Extraction of a large uterus via minimally invasive surgery for high-grade endometrial cancer (HGEC) was associated with an increased risk of intra-abdominal/vaginal disease recurrence, according to results of a study published in Gynecologic Oncology.1

The researchers noted that minimally invasive surgery is a standard approach for surgical staging in women with endometrial cancer. However, results of the LACC trial (ClinicalTrials.gov Identifier: NCT00614211) showed that minimally invasive radical hysterectomy for early-stage cervical cancer was associated with reduced overall survival, calling this approach into question.2

The current retrospective cohort study was designed to assess whether local factors are associated with an increased risk of recurrence in patients diagnosed with HGEC.

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The study included 758 patients with HGEC who underwent minimally invasive surgery between 2012 and 2016 across 8 centers in Canada. An intra-uterine manipulator was used in 35.8% of the patients, and vaginal lacerations occurred in 9.1%.

The median follow-up was 30.5 months, during which time 157 patients (20.71%) had disease recurrence. Of these recurrences, 92 (12.14%) were intra-abdominal/vaginal only, and 60 (7.92%) were extra-abdominal only.

The researchers conducted a multivariable analysis and found that 2 factors were associated with an increased risk of intra-abdominal/vaginal recurrence — stage (odds ratio [OR], 1.397; 95% CI, 1.035-1.889; P =.0280) and uterine weight above the 75th percentile (OR, 2.207; 95% CI, 1.123-4.337; P =.0211).

Only lymphovascular invasion was associated with an increased risk of extra-abdominal recurrence in a multivariable analysis (OR, 2.840; 95% CI, 1.435-5.806; P =.0025).

“These results raise a concern about potential local tumor spill or spill through patent fallopian tubes at the time of extraction of a large uterus through the vagina, which may only impact intra-abdominal recurrences,” the study authors wrote.

They noted that, if further studies confirm these findings, “it will be essential to identify strategies to mitigate these risks, such as suturing the cervix, sealing the fallopian tubes at the beginning of the procedure, [and] packaging the specimen in a designated endo-bag.”


  1. Feigenberg T, Cormier B, Gotlieb WH, et al. Factors associated with an increased risk of recurrence in patients diagnosed with high-grade endometrial cancers undergoing minimally invasive surgery: a study of the society of gynecologic oncology (GOC) community of practice (CoP). Gynecol Oncol. Published online June 25, 2021. doi:10.1016/j.ygyno.2021.06.013
  2. Ramirez PT, Frumovitz M, Parejaet R et al. Minimally invasive versus abdominal radical hysterectomy for cervical cancer. N Engl J Med. 2018; 379(20)1895–1904. doi:10.1056/NEJMoa1806395