Background Impact factor bias, in which positive results are preferentially published in higher-impact journals, may influence evidence visibility and interpretation. Whether such impact factor bias exists in gynecologic oncology trials remains unclear. We evaluated the association between study outcome and journal impact factor in phase III gynecologic oncology randomized controlled trials. Methods A meta-epidemiologic analysis was conducted of phase III gynecologic oncology randomized controlled trials identified through ClinicalTrials.gov up to May 2024. Only completed, two-arm, superiority-design trials (as it allows for a clear and unambiguous interpretation of trial results) with published primary endpoint data were included. Data extracted for each publication included impact factor at year of publication, number of enrolled patients, duration of follow-up, disease site, number of authors, country of first and senior author based on primary institutional affiliation, and primary outcome (classified as positive if the intervention arm demonstrated statistically significant superiority over the control arm). The primary outcome was journal impact factor stratified by study results. Univariate and exploratory multivariable analyses were performed to identify factors associated with higher journal impact factors. Results A total of 36 eligible trials were identified, published during 2009-2024; 47.2% reported positive primary outcomes. The median journal impact factor across all studies was 35.1 (interquartile range [IQR] 18.3–51.6) (range 3.7-158.5). Trials with positive outcomes were published in journals with significantly higher impact factors than those with negative outcomes (44.5 [IQR 18.7–71.5] vs. 24.0 [IQR 5.3–44.5], p=.034). The number of authors was also greater in positive studies (median 21 vs. 16, p=.032). In multivariable linear regression, a positive primary outcome was the only independently associated factor with higher journal impact factor. Positive outcomes were published in journals with, on average, 32.6 (95% CI 6.4-58.8) point higher impact factors, respectively. Follow-up duration and sample size were not significant predictors. Conclusions Positive phase III gynecologic oncology trials were published in higher impact factor journals, with outcome positivity independently associated with impact factor. This pattern may affect evidence visibility and highlights the need to support dissemination of high-quality negative studies.

INTRODUCTION:The Enhanced Recovery After Surgery pathway has transformed peri-operative care in gynecologic surgery through multi-disciplinary, evidence-based protocols. However, real-world adherence to and interpretation of specific Enhanced Recovery After Surgery elements remain heterogeneous, with ongoing discussion about their feasibility and clinical relevance. During the 2025 Enhanced Recovery After Surgery World Congress in Turin, Italy, a rapid-fire debate session addressed 4 "hot topics" in gynecologic Enhanced Recovery After Surgery implementation. GLYCEMIC CONTROL:Peri-operative dysglycemia is associated with worse surgical outcomes, although the evidence favors a targeted rather than universal screening strategy. Universal hemoglobin A1c testing was considered impractical, with screening recommended for patients with diabetes, obesity, or cardiovascular disease to balance safety and oncologic timeliness. REGIONAL ANALGESIA:Although transversus abdominis plane blocks reduce opioid use and prolong analgesia, multi-layer wound infiltration remains a pragmatic and cost-effective alternative, especially in low-resource settings where expertise or ultrasound guidance is limited. VENOUS THROMBOEMBOLISM PROPHYLAXIS:In light of the overall risk profile and low bleeding rates, many patients undergoing laparotomy for adnexal masses are likely to benefit from pharmacologic prophylaxis. Development of gynecology-specific risk models remains an unmet research priority. NORMOTHERMIA:Structured multi-disciplinary warming bundles can significantly reduce peri-operative hypothermia, but implementation must remain flexible to accommodate different institutional resources and thresholds. CONCLUSIONS:The 2025 Enhanced Recovery After Surgery World Congress debates reinforced that the evolution of Enhanced Recovery After Surgery in gynecologic surgery depends less on discovering new interventions than on refining, validating, and implementing existing evidence. Individualized standardization-adapting Enhanced Recovery After Surgery principles to patient and resource variability-remains the cornerstone of enhanced recovery progress.

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.

Statins, potent inhibitors of 3-hydroxy-3-methylglutaryl coenzyme A reductase, have demonstrated anti-neoplastic activity in pre-clinical models; however, their clinical efficacy in gynecologic malignancies remains uncertain. This review evaluates the association between statin use and survival outcomes in cervical, endometrial, and ovarian cancers, and synthesizes emerging pre-clinical and clinical data to clarify their translational potential. A PubMed search identified 44 English-language studies published between January 2005 and August 2025 that reported survival outcomes among gynecologic patients receiving statins, as well as studies assessing statin use in combination with immunotherapy. Across 406,285 patients, evidence in cervical cancer remains limited to a single cohort (n = 76), which showed a markedly reduced risk of mortality among statin users (hazard ratio [HR] 0.098). In endometrial cancer, 5 large observational cohorts (n = 985-295,925) reported post-diagnosis HRs between 0.61 and 0.79. In ovarian cancer, 8 retrospective studies (n = 126-8629) demonstrated HRs ranging from 0.45 to 0.90, and 2 meta-analyses (combined n = 57,564) indicated a survival advantage (HRs 0.74-0.87), particularly for non-serous histologies and among patients initiating statins after diagnosis. Post-hoc analyses of ovarian cancer trials further suggest potential synergy between statins and poly(ADP-ribose) polymerase (PARP) inhibitors. Evidence from non-gynecologic tumors also indicates improved outcomes with concurrent statin use during immunotherapy (overall survival HR 0.76; progression-free survival HR 0.80). Overall, post-diagnosis statin use appears to confer a 10% to 25% improvement in overall survival across gynecologic malignancies, supporting the rationale for prospective, histotype-stratified randomized trials evaluating statins, alone or combined with PARP or immune checkpoint inhibitors, as adjuncts to standard therapy.

Objective Current tissue-based methods for ruling out endometrial cancer in symptomatic women are highly invasive. We explored whether non-invasive vaginal samples could be used to detect endometrial cancer. Methods Women undergoing hysterectomy were enrolled in an exploratory study, PNK001, wherein vaginal swabs, ectocervical swabs, endocervical cytobrushes, and endometrial tissue were obtained. Additionally, we secured RNA sequencing data from The Cancer Genome Atlas and endometrial tissues from the Cooperative Human Tissue Network. We generated sequencing data from swab, cytobrush, and tissue samples representing 27 PNK001 participants and 46 Cooperative Human Tissue Network samples. We analyzed differential expression, cell type signatures, and expressed somatic variants. We performed machine learning analyses on tissue samples and data from 20 PNK001 participants using expressed features and surgical pathology as reference labels. Results Machine learning classifiers trained on and applied to tissue samples achieved receiver operating characteristic area under the curve values of 0.97 and 0.98 on an independent test set. Significant differential gene expression and elevated somatic variant counts were present in endocervical cytobrush samples, ectocervical swabs, and vaginal swabs from women with endometrial cancer. Classifiers trained using expressed genes and variant counts distinguished 5 benign from 15 malignant cases in cytobrush, ectocervical, and vaginal swab samples, with average receiver operating characteristic area under the curve values of 0.6 to 0.96 in cross-validation. Conclusions Vaginal swabs provided sufficient signal to detect endometrial cancer using RNA-based machine learning. We therefore selected the vaginal swab as the primary sample type for a second study (PNK002) to develop and validate a test for endometrial cancer. A non-invasive vaginal swab test with high sensitivity and negative predictive value could potentially rule out cancer in symptomatic women instead of invasive workup.

OBJECTIVE:We aimed to compare oncologic and peri-operative outcomes after minimally invasive surgery versus open surgery among women with clinical stage I uterine leiomyosarcoma. METHODS:We performed a retrospective cohort study using the National Cancer Database (2010-2021). Eligible cases were clinical stage I leiomyosarcoma (cT1a/cT1b) treated with hysterectomy and bilateral salpingo-oophorectomy. Patients were grouped by surgical approach (minimally invasive surgery [laparoscopy/robotic] vs open); conversions were analyzed descriptively and excluded from outcome models. Primary outcome was overall survival; secondary outcomes were length of stay and 30-day readmission. Survival was assessed with Kaplan-Meier and log-rank tests; multi-variable Cox models adjusted for age, adjuvant therapy, margin status, and pathologic stage. RESULTS:Among 683 patients, 208 (30.5%) underwent minimally invasive surgery, 447 (65.4%) open surgery, and 28 (4.1%) had conversions. Minimally invasive surgery patients more often were White (85.1% vs 70.0%) and privately insured (66.8% vs 54.4%), had higher neighborhood income, more clinical stage IA disease (30.3% vs 15.2%), and smaller tumors (median 7.2 cm vs 9.9 cm, all p <.001). Adjuvant chemotherapy and radiotherapy rates were similar between groups. Minimally invasive surgery was associated with a shorter hospital stay (median 1 vs 3 days, p <.001) and comparable 30-day readmission (both 3.8%). In clinical stage IA, unadjusted overall survival favored minimally invasive surgery (68.0% alive at 94 months vs 51.5% open, log-rank p =.028), whereas stage IB showed no difference (median overall survival 79 vs 79 months, p =.72). In multi-variable analysis, surgical approach was not independently associated with overall survival (adjusted hazard ratio 1.16, 95% confidence interval 0.91 to 1.49). Worse overall survival was associated with increasing age, higher stage, and positive margins. CONCLUSIONS:The surgical approach was not independently associated with survival. Future prospective cohorts should capture specimen extraction and tumor disruption to better define which patients can safely undergo minimally invasive approaches.

OBJECTIVE:Glucagon-like peptide-1 receptor agonists are increasingly prescribed for diabetes and obesity among patients undergoing gynecologic surgery. Beyond metabolic effects, glucagon-like peptide-1 receptors are expressed in the central nervous system and are implicated in nociception, reward processing, and neuroinflammatory signaling, suggesting a potential impact of glucagon-like peptide-1 receptor agonist exposure on opioid requirements. This study evaluated whether pre-operative Glucagon-like peptide-1 receptor agonist use is associated with reduced post-operative opioid consumption and differences in post-operative pain, length of stay, and 30-day post-operative complications. METHODS:A single-center retrospective cohort study was conducted including patients undergoing gynecologic surgery between November 2023 and September 2025 within an Enhanced Recovery After Surgery pathway. The exposure was pre-operative Glucagon-like peptide-1 receptor agonist therapy, defined as an active prescription at surgical scheduling. The primary outcome was post-operative opioid use in morphine milligram equivalents in the post-anesthesia care unit and during admission. Secondary outcomes included highest post-anesthesia care unit pain score, length of stay, and 30-day complications according to the Clavien-Dindo complication. Analyses included unadjusted comparisons, multivariable linear regression, and propensity score matching. RESULTS:Among 1320 patients (median age, 51 years), 140 (10.6%) were using Glucagon-like peptide-1 receptor agonist and had a significantly higher pre-operative comorbidity burden, including obesity, diabetes, higher Charlson Comorbidity Index, and ASA class III to IV, compared with non-users (all p < .05). No differences were observed between groups in opioid consumption in the post-anesthesia care unit (27.9 vs 25.8 morphine milligram equivalents) or during admission (16.4 vs 12.7 morphine milligram equivalents), pain scores (5.4 vs 5.3), length of stay (0.8 vs 0.9 days) or complications (15.7% vs 13.4%) (all p > .05). Results were consistent after propensity score matching. In multivariable analysis, obesity was independently associated with higher opioid consumption (β 4.01, p = .019). CONCLUSIONS:Pre-operative Glucagon-like peptide-1 receptor agonist use was not associated with reduced post-operative opioid requirements in a cohort managed under an Enhanced Recovery After Surgery program. Despite greater baseline comorbidity among patients using glucagon-like peptide-1 receptor agonists, short-term post-operative outcomes were similar, without increased complications.

OBJECTIVE:Retractions in scientific publishing have increased sharply in the past 2 decades, with more than 10,000 articles withdrawn globally in 2023. Despite this growth, the scope, causes, and temporal patterns of retractions within gynecologic oncology have not been systematically characterized. Understanding these patterns is essential to safeguard research integrity and maintain confidence in the oncologic evidence base. METHODS:We conducted a descriptive observational analysis of retracted gynecologic oncology publications using the Retraction Watch Database from its inception and publication outputs indexed in Web of Science between 1989 and 2024. Retracted articles were identified across all gynecologic oncology disease sites, and bibliometric characteristics, study type, country of origin, publisher, citation impact, time to retraction, and stated reasons for retraction were analyzed. RESULTS:We identified 220 retracted gynecologic-oncology articles published across 83 journals in all specialties. These retracted publications were cited 4955 times, with median citations per retraction of 6 (range; 0-1855). Ovarian (101, 45.9%), cervical (76, 34.5%), and endometrial cancer (34, 15.5%) were the most represented disease sites, and 126 (57.3%) of retracted articles were basic-science studies. Median time to retraction was 1 year (range; 0-14). Data concerns accounted for the majority of withdrawals (118, 53.6%), followed by compromised peer review (35, 15.9%), image duplication (15, 6.8%), and authorship or ethics issues (15, 6.8%). China accounted for the largest proportion of identified retractions (80.9%), followed distantly by the United States (4.1%) and Japan (2.7%). Two publishers accounted for 47.0% (n = 104) of retractions. When adjusted for overall publication volume (n = 265,102 gynecologic oncology articles), the global rate of retractions rose markedly from 0.7 per 1000 publications in 2000 to 10.1 per 1000 publications in 2024. CONCLUSIONS:These findings suggest opportunities to strengthen editorial and institutional safeguards, robust research-integrity training, and systematic implementation of fraud-detection tools to protect the quality of gynecologic-oncology literature.

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.

BACKGROUND:This is the third updated enhanced recovery after surgery (ERAS®) society guideline presenting a consensus for optimal perioperative care in gynecologic oncology surgery. METHODS:A database search of publications using Embase and PubMed was performed (2018-2025). Studies for key elements within the ERAS gynecologic oncology protocol were selected with emphasis on meta-analyses, randomized controlled trials, and large prospective cohort studies. These studies were then reviewed and graded according to the grading of recommendations, assessment, development and evaluation (GRADE) system. RESULTS:All recommendations on ERAS protocol items are based on best available evidence. The level of evidence for each item is presented accordingly. CONCLUSIONS:The updated evidence base and recommendation for items within the ERAS gynecologic oncology perioperative care pathway are presented by the ERAS® society in this consensus review. Gynecologic surgeons may consider incorporating these recommendations into perioperative pathway design, with efforts to achieve consensus within their practice where feasible.

Surgical trials have been among the most important drivers of practice change in gynecologic oncology, generating evidence across ovarian, endometrial, cervical, and vulvar cancer. These studies have demonstrated that the surgical approach, extent of resection, treatment sequence, and integration with systemic therapies profoundly affect survival, perioperative morbidity, and long-term quality of life, yet the credibility, interpretability, and clinical impact of surgical trials depend not only on their design but also on the way they are conducted. Unlike pharmacologic trials, surgical trials are uniquely vulnerable to bias arising from variability in surgeon expertise, intraoperative decision-making, institutional infrastructure, and adherence to protocol-defined techniques. Failure to adequately standardize or consistently implement treatment protocols may obscure the true effects of an intervention, compromise the internal validity of the study, and diminish the external validity and generalizability of the findings. Conversely, rigorous and well-executed trials enable researchers to make definitive, practice-changing conclusions. This review provides a comprehensive framework for the conduct of multicenter, surgical trials, focusing on key domains including eligibility determination, the timing and implementation of randomization, surgical credentialing, the standardization of surgical procedures, quality assurance, outcome selection, the integration of patient-reported outcomes, patient accrual and informed consent, and equitable trial participation. By outlining principles that balance methodological rigor with pragmatic relevance, this review highlights how optimized trial conduct is essential to generating reliable evidence, accelerating surgical innovation, and improving oncologic and patient-centered outcomes for women with gynecologic cancers.

OBJECTIVE:This study aimed to characterize national trends in hyperthermic intra-peritoneal chemotherapy utilization and associated survival outcomes among patients with stage III high-grade serous ovarian cancer undergoing interval cytoreductive surgery following the OVHIPEC-1 trial. METHODS:A retrospective cohort study using the National Cancer Database. Women diagnosed with stage III high-grade serous ovarian cancer who underwent interval cytoreductive surgery, with or without hyperthermic intra-peritoneal chemotherapy, between 2004 and 2022 were included. hyperthermic intra-peritoneal chemotherapy utilization trends were assessed relative to the 2018 OVHIPEC-1 publication. Survival was analyzed with Kaplan-Meier and Cox proportional-hazards models adjusted for age, stage, and comorbidity. Sensitivity analysis was performed for propensity-matched cohort, and for a cohort restricted to patients treated at centers performing hyperthermic intra-peritoneal chemotherapy. RESULTS:Among 15,946 women included, 335 (2.1%) received hyperthermic intra-peritoneal chemotherapy. Hyperthermic intra-peritoneal chemotherapy utilization was 1.4% before 2018 and 3.2% thereafter, with a 61% relative increase from 2018 to 2022, and an average annual percent change increase of 12.6% (p < .001). The median overall survival for hyperthermic intra-peritoneal chemotherapy cases was 66 months (95% confidence interval 56.7 to 75.2) versus 42 months (95% confidence interval 41.2 to 42.7), log rank p < .001. Cox regression adjusted for age, race, residual disease, and Charlson-Deyo comorbidity score-hyperthermic intra-peritoneal chemotherapy was associated with reduced risk of death; hazard ratio 0.71 (95% confidence interval 0.59 to 0.84). Following propensity matching for patients age, race, insurance type, median income, residual disease, and comorbidity score-hyperthermic intra-peritoneal chemotherapy was associated with a significantly longer median overall survival; 66 months (95% confidence interval 56.7 to 75.2) versus 45 months (95% confidence interval 39.9 to 50.1), log rank p = .013. When the analysis was restricted to patients treated at centers performing hyperthermic intra-peritoneal chemotherapy, it was associated with a significantly longer median overall survival; 66 months (95% confidence interval 56.7 to 75.2) versus 44 months (95% confidence interval 42.5 to 45.4), log rank p < .001. Hyperthermic intra-peritoneal chemotherapy was associated with a longer hospital stay and higher rates of 30-day readmission and mortality. CONCLUSIONS:Hyperthermic intra-peritoneal chemotherapy adoption, although limited nationally, has increased modestly since OVHIPEC-1, with probable survival benefits for selected patients. Translating pivotal trial evidence into widespread clinical practice continues to face implementation barriers.

In advanced ovarian cancer, complete cytoreductive surgery is a cornerstone of treatment, yet defining which patients are "fit for surgery" remains challenging. Although guidelines emphasize comprehensive pre-operative evaluation, standardized assessment tools are lacking, and clinical practices vary widely across institutions. This narrative review synthesizes current evidence on individual patient-related factors that influence surgical fitness, reviews risk-assessment algorithms designed to guide patient selection, and examines the emerging role of pre-habilitation in optimizing perioperative outcomes. A structured literature search of MEDLINE, Embase, and Cochrane databases (January 2004-September 2024), supplemented by targeted PubMed searches (January 2005-April 2025), identified studies evaluating aging, comorbidity, frailty, nutrition, sarcopenia, and pre-habilitation in relation to surgical outcomes. Eligible studies included systematic reviews, randomized controlled trials, and prospective or retrospective cohorts of patients undergoing primary or interval cytoreduction. After application of the inclusion criteria, 33 studies encompassing 41,580 patients were included. The evidence consistently demonstrates that older age (particularly ≥80 years), frailty, comorbidity burden, and malnutrition are associated with increased post-operative complications and mortality following cytoreductive surgery. Several predictive models and nomograms integrating these factors have been developed to estimate perioperative risk, though most lack multi-center external validation. Implementation of an evidence-based triage algorithm that incorporates key patient characteristics and anticipated surgical complexity has been associated with meaningful reductions in post-operative mortality in institutional practice. Emerging data on multi-modal pre-habilitation suggest feasibility and potential benefits, including lower complication rates, shorter hospital stays, and earlier initiation of chemotherapy, though evidence remains preliminary. Current evidence on surgical fitness in ovarian cancer is limited by heterogeneous definitions, retrospective study designs, lack of prospective validation, and inconsistent reliance on clinical judgment alone. Standardized, externally validated tools, consensus-based thresholds for surgical candidacy, and results from ongoing randomized pre-habilitation trials are needed to guide clinical decision-making and improve patient outcomes.

Pelvic artery embolization is a minimally invasive procedure that has evolved as an option for the management of acute bleeding from gynecologic malignancies by occluding blood flow within targeted tumor-feeding vessels. Small observational studies support its efficacy and safety for managing bleeding events from a variety of gynecologic malignancies. However, to date, no comparative studies have evaluated arterial embolization against palliative radiation therapy, surgical interventions, or non-surgical interventions, such as vaginal packing and tranexamic acid, for hemorrhage control. Moreover, theoretical concerns and limited data exist about potential oncological and treatment-related adverse outcomes after obstructing tumoral blood flow and inducing local hypoxia. This narrative review examines arterial embolization within the broader spectrum of management options for acute bleeding in gynecologic malignancies. Existing retrospective studies assessing arterial embolization for hemorrhage control in gynecologic malignancies were identified and included to provide a discussion of technical considerations, complications, outcomes, potential long-term oncologic effects, and theoretical concerns surrounding its clinical use. A systematic search and meta-analysis were not performed. Although no large or prospective studies have examined this topic, existing retrospective data show that embolization can be immediately successful in managing bleeding from gynecologic malignancies, with few procedural complications and variable rates of rebleeding.

Background In 2021, the ConCerv study provided the first prospective evidence that fertility-sparing surgery, including conization or simple hysterectomy, was safe in low-risk cervical cancer, and recurrence rates remained low, although oncologic outcomes were not the primary endpoint. Objective This study aimed to examine temporal trends in 2 fertility-sparing procedures for cervical cancer (trachelectomy and conization) along with associated oncologic outcomes and patterns of academic productivity via 3 separate datasets. Study Design This was a retrospective study of 3 separate database, integrating clinical data from the National Cancer Database (2004-2022; for oncologic outcomes and surgical trends), perioperative outcomes from the American College of Surgeons National Surgical Quality Improvement Program Participant Use Data Files (2012-2022; for postoperative complications), and scholarly output from the Web of Science Core Collection (2000-2025; for bibliometric analysis). In the National Cancer Database, we identified two cohorts of patients aged 18 to 45 years with cervical cancer, irrespective of histologic subtype, who were managed with conservative surgery and nodal staging: the first cohort underwent trachelectomy (radicality not specified), whereas the second cohort underwent conization. Temporal trends were examined using annual procedure counts, proportional utilization, and annual percentage change. Clinicopathologic characteristics were descriptively summarized and compared using appropriate parametric or nonparametric tests and chi-squared tests, with Bonferroni correction for multiple comparisons. Overall survival was analyzed in node-negative cases using Kaplan-Meier and log-rank methods, and treatment effects were evaluated with multivariate Cox regression adjusted for stage, histology, surgical margins, and tumor size, reporting hazard ratios with 95% confidence intervals. Results A total of 1841 patients underwent conservative surgery with lymph node assessment, including 911 trachelectomies (49.5%) and 930 conizations (50.5%). Patients who underwent trachelectomy were younger than those who underwent conization (median: 31 vs 33 years, respectively; P<.001). The number of lymph nodes examined was significantly greater in the trachelectomy cohort than in the conization cohort (15 vs 10, respectively; P<.001). Trachelectomy had a lower proportion of squamous cell carcinoma (465/911 [51.0%]) than conizations (570/930 [61.3%]), and adenocarcinoma was more common among patients who underwent trachelectomy (371/911 [40.7%]) than those who underwent conization (327/930 [35.2%]) (P<.001). In absolute numbers, trachelectomy use increased from 2004 to the mid-2010s, peaking in 2016, but subsequently demonstrated a steady and sustained decline through 2022. Among the whole cohort, the proportion of patients treated with trachelectomy declined from 64.0% in 2011 to 33.3% in 2022 (P<.001). The 10-year overall survival was similar between the groups (93.4% vs 92.3%; log-rank P=.39). In Cox regression, trachelectomy was not associated with overall survival (hazard ratio, 1.02 [95% confidence interval, 0.56-1.86]). Bibliometric analysis identified 1585 trachelectomy-related publications, which peaked in 2021 (n=128) and declined thereafter. Original research comprised 58.0% and reviews 15.6% of publications. Conclusion Trachelectomy use has decreased significantly in recent years, and overall survival was high in both cohorts. This alignment of excellent overall survival with changing practice patterns underscores an ongoing transition toward less radical surgery.

Background We aim to compare oncologic and perioperative outcomes after minimally invasive surgery versus open surgery among women with clinically stage I uterine leiomyosarcoma. Study design We performed a retrospective cohort study using the National Cancer Database (2010–2021). Eligible cases were clinical stage I leiomyosarcoma (cT1a/cT1b) treated with hysterectomy and bilateral salpingo-oophorectomy. Patients were grouped by surgical approach (minimally invasive surgery [laparoscopy/robotic] vs open); conversions were analyzed descriptively and excluded from outcome models. Primary outcome was overall survival; secondary outcomes were length of stay and 30-day readmission. Survival was assessed with Kaplan–Meier and log-rank tests; multivariable Cox models adjusted for age, adjuvant therapy, margin status, and pathologic stage. Results Among 683 patients, 208 (30.5%) underwent minimally invasive surgery, 447 (65.4%) open surgery, and 28 (4.1%) had conversions. Minimally invasive surgery patients more often were White (85.1% vs 70.0%) and privately insured (66.8% vs 54.4%), had higher neighborhood income, more clinical stage IA disease (30.3% vs 15.2%), and smaller tumors (median 7.2 cm vs 9.9 cm; all p<0.001). Adjuvant chemotherapy and radiotherapy rates were similar between groups. Minimally invasive surgery was associated with a shorter hospital stay (median 1 vs 3 days; p<0.001) and comparable 30-day readmission (both 3.8%). In clinical stage IA, unadjusted overall survival favored minimally invasive surgery (68.0% alive at 94 months vs 51.5% open; log-rank p=0.028), whereas stage IB showed no difference (median overall survival 79 vs 79 months; p=0.72). In multivariable analysis, surgical approach was not independently associated with overall survival (adjusted HR 1.16, 95% CI 0.91–1.49). Worse overall survival was associated with increasing age, higher stage, and positive margins. Conclusion The surgical approach was not independently associated with survival. Future prospective cohorts should capture specimen extraction and tumor disruption to better define which patients can safely undergo minimally invasive approaches.

OBJECTIVE:Impact factor bias, in which positive results are preferentially published in higher-impact journals, may influence evidence visibility and interpretation. Whether such an impact factor bias exists in gynecologic oncology trials remains unclear. We evaluated the association between study outcome and journal impact factor in phase III gynecologic oncology randomized controlled trials. METHODS:A meta-epidemiologic analysis was conducted of phase III gynecologic oncology randomized controlled trials identified through ClinicalTrials.gov up to May 2024. Only completed, two-arm, superiority-design trials (as this allows for a clear and unambiguous interpretation of trial results) with published primary endpoint data were included. Data extracted for each publication included impact factor at the year of publication, number of enrolled patients, duration of follow-up, disease site, number of authors, country of first and senior author based on primary institutional affiliation, and primary outcome (classified as positive if the intervention arm demonstrated statistically significant superiority over the control arm). The primary outcome was the journal impact factor stratified by study results. Univariate and exploratory multivariable analyses were performed to identify factors associated with higher journal impact factors. RESULTS:A total of 36 eligible trials were identified, published between 2009 and 2024; 47.2% reported positive primary outcomes. The median journal impact factor across all studies was 35.1 (interquartile range; 18.3-51.6) (range; 3.7-158.5). Trials with positive outcomes were published in journals with significantly higher impact factors than those with negative outcomes (44.5 [interquartile range; 18.7-71.5] vs 24.0 [interquartile range; 5.3-44.5], p =.034). The number of authors was also greater in positive studies (median 21 vs 16, p =.032). In multivariable linear regression, a positive primary outcome was the only independently associated factor with a higher journal impact factor. Positive outcomes were published in journals with, on average, 32.6 (95% confidence interval 6.4-58.8) point higher impact factors, respectively. Follow-up duration and sample size were not significant predictors. CONCLUSIONS:Positive phase III gynecologic oncology trials were published in higher-impact journals, with outcome positivity independently associated with impact factor. This pattern may affect evidence visibility and highlights the need to support dissemination of high-quality negative studies.