1.2%), endometrial hyperplasia +/- atypia (EH) (2.4% vs. 3%), or in combination EC and EH (2.4% vs 4.2%). EC and EH collectively were undiagnosed by either TVUS or EMB until final pathology in 4.2% of cases. <h3>Conclusion</h3> A small subset of asymptomatic postmenopausal women who undergo a SCH at the time of RA-SCP for POP will have underlying gynecologic malignancy or premalignant conditions. EMB or TVUS in these patients have inadequate sensitivity to rule out endometrial pathology and patients should be counseled appropriately regarding the small but possible necessity to remove the cervix in its entirety. Patients may be offered an intraoperative pathology assessment of the SCH prior to attachment of SCP mesh material to the cervix when appropriate.