Symptoms and General Pathology

All Conditions

Neoplasms

Urinary Tract, Sexual Organs, and Pregnancy Conditions

Recurrence

Endometrial Neoplasms

Disease Attributes

Uterine Neoplasms

Genital Neoplasms, Female

Urogenital Neoplasms

Uterine Diseases

Genital Diseases, Female

Genital Diseases

Urogenital Diseases

Female Urogenital Diseases

Pregnancy Complications

Female Urogenital Diseases and Pregnancy Complications

Patients who were operated for endometrial cancer by laparoscopy with the use of a uterine manipulator

Patients who were operated for endometrial cancer by laparoscopy without the use of a uterine manipulator

Patients were operated laparoscopically with the aid or not of an intrauterine probe to manipulate the uterus

UTERINE MANIPULATOR

Stefano Uccella

The investigators sought to retrospectively assess whether the use of a intrauterine device to manipulate the uterus does affect the long-term oncologic outcomes of patients operated by laparoscopy for endometrial cancer

The investigators retrospectively collected data regarding patients who received operation by laparoscopy for presumed clinical stage I endometrial cancer. The subjects were then stratified according to the use or not of the uterine manipulator. The investigators also considered the actual type of manipulator used. Then disease-free, disease-specific and overall survival were evaluated, as well as all the possible factors associated with prognosis.

Data were retrieved from specifically designed research quality internal surgical databases, prospectively updated by trained residents on a regular basis, in order to capture all the possible surgical and follow-up data.

Effect of Uterine Manipulator on Recurrence and Mortality of Endometrial Cancer

Effect of Uterine Manipulator on Recurrence and Mortality of Endometrial Cancer: a Multi-centric Study

Kaplan Meyer curves and Log-rank test to explore disease-specific survival

Kaplan Meyer curves and Log-rank test to explore overall survival

Università degli Studi dell'Insubria

Doctor

Patients with early-stage endometrial cancer who have performed a hysterectomy with a uterine manipulator to mobilize the uterus during the surgery.

Patients with early-stage endometrial cancer who have performed a hysterectomy without a uterine manipulator to mobilize the uterus during the surgery.

The uterine manipulator is a device commonly used in minimally invasive hysterectomy surgery for endometrial cancer. However, without substantial evidence to support its use, surgeons are required to make decisions about its use based only on their personal choice and surgical experience. . It is inserted vaginally through the cervical canal into the endometrial cavity. The uterine manipulator facilitates the uterus mobilization during the surgery, generating tension on the main supporting elements of the uterus to improve surgical field exposure and provide a landmark for the colpotomy.

USE OF UTERINE MANIPULATOR DURING THE HYSTERECTOMY

Pablo Padilla iserte, MD, PhD

Santiago Domingo del Pozo, MD, PhD

Pablo Padilla Iserte, MD, PhD

The uterine manipulator is a device commonly used in minimally invasive hysterectomy surgery for endometrial cancer. However, without substantial evidence to support its use, surgeons are required to make decisions about its use based only on their personal choice and surgical experience.

A retrospective study demonstrated how uterine manipulator use in early-stage endometrial cancer (FIGO I-II) for minimally invasive surgery was associated with a worse oncologic outcome in patients with uterus-confined endometrial cancer (FIGO I-II) who underwent minimally invasive surgery.

The main objective of this study is to prospectively confirm the results obtained retrospectively, assessing the relapse rate in these patients related to the use or not of a uterine manipulator during the endometrial surgery. Secondary, the presence of risk factors that contraindicate the use of the uterine manipulator will also be evaluated.

The primary treatment for early-stage endometrial cancer is surgery, performing a total hysterectomy and bilateral salpingo-oophorectomy with surgical staging if it is indicated.1 The National Comprehensive Cancer Network and European Society of Gynaecological Oncology Consensus recommend minimally invasive approaches (laparoscopic/robotic) in patients with disease limited to the uterus, according to evidence reported from randomized prospective studies (GOG-LAP2 trial).2 This approach leads to lower operative morbidity and a shorter hospital stay compared to open surgery, without compromising oncologic outcomes.3 The uterine manipulator is a device commonly used in minimally invasive gynecologic hysterectomy for benign disease. It is inserted vaginally through the cervical canal into the endometrial cavity. It facilitates the uterus mobilization during the surgery, generating tension on the main supporting elements of the uterus to improve surgical field exposure and provide a landmark for the colpotomy.4

With the introduction of minimally invasive approaches in gynecological oncology treatments, this uterine device has been utilized for endometrial and cervical cancers, with controversy regarding its influence on the spread of tumoral cells and the risk of recurrence. Recently, the LACC trial showed a worse than expected oncological outcome after a laparoscopic/robotic approach in early stage cervical cancer.5 One of the hypotheses generated was that the uterine manipulator might influence this worse prognosis.6 The retrospective European Succor study found the use of a manipulator was associated with a decrease in disease-free survival in cervical cancer in the minimally invasive group.7 Therefore, there are reasonable doubts about the uterine manipulator's safety in hysterectomy performed due to cancer.

In endometrial cancer, the presence of the uterine device in a cavity lined with neoplastic tissue leads to a potential tumor-manipulator interaction. Multiple mechanisms are potentially involved in this relationship but are poorly understood, however, the concept of uterus-confined disease is important to evaluate these interactions.8 Nonetheless, we have limited evidence from retrospectives studies about the uterine manipulator in endometrial cancer surgery, in which no impact of the uterine manipulator's use on oncological outcome has been found.9-12 To date, it remains a controversial conclusion that the theoretical tumor manipulation has no clear impact on oncological prognosis in endometrial cancer.

As is already known in other gynecological tumors (such as early-stage epithelial ovarian cancer or morcellation in unexpected uterine sarcoma), when the confined disease is exposed to the peritoneal cavity, the oncological outcome worsens.29 Therefore, the concept of organ-confined disease is an essential idea to understand our results. In early-stage endometrial cancer, the myometrium acts as a containment barrier, which may be iatrogenically injured by the uterine manipulator.

The MUCEI study by Padilla et al. suggests that the use of a uterine manipulator is associated with worse oncological outcomes in patients with uterus-confined endometrial cancer (FIGO I-II) at the time of surgery; it also presented a lower recurrence-free survival and lower overall survival, regardless of the type of manipulator with no differences in the pattern of recurrence.

The study observed a worse prognosis when the uterine manipulator was used in patients with the uterine-confined disease (FIGO I-II), not present in those patients with the no-confined disease (FIGO III) at the time of surgery. These results support the concept that the uterine manipulator might act in breaking the uterine-confined disease and worsen the oncological outcomes.

The different potential interferences may explain the alteration of the myometrial barrier by the uterine device. Therefore, two hypotheses are presented to explain this relationship between the uterine manipulator and endometrial cancer.

The first is the macroscopic injury hypothesis. During the insertion of any uterine manipulator (with or without balloon) and its use (especially in the atrophic uterus), the manipulator´s shank may weaken the myometrium, iatrogenically leading to uterine rupture and the opening of the tumor to the peritoneal cavity and surgical field.30,31 The uterine rupture is rarely reflected in surgical reports, and it has not been considered in previous analyses. Machida et al. showed a 0.4-1% perforation rate with a balloon manipulator,32 thus, other factors could be involved.

The second hypothesis is the microscopical pathway of dissemination. The uterine device generates a significant increase in pressure inside the endometrial cavity, generating global distension according to Pascal´s principle, which is additionally increased by the maintained push needed during uterine mobilization and colpotomy.33 This increased pressure might be involved in the improved ability of tumor cells to exceed the myometrial barrier, spreading outside the uterus cavity by a passive effect through the fallopian tubes and lymphovascular space.34

Methodology Prospective and non-randomized multicenter descriptive and analytical study in which the characteristics of the patients, the details associated with the surgery, and the oncological results will be studied depending on the use or not of the uterine manipulator.

The non-randomization is due to the fact that the procedure to be evaluated is surgeon-dependent, so the criteria for the use of the uterine manipulator or not will depend on the surgeon according to the protocol of his center. In other words, inclusion in the study does not modify the surgical practice in the patient.

Inclusion criteria include women with endometrial cancer diagnosed with stage I-II in a previous pre-surgical biopsy, the surgery has been performed and there are complete data on surgery, pathological anatomy, and follow-up.

Exclusion criteria include any patient with suspected disease beyond the uterus in the preoperative assessment or confirmed during surgical exploration. Cases without pathological confirmation of endometrial cancer in the final surgical specimen, or final histology of atypical hyperplasia/endometrial intraepithelial neoplasia will not be accepted.

Patients with open surgery, conversion to laparotomy, or vaginal hysterectomy alone will also be excluded.

The surgical variables collected will be: use of uterine manipulator (the type of uterine manipulator and classification of subtypes with or without intrauterine balloon), sealing of the fallopian tubes, surgical staging, intraoperative complications, surgical time and hospital stay. Collection of postoperative complications by Clavien-Dindo Classification. The final histological data of the surgery will be collected according to the type and grade of the tumor according to the WHO classification, the invasion of the myometrium, the presence of invasion of the lymphovascular space, sentinel (+/- ultrastaging) and the number of pelvic lymph nodes. and para-aortic. The Bokhman dual classification of endometrial cancer will be used. and tumors were classified by FIGO staging. Finally, data on adjuvant treatment (vaginal brachytherapy, external beam radiation (ERBT), and chemotherapy scheme), follow-up time, relapse time, and type and pattern of relapse.

Female sex is the eligible gender because endometrial cancer is an exclusive women disease

Uterine Manipulator in Endometrial Cancer Surgery: Pro MUCEI Study

A Prospective Study of the Impact of Uterine Manipulator on Oncological Outcome in Endometrial Cancer Surgery in Early-stage: Pro MUCEI Study

To prospectively evaluate the relapse rate in patients undergoing surgery for apparently early-stage endometrial cancer (FIGO I-II) with minimally invasive surgery with or without the use of a uterine manipulator.

Assess oncological variables: disease-free period and overall survival.

Identify relapse pattern: local, locoregional and distant.

Histology variables in surgical specimen: relationship between lymphovascular invasion and uterine manipulator.

Collect and analyze the characteristics of the surgical procedure and the adjuvant treatment received.

Collect and analyze the characteristics of the histological data and the adjuvant treatment received.

Intraoperative and postoperative complications rate

Instituto de Investigacion Sanitaria La Fe

Principal Investigator

Carcinoma

Total hysterectomy with bilateral salpingo-oophorectomy performed with the use of a uterine manipulator during surgery.

Total hysterectomy with bilateral salpingo-oophorectomy performed without the use of a uterine manipulator during surgery.

The uterine manipulator will be inserted into the uterus to assist in the procedure of total hysterectomy.

Uterine manipulator use

Stefano Uccella, MD, PhD

Simone Garzon, MD

Pier Carlo Zorzato, MD

Minimally invasive surgery is the recommended approach in endometrial cancer (EC) patients based on the results of two randomized controlled trials, given its advantages without compromised oncologic outcomes. The uterine manipulator is commonly used in benign and malignant pathologies to perform a laparoscopic or robotic hysterectomy. However, although regularly used, the uterine manipulator adoption in EC is a controversial technical aspect due to the raised concerns regarding the possible risk of disruption of the tumor mass, the spread of malignant cells, and seeding of the disease, particularly at the level of the vaginal cuff or spread of tumor cells, with increased risk of recurrence and death due to EC. On that basis, given that hysterectomy without a uterine manipulator is feasible, only a randomized controlled trial comparing oncologic outcomes in EC patients after use versus not use of the uterine manipulator will be able to provide high-quality evidence to answer this critical question and allow or exclude the use of a uterine manipulator during minimally invasive hysterectomy for EC.

Multicenter, parallel arms, open-label, randomized controlled trial.

Uterine Manipulator Versus no Uterine Manipulator in Endometrial Cancer Trial

Randomized Controlled Trial on the Oncologic Outcomes of Use Versus Not Use of the Uterine Manipulator in the Surgical Treatment of Apparent Uterine-confined Endometrial Carcinoma

Any recurrence or death related to endometrial cancer (EC) or treatment

Any death related to endometrial cancer (EC) or treatment

Any recurrence per site of first recurrence

Time between first incision and skin closure

Total blood aspirate during the surgical procedure

Perioperative (intraoperative and postoperative) complications graded based on the Clavien-Dindo classification

Presence of lymphovascular space invasion at definitive pathology

Presence of positive peritoneal cytology at definitive pathology

The Functional Assessment of Cancer Therapy - General (FACT-G) - A 27-item questionnaire designed to measure four domains of Health-Related Quality of Life in cancer patients: Physical, social, emotional, and functional well-being. Score range 0-108. The higher the score, the better the Quality of Life.

Study title	NCT ID	Conditions	Interventions	Eligibility	Organization
Effect of Uterine Manipulator on Recurrence and Mortality of Endometrial Cancer	NCT02943811	Endometrial Can...	UTERINE MANIPUL...	18 Years - 100 Years	Università degli Studi dell'Insubria
Uterine Manipulator in Endometrial Cancer Surgery: Pro MUCEI Study	NCT05242276	Endometrial Can...	USE OF UTERINE ...	-	Instituto de Investigacion Sanitaria La Fe
Uterine Manipulator Versus no Uterine Manipulator in Endometrial Cancer Trial	NCT05687084	Endometrial Neo...	Uterine manipul...	18 Years - 100 Years	Universita di Verona

Spots Global Cancer Trial Database for uterine manipulator