Vaginal Hysterectomy for the Treatment of Endometrial Cancer and Endometrial Intraepithelial Hyperplasia in Superobese Patients

Abstract

Objective:

Given the increasing prevalence of obesity, the incidence of endometrial cancer and endometrial intraepithelial neoplasia (EIN) could increase twofold within the next 2 decades. Although hysterectomy is the preferred treatment, increasing body mass indices (BMIs) pose technical challenges to surgeons and are associated with adverse surgical outcomes. This study evaluated perioperative outcomes of superobese (BMI of ≥50 kg/m²) patients who underwent total vaginal hysterectomy (TVH), compared to total abdominal hysterectomy (TAH) or total laparoscopic hysterectomy (TLH) for endometrial cancer or EIN.

Materials and Methods:

This was a retrospective cohort study of 84 patients with BMIs ≥50 kg/m² who underwent hysterectomy for treatment of endometrial cancer or EIN from July 1, 2007, to May 1, 2017, at a tertiary academic medical center. Demographic data, intraoperative parameters, and postoperative data were collected via a retrospective chart review. The primary outcome was a composite of intraoperative injury, Clavien–Dindo post-operative morbidity score, 30-day readmission rate, estimated blood loss >1000 cc, and transfusion. The secondary outcome was survival.

Results:

There was no difference in the combined perioperative primary outcome or survival for patients with BMIs ≥50 kg/m² undergoing TVH for EIN or endometrial cancer, compared to patients undergoing TAH or TLH.

Conclusions:

TVH is a viable surgical route for superobese patients with endometrial cancer or EIN. Further evaluation of the role of TVH in the setting of EIN and endometrial cancer is needed as the superobese population rapidly increases. (J GYNECOL SURG 37:470)

Introduction

Obesity is a growing global health concern that is projected to affect more than 21% of females by 2025.¹ In particular, superobese patients—defined by some researchers as patients with body mass indices (BMIs) ≥50 kg/m²—have become the fastest-growing obesity group in the United States.^2,3 Severely obese individuals tend to have more complex health problems and present greater technical challenges to the health system than even moderately obese individuals.³ A study by Andreyeva et al. noted that health care costs for individuals with BMIs of 35–40 are 50% higher than for normal weight individuals.⁴ In addition, for individuals with BMIs >40, health care costs were double those of patients with normal weight.⁴

Obesity is also associated with increased risks for a number of gynecologic malignancies.^5,6 Of these, endometrioid endometrial cancer has the strongest association with obesity, but serous and clear-cell adenocarcinomas, as well as poorly differentiated and mixed uterine tumors and uterine sarcomas, also have an association.⁷ Obese women have a 2.5-fold increased risk of developing endometrial cancer, compared to nonobese women.⁸ Furthermore, there appears to be an increasing risk with increasing BMI. For every 5 kg/m² increase in BMI, relative risk of endometrial cancer increases by as much as 1.5-fold.⁹ This increase is due, in part, to the peripheral conversion of androgens to estrone in adipose tissue, resulting in unopposed estrogen exposure.¹⁰ Given the increasing prevalence of obesity, it is expected that the incidences of endometrial cancer and endometrial intraepithelial neoplasia (EIN) could increase twofold within the next 2 decades.^11,12

Treatment of endometrial cancer typically involves hysterectomy, bilateral salpingo-oophorectomy, and lymph-node assessment. Chemotherapy and/or radiation might be needed postoperatively.^13,14 The gynecologic literature notes that increasing BMI is associated with incrementally worse surgical outcomes in patients who have endometrial cancer, including infections and venous thromboembolism.^2,15–16 Superobesity presents further technical challenges to surgeons.¹⁷ In such patients, lymph-node assessment might not be possible, as operative exposure can be limited.¹⁸ Minimally invasive—specifically endoscopic—procedures can attenuate some morbidity in these patients.¹⁵

Currently, much of the published literature on surgery in superobese patients consists of retrospective data in the field of bariatrics. It is insufficient to describe the risks and benefits of surgery and best practices completely in this particular group.¹⁹ Some bariatric surgeons have established requirements for weight loss prior to scheduling surgery as a result of experience with insufficient exposure and intolerance of pneumoperitoneum.²⁰ Others have suggested that superobesity is not a contraindication to immediate bariatric laparoscopic procedures.²¹ This is confounded by the fact that bariatric procedures do not require the steep Trendelenburg positioning that is necessary in gynecologic laparoscopy. Thus, positioning for gynecologic surgery poses added risk for difficulty with ventilation, resulting in hypoxia, hypercapnia, and pulmonary barotrauma.

Gynecologic surgeons have access to a pelvic surgery route in lieu of abdominal and laparoscopic approaches. Total vaginal hysterectomy (TVH) is thus an option for treatment of endometrial cancer in superobese patients. The decreased operative time and the absence of an abdominal incision or abdominal insufflation is an advantage.^22,23 For this reason, superobese patients with endometrial cancer and EIN at the current authors' institution have been referred to the Female Pelvic Medicine and Reconstructive Surgery (FPMRS) service for TVH, after determination that total abdominal hysterectomy (TAH) or total laparoscopic hysterectomy (TLH) were less-feasible approaches.

Although previous studies have compared the different routes of hysterectomy in obese patients, few studies have addressed outcomes for patients with endometrial cancer.^22,24,25 Additionally, many studies comparing routes of hysterectomy only analyze outcomes for laparotomy versus laparoscopy.^26,27 Among the studies of vaginal hysterectomy for endometrial cancer, the mean BMI is either in the 30s or not described.^28,29 To the current authors' knowledge, there are no data on the outcomes of vaginal hysterectomy for endometrial cancer in superobese patients. It is well-understood that this patients in this demographic group have a different risk of surgical morbidity than even moderately obese patients. The primary aim of this study was to determine if perioperative outcomes of superobese patients who undergo TVH differ significantly, compared to patients who undergo either TAH or TLH for endometrial cancer or EIN.

Materials and Methods

This study was approved by the Vanderbilt University Medical Center (VUMC, in Nashville, TN) institutional review board (Number 170705 on April 27, 2017). The number of superobese patients with endometrial pathology has increased at this institution in recent years (see Fig. 1). A retrospective cohort study was conducted of women with BMIs ≥50 and pathologic diagnoses of endometrial cancer or EIN, found on endometrial sampling, who subsequently underwent hysterectomy for treatment. Patients with EIN were included due to the 40% risk of underlying endometrial cancer and the fact that they are often clinically managed similarly to early stage endometrial cancer.³⁰ Preoperative patient demographics and characteristics as well as postoperative outcomes were collected. The hypothesis was that a composite primary outcome of surgical morbidity would not differ by route of hysterectomy.

FIG. 1.

Total number of endometrial cancer cases treated at Vanderbilt University Medical Center 2000–2019 with proportion of patients having body mass indices (BMIs) ≥50.0. Data obtained through Synthetic Derivative, a deidentified mirror chart.

A convenience sample of all patients between July 1, 2007 and May 1, 2017 with BMIs ≥50 and a diagnosis of endometrial cancer or EIN (International Classification of Diseases [ICD]9: 182.0, 233.2, 621.35; and ICD10: C54.1, D07.0, N85.0) were identified from administrative data using Current Procedural Terminology^® codes for hysterectomy. Exclusions were diagnoses of cervical cancer (ICD9: 180.8, 180.9, 233.1; and ICD10 C53.8, C53.9) or benign endometrial hyperplasia (ICD9: 621.34; and ICD10: N85.01), if patients were not offered hysterectomy as treatment due to medical comorbidities, or if patients did not have documented BMIs ≥50 . within 3 months of the surgeries.

All patients who underwent TVH were comanaged with gynecologic oncologists. Hysterectomies were performed by either FPMRS surgeons or gynecologic oncology providers. The recommended route of hysterectomy was a joint decision between the FPMRS surgeon and gynecologic oncology provider based on the degree and distribution of obesity and other comorbidities that, in the judgment of the surgeon, would preclude the Trendelenberg positioning and pneumoperitoneum required for TLH. An endoscopic approach was favored when possible. The decision to remove lymph nodes was made by applying Mayo criteria.³¹ It was routine practice to perform bilateral salpingo-oophorectomy, unless the patient was premenopausal or intraoperative factors precluded that procedure.²⁹

Demographic data were collected, including age, ethnicity, parity, history of pelvic surgery (specifically history of oophorectomy), BMI, American Society of Anesthesiologists (ASA) score, endometrial pathology, planned hysterectomy route, and actual hysterectomy route. A Charlson comorbidity index score was assigned to each patient to assist in modeling underlying health status.³² This score predicts 10-year overall survival based on medical comorbidities. Intraoperative parameters, including concomitant procedures (such as oophorectomy and lymph-node dissection), estimated blood loss (EBL), intraoperative injury, and operative time were also collected. Postoperative data were obtained, including transfusion, intensive care unit (ICU) admission, reoperation, 30-day readmission, and Clavien–Dindo morbidity score (a validated tool for classification of postoperative morbidity based on the therapy used to correct the complication).³³

Patient charts were also consulted for the last-known follow-up with a gynecologist and last-known contact with any provider within VUMC's medical system. Fifteen percent of charts were reviewed again by a second author to ensure accurate data transfer. Discrepancies were resolved by consensus of the authors. Death data were obtained from the National Death Index (NDI) and matched by social security number. In epidemiologic studies, the NDI sensitivity ranged from 87.0% to 97.9%.³⁴ Patients were subdivided into 3 groups for analysis: (1) TVH; (2) TLH (including robotic-assisted TLH [RA-TLH]); and (3) TAH. Patients that were not offered surgical management for their condition were not considered in the analysis.

The primary outcome was a composite of binary outcomes of intraoperative injury, Clavien–Dindo postoperative morbidity score 3 or higher, 30-day readmission, EBL >1000 cc, or intraoperative or postoperative blood transfusion. The secondary outcome was length of known overall survival. Overall survival was chosen due to the difficulty in obtaining accurate cause of death from public records as well as a desire to capture mortality that might have been secondary to longer-term morbidity from surgery. Patients without social security numbers associated with a death record in the national death index were presumed to be alive and censored on December 31, 2017.

Demographic and clinical characteristics were summarized using descriptive statistics. The mean (standard deviation [SD]) or median with an interquartile range (IQR) was used to describe continuous variables and percent (n) was used to describe categorical variables. The 3 treatment groups were compared using a Kruskal–Wallis test and Pearson's χ² test when appropriate. A multivariable logistic regression model was used to assess the differences in the composite primary outcomes among the treatment groups, adjusting for age, prior surgery, Charlson comorbidity score, and known vaginal parity. These variables were chosen by the authors as some that could affect the decision on mode of surgery in a superobese patient. Overall survival was described using Kaplan–Meier estimates and was compared by a log-rank test. All analyses were performed using statistical software R, version 3.3.0.

Data were extracted manually. They were collected and managed using Research Electronic Data Capture (REDCap) tools hosted at the VUMC.³⁵ REDCap is a secure, web-based software platform designed to support data capture for research studies, providing (1) an intuitive interface for validated data capture; (2) audit trails for tracking data manipulation and export procedures; (3) automated export procedures for seamless data downloads to common statistical packages; and (4) procedures for data integration and interoperability with external sources.

Results

Eighty-four patients met the study's inclusion criteria (Tables 1 and 2). The mean age was 54 (range: 29–74). Patients were predominantly Caucasian. Median BMI was 54.5 kg/m² (range: 50–73 kg/m²). The median Charlson Comorbidity Index was 4 (range: 0–10). Mean age, race, median BMI, and median Charlson Comorbidity Index did not differ significantly by route of hysterectomy. Among these 84 patients, the preoperative diagnosis was EIN in 24 (29%) and endometrial cancer in 59 (71%). One patient had a diagnosis of gynecologic malignancy of an uncertain type prior to surgery.

Table 1.

Patients' Demographics by Planned Procedures

Variables	TLH (n = 33)	TVH (n = 28)	TAH (n = 23)	p-Value
Age in yrs, median (IQR)	53.6 (45.1–61.2)	58.8 (50.3–65.6)	52.0 (46.2–59.0)	0.14^a
BMI, median (IQR)	52.5 (50.6–57.1)	55.9 (51.8–59.0)	54.7 (53.0–58.8)	0.12^a
Known vaginal parity				0.033^b
Yes	41%	70%	38%
No	59%	30%	62%
Ethnicity				0.96^b
Caucasian	88%	89%	87%
Black	12%	11%	13%
ASA score				0.087^b
3	96.9%	81.5%	78.3%
4	3.1%	18.5%	21.7%
Charlson comorbidity index, mean (SD)	3.8 (1.5)	4.9 (1.9)	4.6 (2.4)	0.07^a
Prior surgery				0.39^b
Yes	73%	82%	65%
No	27%	18%	35%
Preoperative endometrial pathology				0.35^b
EIN	21%	39%	22%
Endometrial cancer	76%	61%	78%
Other	3%	0%
Endometrial cancer histology				0.38^b
Endometrioid (all)	84.0%	88.2%	88.9%
Grade 1 (n)	16	11	11
Grade 2 (n)	2	3	4
Grade 3 (n)	3
Other (n)		1	3
Serous (all)	16.0%	5.9%	5.6%
Grade 1 (n)	1
Grade 2 (n)
Grade 3 (n)	2
Other (n)	1	1	1
Clear-cell (all)	0.0%	5.9%	0.0%
Grade 1 (n)
Grade 2 (n)		1
Grade 3 (n)
Other (n)
Other (all)	0.0%	0.0%	5.6%

Kruskal–Wallis test.

Pearson's test.

TLH, total laparoscopic hysterectomy; TVH, total vaginal hysterectomy; TAH, total abdominal hysterectomy; yrs, years, IQR, interquartile range; BMI, body mass index; ASA, American Society of Anesthesiology; SD, standard deviation, EIN, endometrial intraepithelial neoplasia.

Table 2.

Patients' Demographics by Actual Procedures

Variables	TLH (n = 25)	TVH (n = 30)	TAH (n = 29)	p-Value
Age, yrs, median (IQR)	52.5 (42.5–64.1)	59.4 (51.0–65.4)	53.1 (47.5–57.7)	0.086^a
BMI, median (IQR)	52.4 (50.4–56.4)	56.3 (52.4–58.3)	54.7 (53.0–59.4)	0.044^a
Known vaginal parity				0.068^b
Yes	42%	67%	38%
No	58%	33%	62%
Ethnicity				0.71^b
Caucasian	83%	90%	90%
Black	17%	10%	10%
ASA score				0.21^b
3	95.8%	86.2%	79.3%
4	4.2%	13.8%	20.7%
Charlson comorbidity index, mean (SD)	3.8 (1.6)	4.9 (1.9)	4.4 (2.2)	0.093^a
Prior surgery				0.12^b
Yes	64%	87%	69%
No	36%	13%	31%
Preoperative endometrial pathology				0.49^b
EIN	20%	33%	28%
Endometrial cancer	76%	67%	72%
Other	4%	0%	0%
Final endometrial cancer histology				0.53^b
Endometrioid	89.5%	80.0%	90.5%
Grade 1 (n)	19	10	12
Grade 2 (n)	1	6	6
Grade 3 (n)	2
Other (n)	1	1	3
Serous-cell	10.5%	15.0%	4.8%
Grade 1 (n)		1
Grade 2 (n)
Grade 3 (n)
Other (n)		2	1
Clear-cell	0.0%	5.0%	0.0%
Grade 1 (n)
Grade 2 (n)		1
Grade 3 (n)
Other (n)
Other	0.0%	0.0%	4.8%
Final endometrial cancer stage				0.042^b
No cancer	0.0%	10.0%	0.0%
1A	78.9%	75.0%	40.0%
1B	15.8%	15.0%	35.0%
2	5.3%	0.0%	20.0%
3A	0.0%	0.0%	5.0%

Kruskal–Wallis test.

Pearson's test.

TLH, total laparoscopic hysterectomy; TVH, total vaginal hysterectomy; TAH, total abdominal hysterectomy; yrs, years; IQR, interquartile range; BMI, body mass index; ASA, American Society of Anesthesiology; SD, standard deviation; EIN, endometrial intraepithelial neoplasia.

Thirty patients (36%) underwent TVH, 29 (34%) had TAH, 21 (25%) had RA-TLH, and 4 (5%) had TLH. For the statistical analysis, TLH and RA-TLH were combined. The TVH group had the highest median BMI at 55.9 (IQR: 51.8–59.0). Five patients each in the TAH and TVH groups were ASA class 4, compared to only 1 in the TLH group.

There were 9 intraoperative conversions: 4 from RA-TLH to TAH, 3 of which were due to adhesions and 1 conversion due to patient inability to tolerate a steep Trendelenberg position. There were 3 conversions from RA-TLH to TVH, 2 of which were due to patient inability to tolerate steep Trendelenberg positions and 1 conversion due to poor surgical visualization. There was 1 conversion from TLH to TVH due to poor surgical visualization and 1 conversion from TVH to TAH due to intraoperative bleeding. Table 3 provides perioperative data according to procedures actually performed.

Table 3.

Operative Outcomes by Actual Procedures

Variables	TLH (n = 25)	TVH (n = 30)	TAH (n = 29)	p-Value
Planned treatment
TLH	100.0%	10.0%	17.2%
TVH	0.0%	90.0%	3.4%
TAH	0.0%	0.0%	79.3%
Oophorectomy performed if planned (i.e., ovaries present, etc.)				< 0.001^a
Yes	95.8%	10.3%	100.0%
No	4.2%	89.7%	0.0%
Concomitant lymph-node dissection				0.38^a
Yes	29%	0%	28%
No	71%	100%	72%
Concomitant para-aortic lymph-node dissection				0.75^a
Yes	8.3%	0.0%	10.3%
No	91.7%	100.0%	89.7%
Operative time in min, median (IQR)	263 (195–318)	104 (87–122)	233 (186–305)	< 0.001^b
EBL, median (IQR)	150 (100–200)	200 (100–300)	550 (325–800)	< 0.001^b
EBL ≥1000 mL				0.14^a
Yes	0.0%	0.0%	6.9%
No	100.0%	100.0%	93.1%
Intraoperative injury				0.3^a
Yes	4%	0%	0%
No	96%	100%	100%
Clavien–Dindo postoperative morbidity score				0.076^a
1	46.2%	42.9%	20.8%
2	46.2%	42.9%	58.3%
3	7.7%	0.0%	20.8%
4	0.0%	14.3%	0.0%
Transfusion during admission?				0.59^a
No transfusion	100.0%	96.7%	93.1%
Transfusion while in OR	0.0%	0.0%	3.4%
Transfusion during postoperative course	0.0%	3.3%	3.4%
Postoperation LOS in d, median (IQR)	1.0 (1.0–1.0)	1.0 (1.0–2.0)	4.0 (3.0–5.0)	< 0.001^b
ICU admission postoperation?				0.068^a
Yes	0%	13%	21%
No	100%	87%	79%
Readmission within 30 days postoperation?				0.12^a
Yes	12.0%	3.3%	20.7%
No	88.0%	96.7%	79.3%

Pearson's test

Kruskal–Wallis test.

TLH, total laparoscopic hysterectomy; TVH, total vaginal hysterectomy; TAH, total abdominal hysterectomy; min, minutes; IQR, interquartile range; EBL, estimated blood loss; OR, operating room; LOS, length of stay; d, days; ICU, intensive care unit.

Oophorectomy was performed in 10% of TVHs. Ovaries were left in situ electively in 1 premenopausal woman undergoing TLH for EIN. Pelvic lymph-node dissection was performed in 7 (28%) patients undergoing TLH and 8 (28%) patients undergoing TAH.

Patients undergoing TAH had a higher mean EBL of 549 mL (range: 150–1250 mL), compared to patients undergoing TVH (208 mL; range: 25–700 mL) or TLH (161 mL; range; 10–500 mL) The p-value was <0.0001. The mean + SD operative time in minutes was significantly shorter in the TVH group, compared to the TAH or TLH groups, 120 + 74.5 minutes versus 257 + 91.1 minutes versus 256.6 + 101.1 minutes (p < 0.0001), respectively. For the entire study group, there was only 1 intraoperative injury. This was a bladder serosal injury that occurred during a TLH.

There were no significant differences in the combined primary outcome among the 3 surgical procedures (Table 4). In a multivariable logistic regression, age, history of prior surgery, vaginal parity, and Charlson comorbidity score did not affect the primary outcome significantly (Table 5). There was also no significant difference in the secondary outcome of survival, which was measured by records of deaths in the national death index (Table 6). Twenty-one percent of patients undergoing TAH required ICU admission and 21% had 30-day readmissions to the hospital. By comparison, in the TVH group, 13% required ICU admission and 3% had 30-day readmissions. In the current study cohort, 30% of planned TVH patients were nulliparous and 87% had undergone prior abdominal surgeries. There was only 1 conversion of TVH to another approach.

Table 4.

Primary Outcomes by Actual Procedures^a

Variables	TLH (n = 25)	TVH (n = 30)	TAH (n = 29)	p-Value
Intraoperative injury				0.3
0	96%	100%	100%
1	4%	0%	0%
Clavien–Dindo postoperative morbidity score				0.076
1	46.2%	42.9%	20.8%
2	46.2%	42.9%	58.3%
3	7.7%	0.0%	20.8%
4	0.0%	14.3%	0.0%
Readmission within 30 d postoperation?				0.12
Yes	12.0%	3.3%	20.7%
No	88.0%	96.7%	79.3%
EBL ≥1000 mL				0.14
Yes	0.0%	0.0%	6.9%
No	100.0%	100.0%	93.1%
Transfusion during admission?				0.59
No transfusion	100.0%	96.7%	93.1%
Transfusion while in OR	0.0%	0.0%	3.4%
Transfusion during postoperative course	0.0%	3.3%	3.4%
Combined primary outcome				0.1
No	84%	87%	66%
Yes	16%	13%	34%

Pearson's test.

TLH, total laparoscopic hysterectomy; TVH, total vaginal hysterectomy; TAH, total abdominal hysterectomy; d, day(s); EBL, estimated blood loss; OR, operating room.

Table 5.

Logistic Regression for Combined Primary Outcome^a

Variables	OR (95% CI)	p-Value
Age (10-yr increase)	0.65 (0.33–1.30)	0.225
Prior surgery (Yes:No)	1.16 (0.29–4.59)	0.838
Comorbidity index(1-point increase)	1.07 (0.76–1.50)	0.694
Actual treatmentTLH:TVH	0.88 (0.17–4.65)	0.409
Actual treatmentTAH:TVH	2.06 (0.49–8.72)	0.409
Known vaginal parity(Yes:No)	0.52 (0.14–1.90)	0.324

Combined primary outcome: intraoperative injury; Clavien–Dindo postoperative morbidity score ≥3; 30-day readmission; estimated blood loss >1000 cc; or transfusion intra- or postoperatively.

OR, odds ratio; CI, confidence interval; yr, year; TLH, total laparoscopic hysterectomy; TVH, total vaginal hysterectomy; TAH, total abdominal hysterectomy.

Table 6.

Long-Term Outcomes by Actual Procedures

Variables	TLH (n = 25)	TVH (n = 30)	TAH (n = 29)
Length of follow-up (yrs)	0.923 (0.131–2.360)	0.497 (0.087–1.166)	1.864 (0.348–4.408)
Known recurrence at date of last visit with oncologist or gynecologic surgeon?
Yes	8.0%	3.3%	7.1%
No	92.0%	96.7%	92.9%
NDI death
No	92%	90%	83%
Yes	8%	10%	17%

TLH, total laparoscopic hysterectomy; TVH, total vaginal hysterectomy; TAH, total abdominal hysterectomy; yrs, years; NDI, National Death Index.

Among patients with cancer, the final diagnosis was stage IA, grade 1 endometrioid adenocarcinoma in the majority of patients (Table 2). However, pathology was more often more-advanced in patients who underwent TAH. In patients who underwent TLH and TVH, 21.1% and 15.0%, respectively, had ≥ stage IB disease noted on final pathology, versus 55.0% in patients undergoing TAH (p = 0.042). The final diagnosis was changed from EIN to grade 1 endometrioid adenocarcinoma of the endometrium in 7 patients. Stage Ib cervical cancer was the final diagnosis in 1 patient. Synchronous endometrioid adenocarcinoma of the ovary was diagnosed in 2 patients, both of whom presented with adnexal masses.

Adjuvant radiation was given to 4 patients, each undergoing TAH and TLH, and to 3 patients undergoing TVH. Adjuvant chemotherapy was required for 3 patients undergoing TAH, 1 patient undergoing TLH, and 2 patients undergoing TVH. Median follow-up was 21.8 months (range: 0.8–119.8 months; Table 4). Among patients with endometrial cancer there were 2 recurrences, each in the TAH and TLH groups, and 1 recurrence after TVH.

Discussion

To the current authors' knowledge, this is the largest series of superobese patients undergoing TVH for EIN and endometrial cancer in the literature. The data would suggest that perioperative outcomes and survival are equivalent for patients with BMIs ≥50 undergoing TVH for EIN or endometrial cancer, compared to patients undergoing the more-conventional routes of TAH and TLH. This study demonstrated that, in women with superobesity—for whom the risk of morbidity from abdominal or laparoscopic hysterectomy and conventional surgical staging is high—TVH is a safe and effective alternative with similar or improved complication and cancer outcomes. Nulliparity and prior abdominal surgery are often noted as relative contraindications for TVH, although the cohort undergoing TVH included patients with both factors.

The approach to lymph-node assessment in the setting of endometrial cancer is evolving. The main disadvantage of a vaginal approach is that lymph-node assessment is not possible. However, surgical staging can be compromised in the obese patient regardless of approach. In the Gynecologic Oncology Group's LAP2 study, complete staging with removal of pelvic and para-aortic lymph nodes was not possible in 4% of patients undergoing laparotomy and in 8% of patients undergoing laparoscopy (p < 0.0001).²⁷ Among women with BMIs > 50 kg/m² undergoing robotic hysterectomy for endometrial cancer, lymph-node dissection was not possible in 25%.³⁶ In this current study, pelvic lymph-node dissection was performed in only 29% of patients undergoing TLH and in 28% of those undergoing TAH.

For patients with low-risk endometrial cancer, lymphadenectomy has been shown to increase morbidity and cost of care, without significant benefit.³⁷ Some researchers have questioned the value of routine pelvic lymphadenectomy in early stage endometrial cancer.³⁸ Comparison of vaginal hysterectomy and robotic hysterectomy for the management of patients with endometrial cancer has shown similar surgical and oncologic outcomes with lower cost for the vaginal approach in moderately obese individuals.²⁸

Conclusions

The population of patients examined in this study represents an example of an emerging problem in our society of potentially life-threatening problems in superobese, highly comorbid patients who have difficulty tolerating the positioning needed for endoscopy. The steep Trendelenburg positioning needed for extended periods of time make respiratory sufficiency difficult or impossible. Risk–benefit reasoning favors the natural orifice approach of vaginal hysterectomy in this circumstance if ideal staging via an open approach or endoscopy is not tolerable, in the current authors' opinion. More study on the role of TVH for EIN and endometrial cancer is needed as the superobese population rapidly increases. Prior researchers have cited the need for a randomized controlled trial for TVH in the setting of endometrial cancer.³⁹ Directions for further research include determining the preoperative characteristics among superobese patients with endometrial pathology for whom TVH may balance risk of comorbidities and complications with technical challenges of surgery.

Footnotes

Acknowledgments

The authors would like thank Marc Robinson, MS, and Mohamed Mokhtar Desouki, MD, PhD, for their assistance in this work.

Author Disclosure Statement

No financial conflicts of interest exist.

Funding Information

Funding was provided through the Vanderbilt Institute for Clinical and Translational Research grant support (UL1 TR000445 from NCATS/NIH).

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