Unexpected Pathology During Pelvic Organ Prolapse Repair in an Urban Population

Objectives: The lifetime risk of undergoing surgery for pelvic organ prolapse (POP) repair is expected to rise with the aging population. In preparation for POP surgery with or without concomitant hysterectomy, patients are routinely counseled regarding risks of abnormal gynecologic pathology. There are relatively few data evaluating the risk of occult malignancy found incidentally during POP repair among racially and ethnically representative groups of patients. The objective of this study is to provide representative estimates for unexpected gynecologic pathology incidence amongst low-risk patients considering surgery for symptomatic POP.

Methods: A retrospective chart review of patients undergoing hysterectomy for POP between January 2015 and June 2023 was conducted in an urban academic medical center. Patients whose primary indication for surgery was not POP, or those with known uterine, cervical, or adnexal pathology, were excluded. Data abstracted from the electronic health record included demographic and obstetric history, preoperative ultrasound evaluation and known clinical risk factors for gynecologic malignancy. Data were analyzed using descriptive statistics.

Results: 230 non-oncologic patients underwent hysterectomy as part of POP repair between 2015 and 2023. Half (49.6%) of patients were white, 16.5% Black, and 37.0% Hispanic. Specific demographic and procedural characteristics are listed in Table 1. Three patients (1.3%) were diagnosed with abnormal uterine pathology; one patient with endometrial hyperplasia and two with uterine malignancy. Of the two patients diagnosed with malignancy, one had a history of postmenopausal bleeding. Both underwent preoperative pelvic ultrasound, one of which revealed a thickened endometrium. Two patients (0.8%) were diagnosed with cervical dysplasia. Preoperative symptoms and pathology results are represented in Figure 1. Overall, 4 of 5 patients with premalignant or malignant lesions had presented with a history of abnormal uterine bleeding. None of the patients with concurrent oophorectomy or salpingectomy had pre-malignant or malignant pathology.

Conclusions: The overall incidence of unexpected gynecologic pathology at the time of hysterectomy for prolapse among the present cohort was 2.2%. Our relatively high incidence of uterine cancer (0.9%), compared to prior studies (0-0.3%), warrants further investigation amongst larger cohorts of racially and ethnically diverse patients. These findings highlight the importance of preoperative counseling regarding possible oncologic pathology at the time of prolapse surgery, particularly in patients with postmenopausal bleeding.