Route of hysterectomy for endometrial pathology in superobese patients

Endometrial cancer and endometrial intraepithelial neoplasia (EIN) are both associated with obesity due to unopposed estrogen exposure. As obesity rates in the US increase, the number of patients with these pathologic diagnoses increases. In many cases, intraoperative staging is recommended. However, complete staging may not be possible in superobese patients due to the need for steep Trendelenburg positioning or prolonged operative duration. At our institution, patients in whom intraoperative staging is deemed to present undue risk may be referred to FPMRS for consideration of total vaginal hysterectomy (TVH), emphasizing primary tumor removal. This pilot study seeks to evaluate the immediate postoperative outcomes of patients who undergo TVH and to compare the outcomes and rates of complications with patients who undergo abdominal hysterectomy and laparoscopic hysterectomy. We performed a retrospective case series of patients with BMI ≥50 kg/m2 with endometrial cancer or EIN. Patients were identified utilizing the following ICD-9 and ICD-10 codes: 182.0 (malignant neoplasm of corpus uteri), 233.2 (carcinoma in situ of other and unspecified part of uterus), 621.35 (EIN), C54.1 (malignancy of uterus), D07.0 (CIS of endometrium), and N85.02 (EIN). Patients were excluded from the study if pathology revealed a cervical cancer primary (180.8, 180.9, 233.1, C53.8, C53.9), benign endometrial hyperplasia (621.34 or N85.01), or if the patient’s BMI did not reach 50 within 3 months of surgery or diagnosis. The medical records were manually queried to obtain demographic and outcome data. Ninety-six patients were identified that met our inclusion criteria from 7/1/2007 to present. Thirty patients (31%) underwent TVH, 29 had total abdominal hysterectomy (TAH), 21 had robotic-assisted total laparoscopic hysterectomy (RA-TLH), and 4 had total laparoscopic hysterectomy (TLH). Twelve were not recommended surgical therapy. The planned procedure matched the actual procedure in 89% of cases. There were 9 conversions: 4 from RA-TLH to TAH, 3 from RA-TLH to TVH, 1 from TLH to TVH, and 1 from TVH to TAH. Of the patients who underwent TVH, oophorectomy was performed in 10%. Of the patients who underwent hysterectomy via other routes, oophorectomy was performed in 98%. The average length of procedure was shorter for TVH than for other routes (Table 1). Clavien dindo grade 3 or 4 complications and 30 day post-operative readmission rates were comparable for patients undergoing TVH as compared to other surgical routes. Our pilot study comparing routes of hysterectomy in super obese patients with endometrial cancer and EIN demonstrates comparable intraoperative and postoperative complications rates between TVH and other routes of hysterectomy.