Objective
The aim of this study was to assess the risk of unanticipated abnormal gynecologic pathology at the time of reconstructive pelvic surgery to better understand risks of uterine conservation in the surgical treatment of uterovaginal prolapse.
Study Design
This was a retrospective analysis of pathology findings at hysterectomy with reconstructive pelvic surgery over a 3.5-year period.
Results
Seventeen of 644 patients had unanticipated premalignant or malignant uterine pathology (2.6%; 95% confidence interval, 1.7–4.2). Two (0.3%; 95% confidence interval, 0.09–1.1) had endometrial carcinoma. All cases of unanticipated disease were identified in postmenopausal women.
Conclusion
Premenopausal women with uterovaginal prolapse and normal bleeding patterns or with negative evaluation for abnormal uterine bleeding have a minimal risk of abnormal gynecologic pathology. In postmenopausal women without bleeding, the risk of unanticipated uterine pathology is 2.6% but may be reduced by preoperative endometrial evaluation. However, in women with a history of postmenopausal bleeding, even with a negative endometrial evaluation, we do not recommend uterine preservation at the time of prolapse surgery.
There is a growing interest among pelvic surgeons in uterine conservation at the time of pelvic organ prolapse (POP) surgery. This interest is born out of both a desire to expand minimally invasive surgical options, as well as efforts to cater to patient preference. Although there are no randomized trials comparing uterine conservation with hysterectomy-based uterovaginal prolapse procedures, existing evidence cites comparable success rates of 79–100% for multiple uterine-sparing POP procedures. These include vaginal sacrospinous hysteropexy, laparoscopic sacrohysteropexy, and laparoscopic uterosacral ligament suspension.
However, many providers are still reluctant to conserve the uterus at the time of POP surgery and cite concerns regarding the quality of existing evidence supporting the procedures, as well as a concern that the patient may currently harbor or later have lesions develop that necessitate uterine evaluation and/or hysterectomy. This study aims to assess the risk of premalignant and malignant uterine, cervical, and ovarian pathology at the time of surgery for uterovaginal prolapse, to better understand the risks of uterine conservation in the surgical treatment of POP.
Materials and Methods
All operations for symptomatic uterovaginal prolapse that included hysterectomy and were performed by members of the Center for Urogynecology and Reconstructive Pelvic Surgery at the Cleveland Clinic (Cleveland, OH) between Jan. 1, 2005–Aug. 14, 2008, were identified using International Classification of Diseases, Ninth Revision codes and were reviewed via the electronic medical record. Demographic characteristics, symptoms, and medical histories were collected from clinic notes. Operative and pathology reports were reviewed for information on the procedure(s) performed, as well as the intraoperative findings and final pathology.
Cases with premalignant or malignant uterine or cervical pathology recognized before surgery were excluded from this analysis. This eliminated cases of known endometrial hyperplasia, cervical dysplasia, and carcinoma. Patients with adnexal lesions identified preoperatively were also excluded. In addition, our clinic policy requires women have a normal Papanicolaou (Pap) smear test within 1 year or a negative Pap smear test and human papillomavirus titer within 3 years of surgery.
Women were considered postmenopausal if clinic notes explicitly indicated the patient was postmenopausal and/or if the patient’s last menstrual period was greater than 1 year before the intake visit. All other women were considered premenopausal. Subjects were labeled as having abnormal uterine bleeding if clinic or operative notes documented a complaint or evaluation of menorrhagia, intermenstrual bleeding, or postmenopausal bleeding.
We performed the statistical analysis using JMP software (version 7.0; SAS Institute, Cary, NC). We calculated the frequency and 95% confidence intervals (CIs) of each pathology finding. Student t tests were performed to evaluate the relationship between abnormal pathology and continuous variables, whereas χ 2 tests were used to evaluate the risk of abnormal pathology by menopausal status, hormone replacement therapy use, and the presence of endometrial polyps.
Results
A total of 681 patients underwent hysterectomy and associated reconstructive surgery for uterovaginal prolapse during the study period. Thirty-seven (5.4%) had known abnormal gynecologic pathology preoperatively and were excluded from this analysis. This included endometrial cancer (n = 5), endometrial hyperplasia (n = 7), abnormal Pap smear tests (n = 15), cervical cancer (n = 1), and adnexal masses (n = 9). Each underwent a procedure for the abnormal pathology concomitantly with a pelvic reconstructive or incontinence procedure. There were 644 patients who had no known premalignant or malignant gynecologic pathology preoperatively and are the subjects of this report. Their mean age was 59.7 ± 12.0 (range, 31–94) years, with a mean body mass index of 27.2 ± 5.2. A total of 466 (72.3%) women were postmenopausal.
Ninety-eight (15.2%) women complained of abnormal uterine bleeding preoperatively. Approximately one-half (n = 45) of these women were postmenopausal. Each had a negative diagnostic evaluation, including an ultrasound and/or endometrial biopsy. In contrast, women without concerning symptoms or examination findings do not routinely undergo preoperative screening ultrasounds or endometrial biopsies in our practice.
Table 1 describes the operative procedures performed. There were 568 (88.2%) hysterectomies performed vaginally. A total of 569 (88.5%) patients underwent a vaginal vault suspension, whereas 519 (80.6%) patients had an anterior or posterior colporrhaphy, and 401 (62.3%) patients required an incontinence procedure. Oophorectomy was performed in 167 (25.9%) cases, secondary to either patient preference, family history of breast or ovarian cancer, and/or abnormal ovarian appearance at the time of hysterectomy.
| Procedure | n (%) |
|---|---|
| Hysterectomy, any | 644 (100) |
| Vaginal | 568 (88.2) |
| Abdominal | 39 (6.0) |
| Laparoscopic | 32 (5.0) |
| Robotic | 5 (0.8) |
| Oophorectomy | 167 (25.9) |
| Vaginal vault suspension | 569 (88.5) |
| Uterosacral ligament | 498 (77.4) |
| Sacrospinous ligament | 12 (1.9) |
| Sacral colpopexy | 43 (6.7) |
| Ileococcygeus | 16 (2.5) |
| Incontinence procedure | 401 (62.3) |
| Midurethral sling | 319 (49.5) |
| Burch colposuspension | 29 (4.5) |
| Colporrhaphy | 519 (80.6) |
| Anterior | 185 (28.7) |
| Posterior | 73 (11.3) |
| Anterior and posterior | 261 (40.5) |
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