Are Uterine Manipulators Harmful in Minimally Invasive Endometrial Cancer Surgery? A Retrospective Cohort Study

The objective of our study was to assess the oncological safety of uterine manipulators (UMs) in apparent early-stage (FIGO I-II 2009) endometrial cancer treated by minimally invasive surgery (MIS).

Our single-center retrospective study includes patients who underwent endometrial cancer surgery for apparent early-stage disease by either laparoscopy or by robotic or laparoscopic-assisted vaginal hysterectomy from November 2012 to December 2020. Data on UMs, isolated tumor cells (ITCs), cytology, lymphovascular space invasion, free cancer cells in fallopian tubes, stage, histology and grade were collected. Primary and secondary outcomes were cancer recurrence and disease-specific death. Kaplan-Meier curves and multivariate logistic regression were used for statistical analysis.

A total of 930 women with early-stage endometrial cancer were included; 789 (84.8%) had hysterectomy with a uterine manipulator and 141 (15.2%) without. A total of 88% had endometrioid histology, 71.6% were grade 1 and 95.7% had stage I disease. A higher risk of recurrence was observed with the Hohl manipulator (HR: 2.83. 95% CI: 1.004-7.98 p = 0.0492) on univariate analysis. On multivariate analysis, neither UM was associated with recurrence. With a mean follow-up of 48 months (range 3-118), no effect was seen on disease-specific death in either Hohl or V-Care (HR: 1.66. 95% CI: 0.48-5.70 and HR:1.29. 95% CI: 0.33-4.98). In high-grade histologies, UMs were strongly associated with recurrence (HR: 12.1. 95% CI: 1.52-96.6 p = 0.019) and disease-specific death (HR: 10.2. 95% CI: 1.12-92.1 p = 0.032).

The use of UMs in MIS for endometrial cancer was associated with higher rates of recurrence without affecting disease-specific death, except in high-grade histologies.