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Many surgeons performing minimally invasive hysterectomies for endometrial cancer have experienced intraoperative tumor spill, but few changed how these patients were managed post-op, according to a survey-based study.

Among over 200 U.S. surgeons, 90% reported using an intrauterine manipulator during minimally invasive hysterectomy for endometrial cancer, with the majority (87%) experiencing a perforation, reported Erica Chang-Patel, MD, of the LAC+USC Medical Center in Los Angeles.

Nearly all of the respondents performed the colpotomy laparoscopically, and 60% experienced a tumor spill, said Chang-Patel in a virtual presentation at the American Association of Gynecologic Laparoscopists (AAGL) annual meeting.

However, only 15% of surgeons reported changing their postoperative management after a tumor spill during colpotomy, and 11% after a uterine perforation with a manipulator.

"Many surgeons have experienced intraoperative tumor spillage during minimally invasive hysterectomy for endometrial cancer," Chang-Patel stated. "Tumor spillage may change a gynecologic oncologist's postoperative management."

This is likely the first investigation of tumor spill during minimally invasive hysterectomy for endometrial cancer, Chang-Patel said. She added that further research is warranted to better understand oncologic outcomes and management after surgery.

Chang-Patel noted techniques to minimize intraoperative tumor spill, including ligating or ablating fallopian tubes prior to insertion of a manipulator, and avoiding the use of a manipulator whenever possible, especially in cases of deep invasion. Additionally, Chang-Patel suggested cleaning exposed tumor contents in the upper vaginal canal prior to performing a laparoscopic colpotomy.

Endometrial cancer is the most common gynecologic malignancy in the U.S. and the sixth most common cancer among women worldwide. While hysterectomy -- which is curative for endometrial cancer -- was traditionally performed by laparotomy among these patients, many studies now support the use of minimally invasive approaches, Chang-Patel said.

But many are concerned about the risk of intraoperative tumor spill with these laparoscopic approaches. This occurs when a sterile surgical field is unexpectedly exposed to tumor cells. Decreased has been observed with tumor spill in several other malignancies, including early stage ovarian and cervical cancers, as well as gallbladder adenocarcinoma and rectal carcinoma.

For their study, Chang-Patel and colleagues surveyed Society of Gynecologic Oncology members, assessing the main elements of tumor spill during minimally invasive hysterectomy. They emailed the survey to more than 1,000 members for voluntary participation, with the final analysis including 220 provider responses.

Nearly half of the respondents completed their subspecialty training more than 10 years prior, and 74% performed more than 40 surgeries a year.

During minimally invasive hysterectomy for endometrial cancer, approximately 60% of surgeons reported that they obtain peritoneal washings, and 14% ligate or ablate fallopian tubes.

Chang-Patel recognized that the survey had a modest response rate, which may limit the generalizability of these findings. Additionally, the survey provided only qualitative results, it was not validated, and it did not evaluate the oncologic outcomes due to tumor spill.

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