Outcomes After Hysterectomy for Endometrial Cancer/EIN with Concomitant Pelvic Floor Procedures

Objectives: To evaluate if postoperative morbidity increased with the addition of concomitant pelvic organ prolapse (POP) and/or urinary incontinence (UI) procedures at time of hysterectomy for endometrial cancer (EC) or endometrial hyperplasia (EH).

Methods: This retrospective analysis of women undergoing hysterectomy for EC/EH between 2017- 2022 used the National Surgical Quality Improvement Program (NSQIP) database. The primary composite outcome was any major complication within 30 days of surgery. Comparisons were made between women who had hysterectomy with concurrent POP and/or UI procedures (POPUI) versus those who had a hysterectomy alone (HYSTalone). A subgroup analysis was performed in patients with EC. Additionally, a propensity score matching cohort was created using these variables: age, race, BMI, severe cardiac disease history, endometrial cancer stage, ASA score, and presence of gross abdominal disease.

Results: 23,144 patients underwent hysterectomy for EC/EH. Mean age was 61.1 (±11.5). Most were obese (67.2%) and white (68.6%). 22% had EH and 78% had EC (65.1% stage I-II).

Only 1.9% (n=432) had POP and/or UI procedures. POPUI patients were older, predominantly white, had higher parity, lower BMI, and lower ASA class (Table 1). POPUI patients were less likely to have EC (65.7% vs 78.3%, p< .0001). They were more likely to undergo vaginal hysterectomy (17.8% vs 1.4%, p< .0001) and have their hysterectomy performed by general obstetrician-gynecologists or urogynecologists as opposed to gynecologic oncologists.

In POPUI, 61.8% underwent POP procedures [32.6% sacrocolpopexy, 53.5% USLS, 7.9% SSLF, and 0.5% obliterative], 28.9% SUI procedures [89.6% sling, 4.0% Burch, 7.2% laparoscopic and 2.4% Kelly], and 9.3% both. Operative time was 19 mins longer (161.3 ± 69.8 vs 142.5 ± 61.5, p< .0001), but were more often outpatient (65.7% vs 58.8%, p=.0036). There were no differences in peritoneal biopsies, lymph node dissections, gross abdominal wall disease, or uterine weight.

For the primary outcome, major complications were low and not significantly different between POPUI and HYSTalone (3.7% vs 3.6%, p=.094). There were no significant differences in secondary outcomes (Table 2).

A subgroup analysis of EC alone (n=18,060) found that HYSTalone subset did not have more advanced cancers (p=0.54), yet the surgeon was more likely a gynecologic oncologist (87.1% vs 68.0%, p < .0001).

With the propensity score analysis, baseline differences including age, race, parity, BMI, ASA class, cancer diagnosis, hysterectomy type, performing surgeon, operation time, and outpatient procedure were no longer significant. Our primary outcome, major complications, remained no different between groups (4.0% vs 4.5%, p = 0.73, Table 2).

Conclusions: Concomitant prolapse and/or incontinence procedures were uncommon and did not increase the low rate of 30-day major complications for women undergoing hysterectomy for EC/EH. Women who had surgery with generalists or urogynecologists were more likely to undergo a concomitant prolapse and/or incontinence, as opposed to gynecologic oncologists.