Objective:Cesarean hysterectomy for placenta accreta spectrum (PAS) is associated with significant morbidity. The role of adjunctive procedures, including tranexamic acid administration, ureteral stent placement, and endoarterial embolization or balloon placement, in mitigating surgical morbidity during cesarean hysterectomy for PAS is currently under active investigation. This study aimed to assess temporal trends, characteristics, and outcomes associated with adjunctive procedures during cesarean hysterectomy for PAS. Study Design:This retrospective study used the Premier Perspective database in the United States. The study population included pregnant patients who underwent cesarean hysterectomies for PAS between 2016 and 2023. Targeted adjunctive procedures included tranexamic acid administration, ureteral stent placement, and endoarterial embolization or balloon placement. A multivariate model was created to assess the association between adjunctive procedures and surgical morbidity. Results:Among 4,337 cesarean hysterectomies for PAS, 39.3%, 24.6%, and 16.1% received tranexamic acid, ureteral stent placement, and endoarterial embolization or balloon placement, respectively. During the 8-year study period, tranexamic acid administration increased 5.7-fold from 11.7% to 66.4%, and ureteral stent placement increased 1.6-fold from 19.2% to 30.3% (both p-trend <0.001). Nearly two-thirds of patients had postpartum hemorrhage (62.6%), and nearly one in five had urinary tract injury (18.7%). These three adjunctive procedures were not associated with decreased postpartum hemorrhage or urinary tract injury. Conclusion:These data suggest that the utilization of tranexamic acid and ureteral stent placement is increasing during cesarean hysterectomy for PAS in the United States. Reflecting the increases in real-world practice, whether these adjunctive procedures improve surgical morbidity of cesarean hysterectomy for PAS warrants further investigation with prospective studies. Key Points:· Tranexamic acid and ureteral stent use increased during PAS cesarean hysterectomy.. · Endoarterial procedures showed no significant temporal increase.. · Surgical morbidity remained substantial despite adjunctive procedure use..

Background:Gestational trophoblastic neoplasia (GTN) can cause significant morbidity and mortality if not appropriately recognized and treated. Low-dose induction chemotherapy is recommended for "ultra-high risk" GTN- defined as prognostic score ≥ 13 - to prevent mortality from hemorrhage that occurs when tumors respond rapidly. Case:A 22-year-old patient presented with hemoptysis due to pulmonary metastases from GTN, but with WHO score < 13. A multi-disciplinary care team began treatment with low-dose induction chemotherapy to prevent worsening pulmonary hemorrhage. While she required intubation to complete induction chemotherapy, she did not suffer further pulmonary hemorrhage during treatment. Conclusion:Low-dose induction chemotherapy should be considered as treatment for patients with GTN and pulmonary metastasis causing hemorrhage even if WHO score is <13.

To evaluate the association between intrauterine manipulator use and survival outcomes in patients undergoing minimally invasive hysterectomy for endometrial cancer because the oncologic effects of intrauterine manipulator use remain controversial. A comprehensive systematic review of the literature published up to December 31, 2024, was conducted with the PubMed, Scopus, Web of Science, and Cochrane Library databases. Two independent investigators screened comparative studies, including prospective or retrospective studies and randomized controlled trials, examining oncologic outcomes in patients with endometrial cancer who underwent minimally invasive hysterectomy with or without an intrauterine manipulator. Studies with insufficient outcome data, including those involving patients who underwent open abdominal hysterectomy and those published in languages other than English, were excluded. Data extraction and synthesis were performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. Random-effects analysis was used for data pooling. The primary outcomes were disease-free survival and overall survival. Confounding factors affecting prognosis and risk of bias were also evaluated. Between 2013 and 2024, 12 eligible studies, including 10 retrospective studies and two randomized controlled trials, enrolled 6,029 patients who underwent minimally invasive hysterectomy with an intrauterine manipulator and 4,776 patients without one. In the unadjusted pooled analysis, disease-free survival was lower in patients who underwent surgery with an intrauterine manipulator than in those without (nine studies, hazard ratio 1.18, 95% CI, 1.01–1.38, P =.04). Albeit statistically nonsignificant, the hazard ratio for all-cause mortality comparing intrauterine manipulator use with nonuse was 1.27 (six studies, 95% CI, 0.99–1.62, P =.06). Only a limited number of studies (4 of 12 studies, 33.3%) examined survival outcomes after adjustment for factors such as adjuvant treatment and tumor histology. Most studies (7 of 12, 58.3%) had a moderate risk of bias, and five (41.6%) had a serious risk of bias. This meta-analysis suggests that intrauterine manipulator use during minimally invasive hysterectomy may be associated with decreased disease-free survival in patients with endometrial cancer; however, the association with overall survival is marginal and did not reach statistical significance. Considering that most studies included in this meta-analysis were retrospective, did not adjust for prognostic factors such as postoperative treatment, and were of low to moderate quality, the associations found in this study warrant further investigation in future prospective trials. PROSPERO, CRD42023428140.

OBJECTIVE:Malignant ovarian germ cell tumors (MOGCTs) are rare non-epithelial ovarian malignancies. Although comprehensive surgical staging, including lymphadenectomy, is recommended by current guidelines, the prognostic benefit in early-stage disease remains uncertain. We evaluated patterns of lymphadenectomy use and its association with survival in stage T1 MOGCTs. METHODS:Using the National Cancer Database, we identified women with stage T1 MOGCTs diagnosed between 2018 and 2022. Multivariable log-linear regression was used to identify factors associated with lymphadenectomy. Propensity score inverse probability of treatment weighting (IPTW) was applied to estimate the association between lymphadenectomy and survival using weighted Kaplan-Meier and Cox proportional-hazards models. RESULTS:Among 740 patients, 47.3% underwent lymphadenectomy, with use declining from 53.3% in 2018 to 36.2% in 2022 (P = 0.02). Dysgerminoma histology (aRR 1.78, 95% CI: 1.19-2.66), larger tumor size (>150 mm, aRR 1.44, 95% CI: 1.03-2.01), and performance of hysterectomy (aRR 1.40, 95% CI: 1.04-1.87) were associated with increased likelihood of undergoing lymphadenectomy. The median number of nodes examined was 9 (IQR 4-16), with nodal metastases identified in 6.6% of cases, most commonly among dysgerminomas. After PS IPTW, patients who underwent lymphadenectomy were more likely to receive adjuvant chemotherapy (52.8% vs. 44.7%; SMD = 0.16), and lymphadenectomy was not associated with improved survival (aHR 1.23, 95% CI: 0.38-4.06). CONCLUSIONS:In stage T1 MOGCTs, lymphadenectomy was not associated with improved survival but was associated with higher rates of adjuvant chemotherapy use. Given the low rate of nodal metastasis and excellent survival outcomes, a selective approach to lymphadenectomy may be appropriate.

BACKGROUND:Conversion to laparotomy during minimally invasive hysterectomy for endometrial cancer has been an area of active research interest. Such data are scarce within a more contemporary study period. OBJECTIVE:The primary objective was to compare laparotomy conversion rates between robotic-assisted and conventional laparoscopic hysterectomy for endometrial cancer; the secondary objective was to assess unplanned readmissions and perioperative mortality per surgical modality. STUDY DESIGN:This comparative effectiveness study queried the Commission-on-Cancer's National Cancer Database in the United States. The study population included 210,615 patients with stage I to III endometrial cancer who underwent upfront minimally invasive hysterectomy from 2012 to 2023. Exposure was intent-level surgical modality, comparing robotic-assisted and conventional laparoscopic hysterectomy (n=164,137 and n=46,478, respectively). The primary outcome measure was laparotomy conversion, defined as open surgery at the per-procedure level; the secondary outcome measures included unplanned postdischarge readmission and perioperative mortality within 30 days of the index anticancer surgery. Temporal trends were assessed with linear segment regression model. The exposure-outcome association was assessed in propensity score inverse probability of treatment weighting cohort to reduce the differences in baseline clinico-pathologic characteristics between the 2 surgical modality groups, created with a multivariable generalized linear model with Poisson distribution. A classification tree was constructed to visualize the patterns of clinico-pathologic characteristics associated with laparotomy conversion. RESULTS:Over the 12-year study period, laparotomy conversion rates decreased from 2.1% to 1.0% in the robotic-assisted hysterectomy group (average annual percentage change, -5.1%; 95% confidence interval, -7.6% to -3.1%) and from 9.0% to 4.8% in the conventional laparoscopic hysterectomy group (average annual percentage change, -6.1%; 95% confidence interval, -7.3% to -4.9%). Larger tumor size was associated with a higher laparotomy conversion rate for both surgical modalities: inflection points for increasing laparotomy conversion rates were 5 cm and 4 cm for robotic-assisted and conventional laparoscopic surgery, respectively. In the propensity score weighted model, robotic-assisted hysterectomy was associated with a 78% lower laparotomy conversion rate compared to conventional laparoscopic hysterectomy (1.5% vs 6.3%; incidence rate ratio, 0.22; 95% confidence interval, 0.21 to 0.24). Unplanned readmission (16.9 vs 19.0 per 1000; incidence rate ratio, 0.89; 95% confidence interval, 0.83 to 0.96) and perioperative mortality (2.0 vs 2.6 per 1000; incidence rate ratio, 0.80; 95% confidence interval, 0.65 to 0.99) rates were also lower for robotic-assisted hysterectomy compared to conventional laparoscopic hysterectomy. A classification tree identified 20 unique clinico-pathologic patterns associated with laparotomy conversion, of which 3 patterns exceeded 10%. All 3 patterns had conventional laparoscopic hysterectomy for tumor size of 6 cm or greater, whereas robotic-assisted surgery for tumor size of smaller than 4 cm had a rate of 1% or lower. CONCLUSION:The results of this study suggest that among the Commission-on-Cancer-affiliated hospitals in the United States, laparotomy conversion during minimally invasive hysterectomy for endometrial cancer has decreased. While limited by potential confounding by surgeon- or patient-related factors, these data suggest that surgeons who preferentially perform robotic-assisted hysterectomy may have lower associated rates of laparotomy conversion, unplanned postdischarge readmission, and perioperative mortality compared to those who perform conventional laparoscopic hysterectomy. Whether perioperative morbidity differs according to a surgeon's preferred practice for minimally invasive surgery warrants further evaluation.

OBJECTIVE:To evaluate the association between intrauterine manipulator use and survival outcomes in patients undergoing minimally invasive hysterectomy for endometrial cancer because the oncologic effects of intrauterine manipulator use remain controversial. DATA SOURCES:A comprehensive systematic review of the literature published up to December 31, 2024, was conducted with the PubMed, Scopus, Web of Science, and Cochrane Library databases. METHODS OF STUDY SELECTION:Two independent investigators screened comparative studies, including prospective or retrospective studies and randomized controlled trials, examining oncologic outcomes in patients with endometrial cancer who underwent minimally invasive hysterectomy with or without an intrauterine manipulator. Studies with insufficient outcome data, including those involving patients who underwent open abdominal hysterectomy and those published in languages other than English, were excluded. TABULATION, INTEGRATION, AND RESULTS:Data extraction and synthesis were performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. Random-effects analysis was used for data pooling. The primary outcomes were disease-free survival and overall survival. Confounding factors affecting prognosis and risk of bias were also evaluated. Between 2013 and 2024, 12 eligible studies, including 10 retrospective studies and two randomized controlled trials, enrolled 6,029 patients who underwent minimally invasive hysterectomy with an intrauterine manipulator and 4,776 patients without one. In the unadjusted pooled analysis, disease-free survival was lower in patients who underwent surgery with an intrauterine manipulator than in those without (nine studies, hazard ratio 1.18, 95% CI, 1.01-1.38, P =.04). Albeit statistically nonsignificant, the hazard ratio for all-cause mortality comparing intrauterine manipulator use with nonuse was 1.27 (six studies, 95% CI, 0.99-1.62, P =.06). Only a limited number of studies (4 of 12 studies, 33.3%) examined survival outcomes after adjustment for factors such as adjuvant treatment and tumor histology. Most studies (7 of 12, 58.3%) had a moderate risk of bias, and five (41.6%) had a serious risk of bias. CONCLUSION:This meta-analysis suggests that intrauterine manipulator use during minimally invasive hysterectomy may be associated with decreased disease-free survival in patients with endometrial cancer; however, the association with overall survival is marginal and did not reach statistical significance. Considering that most studies included in this meta-analysis were retrospective, did not adjust for prognostic factors such as postoperative treatment, and were of low to moderate quality, the associations found in this study warrant further investigation in future prospective trials. SYSTEMATIC REVIEW REGISTRATION:PROSPERO, CRD42023428140.

The 2023 International Federation of Gynecology and Obstetrics revision introduced stage IA3 to recognize a biologically favorable subset of low-grade endometrioid endometrial cancers characterized by superficial myometrial invasion, absence of substantial lymphovascular space invasion, and unilateral, intra-capsular ovarian involvement. This reclassification reflects an evolving understanding, shaped by pathology, molecular profiling, and outcomes research that many uterus-ovary endometrioid pairs are clonally related yet clinically indolent, challenging historical assumptions that all adnexal involvement warrants intensified adjuvant treatment. Emerging molecular data suggest that this pattern of disease reflects a form of restricted metastatic spread limited to the endometrium-ovary interface, where a uniquely compatible microenvironment allows localized implantation without widespread peritoneal dissemination. In this narrative review, we synthesize the current literature and prevailing schools of thought regarding the prognostic meaning of adnexal involvement, the distinction between synchronous double primaries and limited metastatic spread, and the implications of molecular classification for risk assessment. We summarize evidence indicating favorable survival in rigorously defined IA3 cohorts, while underscoring persistent uncertainties arising from retrospective study designs, variable pathologic thresholds, and incomplete molecular annotation. Rather than prescribing definitive management, this review frames IA3 as a testing ground for risk-adapted care that integrates meticulous pathology with molecular context, acknowledges areas of controversy, and identifies priorities for future research. Collectively, these perspectives aim to support thoughtful, individualized decision-making as the field converges on when "less may be more" for appropriately selected IA3 patients. Given the limited and retrospective nature of available data, definitive treatment recommendations cannot yet be made, reinforcing the need for prospective, molecularly stratified studies to inform future practice.

This comparative effectiveness study of 15,572 patients with stage IA ovarian cancer who underwent primary anti-cancer surgery with adnexectomy from 2012 to 2022, identified in the Commission-on-Cancer’s National Cancer Database, compared the overall survival of 5867 patients who underwent minimally invasive surgery with that of 9705 patients who underwent open surgery. In the propensity score inverse probability of treatment weighting cohort for node-staged cases, the 5-year overall survival rates were 92.4% (95% confidence interval 91.1% to 93.7%) for the minimally invasive surgery group and 92.0% (95% confidence interval 91.2% to 92.7%) for the open surgery group. Controlling for postoperative chemotherapy use, the adjusted hazard ratio for minimally invasive surgery compared with open surgery was 0.94 (95% confidence interval 0.80 to 1.11). This survival association was consistent when including node-unstaged cases or for histology subgroups, including type I epithelial ovarian cancer, type II epithelial ovarian cancer, sex cord-stromal tumors, and malignant germ cell tumors. Associations were also similar when the modality of minimally invasive surgery was assessed as robot-assisted or conventional laparoscopic surgery. In conclusion, the results of this comparative effectiveness study suggest that minimally invasive surgery may not negatively influence overall survival for stage IA ovarian cancer when adnexectomy is performed without ovarian capsule rupture during surgery.

Early detection of epithelial ovarian cancer (EOC) remains a major clinical challenge. Although serum tumor markers are widely used for detection, their diagnostic performance remains limited. We previously developed a comprehensive serum glycopeptide spectrum analysis (CSGSA) approach that integrates tumor marker measurements and enriched glycopeptides (EGPs) using convolutional neural networks. In this study, we evaluated whether a two-step LightGBM framework incorporating cancer antigen 125 (CA125), human epididymis protein 4 (HE4), cancer antigen 72 − 4 (CA72-4), and EGPs could improve the diagnostic specificity and projected positive predictive value (PPV) for EOC detection compared with conventional biomarker-based approaches. The study included 553 patients with EOC and 1,144 non-EOC controls (healthy individuals or patients with benign conditions). Serum levels of CA125, HE4, and CA72-4 were measured along with 1,712 EGPs. Diagnostic models were developed using machine learning algorithms and evaluated for accuracy, area under the receiver operating characteristic curve (ROC-AUC), PPV, and negative predictive value (NPV). The highest diagnostic performance was achieved using a two-step classification framework. First, patients were stratified into high-, intermediate-, and low-risk groups based on tumor markers and age. Second, the intermediate-risk group was reclassified using a model incorporating EGP-derived features. Among the evaluated algorithms, LightGBM achieved the best performance, yielding a prevalence-adjusted (projected) PPV of 18.7

In this retrospective cohort study examining 197 patients with T1b3, T2a2, and T2b small cell neuroendocrine carcinoma of the uterine cervix identified in the Commission-on-Cancer's National Cancer Database from 2006 to 2022, the majority received non-hysterectomy treatment with a combination of external beam radiotherapy and chemotherapy (63.5%), followed by primary hysterectomy and post-operative external beam radiotherapy and chemotherapy (17.8%), primary hysterectomy and postoperative chemotherapy without external beam radiotherapy (9.6%), and hysterectomy after a combination of external beam radiotherapy and chemotherapy (9.1%). The median tumor size was 6 cm. Among the hysterectomy cases, nearly one-quarter had surgical margins with tumor involvement (23.2%). The median follow-up was 7.6 years. When compared to a combination of external beam radiotherapy and chemotherapy without hysterectomy, primary hysterectomy followed by postoperative combination external beam radiotherapy and chemotherapy was associated with improved overall survival in multivariable analysis (5-year overall survival rate, 68.9% vs 46.9%; adjusted-hazard ratio, 0.42; 95% confidence interval, 0.24 to 0.74). This association was similar for node-positive cases in exploratory analysis. In conclusion, the results of these hypothesis-generating analyses may propose a possible role of hysterectomy in conjunction with radiotherapy and chemotherapy in select patients with early bulky locally advanced small cell neuroendocrine carcinoma of the uterine cervix, particularly when access to high-quality radiotherapy is not available.

OBJECTIVE:While ovarian preservation has been shown to be safe for premenopausal patients with low-grade, early-stage endometrioid endometrial cancer, there is limited data for higher risk tumors. We assessed the trends, predictors, and survival associated with ovarian preservation at the time of hysterectomy among premenopausal women with high-risk, early-stage endometrial cancers. METHODS:Women <50 years of age with stage I-II grade 2 endometrioid or high-risk (grade 3 endometrioid, non-endometrioid) endometrial cancers diagnosed from 2012 to 2022 and recorded in the National Cancer Database (NCDB) were examined. A multivariable logistic regression model, was used to examine factors associated with ovarian preservation. Adjusted survival curves and a Cox proportional hazards model (with inverse probability of treatment weighting [IPTW]) were used to compare the hazards of survvial in women who did and did not undergo ovarian preservation. RESULTS:A total of 7230 women including 295 (4.1 %) who underwent ovarian preservation were identified. The rate of ovarian preservation declined over time. Older age was associated with lower odds of ovarian preservation. After IPTW, 5-year survival was 94.2 % (95 % CI: 90.2-96.6 %) with ovarian preservation and 94.4 % (95 % CI: 93.5-95.2 %) with oophorectomy. In the weighted Cox proportional hazards model, ovarian preservation was not associated with overall survival (HR = 1.05, 95 % CI = 0.57-1.94). CONCLUSIONS:Use of ovarian preservation in premenopausal women with high-risk endometrial cancers has decreased over time. Ovarian preservation was not associated with an adverse impact on survival.

This cohort study examines the associations of minimally invasive surgery, intraoperative capsule rupture, and overall survival among patients with stage I ovarian cancer.

In this cross-sectional study examining 211,708 patients with a diagnosis of uterine prolapse who underwent hysterectomy between 2016 and 2019 identified in the Healthcare Cost and Utilization Project's Nationwide Ambulatory Surgery Sample, co-diagnosis of gynecologic malignancy was reported in 2,398 (1.1%) patients, and they were less likely to receive reconstructive surgery at hysterectomy (odds ratio [OR] 0.90, 95% CI 0.84–0.96). This absence of reconstructive surgery was most pronounced among patients with complete uterine prolapse and gynecologic malignancy (OR 0.68, 95% CI 0.57–0.81). The association was also consistent in coexisting gynecologic premalignancy (n=3,357 [1.6%]). In conclusion, this national-level assessment suggests that patients with uterine prolapse and coexisting gynecologic malignancy or premalignancy may be less likely to receive reconstructive surgery for pelvic floor dysfunction at hysterectomy.