AAGL 2013: Risk of Morcellating Abnormal Uterine Pathology “Considerable”

Unanticipated uterine pathology is a risk of robotic sacrocolpopexy, but how much of a risk has been unknown until two gynecological surgeons helped quantify it.

Melissa Pendergrass, MD, of Legacy Health, Portland, Oregon, and Blake Osmundsen, MD, of Comprehensive Gynecology Associates, also in Portland, evaluated the prevalence of and risk factors for unanticipated uterine pathology during robotic sacrocolpopexy for pelvic organ prolapse. Their results, which were presented by Dr. Pendergrass last month at AAGL’s 42nd Global Congress on Minimally Invasive Gynecology, revealed a 6% prevalence of unanticipated uterine pathology at the time of robotic sacrocolpopexy in a low-risk urogynecology patient population.

The study included 119 women who underwent a hysterectomy during robotic sacrocolpopexy between March 2010 and March 2012 at any of 4 large community hospitals in Portland, Oregon. Most of these women (n=88) had supracervical hysterectomy with morcellation, and 31 underwent total hysterectomy. Before surgery, 14 women were noted to have abnormal uterine bleeding and were evaluated appropriately.

Patient characteristics included a mean age of 59 years, an average BMI of 27, an 11% prevalence of diabetes mellitus, and an 8% prevalence of systemic hormone therapy use. In addition, nearly all (98%) of the patients were white.

Seven women (6%) had unanticipated uterine pathology (95% CI, 2%-11%). Of these 7 women, 3 had complex endometrial hyperplasia with atypia and 4 had endometrial cancer. Patients with unanticipated pathology were more likely to trend towards having a higher BMI (odds ratio, 1.19 [0.99-1.43]; P=0.07) and diabetes (odds ratio, 25 [1.47-423]; P=0.03).

These findings are concerning because there is potential to leave cancerous tissue in the abdomen when morcellating (pulling the uterus out of the abdomen in strips, explained Dr. Pendergrass. “We are unable to accurately grade or stage the tumor because the pathology is unreliable, and we don't know how to treat a patient who has cancer that has been morcellated after sacrocolpopexy. The options include re-operation, radiation therapy, or observation. There are no clear guidelines,” she continued.

“In a time of escalating concern for mesh erosion, supracervical hysterectomies are being performed more frequently in combination with sacrocolpopexies, when compared with total hysterectomies,” explained Dr. Pendergrass. “Our findings bring to light the considerable risk of morcellating abnormal uterine pathology in a patient without abnormal uterine bleeding.”

“As robotic sacrocolpopexy gains momentum to become the accepted primary surgical treatment for pelvic organ prolapse, we will likely continue to see unanticipated pathology in this patient population,” Dr. Pendergrass stated.

These results expose a possible need for screening women pre-operatively, particularly those with risk factors such as obesity or diabetes, she suggested.