Unexpected Pathology During Pelvic Organ Prolapse Repair in an Urban Population

The prevalence of symptomatic pelvic organ prolapse (POP) in the United States is estimated at 3%, with around 300,000 patients undergoing surgical correction of POP annually. Surgical correction of POP often includes hysterectomy, and a potential risk of this procedure is unexpected pathology. Previous literature has shown the risk of premalignancy or malignancy in patients having procedures for benign indications to be 0.22% to 2.6%; understanding this risk is important when counseling patients as well as when considering preservation of the uterus. There is limited evidence, however, surrounding the rate of abnormal pathology at POP repair for racially and ethnically diverse populations. Preliminary evidence has suggested that rates may be higher in racial or ethnic subgroups, and this study was designed to assess this possibility. The purpose of this study was to provide a rate for abnormal uterine, cervical, fallopian tube, and ovarian pathology in a diverse population of nononcologic patients undergoing surgery for symptomatic POP. This was a retrospective study using data from an urban academic medical center. Inclusion criteria were patients above the age of 18 undergoing hysterectomy for POP between January 2018 and June 2023. Exclusion criteria were a primary indication for hysterectomy that did not include POP, patients who did not have a hysterectomy, patients who only received care from a benign gynecologist, and patients who had a known premalignant or malignant gynecologic lesion. The final analysis included 229 patients without a known premalignancy or malignancy before hysterectomy for POP. This cohort included 36% Hispanic individuals, 17% non-Hispanic Black individuals, and 38% non-Hispanic White individuals. A total of 75% of patients were postmenopausal, and ~23% had experienced abnormal bleeding. Incidence of unexpected pathology was 1.7%. Patients with abnormal findings included 2 patients with endometrial carcinoma (1 non-Hispanic black, 1 non-Hispanic White) and 2 patients with cervical dysplasia (1 non-Hispanic White, 1 Hispanic). These results indicate that the rate of unexpected malignancy was 1.7% in this cohort, much higher than the expected rate of 0.9%. This risk estimate may be useful in counseling patients who desire uterine preservation when undergoing surgical reconstruction for POP. Previous recommendations have indicated that in asymptomatic individuals, endometrial biopsy or evaluation is not necessary due to the low risk of unexpected malignancy, but if there is suspicion, such as abnormal uterine bleeding, greater age, menopausal status, hypertension, anemia, or weight loss, then endometrial assessment should be considered. This study's estimated risk of unexpected malignancy does not necessarily impact these recommendations, but does emphasize that care should be taken to assess all symptoms and counsel patients accordingly. Future research should focus on characterizing risks and benefits of uterine preservation in all ethnic and racial groups, and on estimating possible elevated risks in these groups.