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Objective: To estimate the effects of surgeon and hospital volume on perioperative morbidity and mortality in women who underwent hysterectomy for endometrial cancer.Methods: Patients who underwent abdominal hysterectomy for endometrial cancer between 2003 and 2007 and who recorded in an inpatient, acute-care database were examined. Procedure-associated intraoperative, perioperative, and postoperative medical complications, as well as hospital readmission, length of stay, intensive care unit (ICU) use, and mortality were examined. Surgeons and hospitals were stratified into volume-based tertiles and outcomes analyzed using multivariable, generalized estimating equations.Results: A total of 6,015 women were identified. After adjustment for case-mix variables and hospital volume, perioperative surgical complications (15.2% compared with 11.7%) (odds ratio [OR] 0.57; 95 confidence interval [CI] 0.38-0.85), medical complications (31.4% compared with 22.0%) (OR 0.57; 95% CI 0.37-0.88), and ICU utilization (8.9% compared with 3.5%) (OR 0.47; 95% CI 0.28-0.80) were lower in patients treated by high-volume surgeons. Surgeon volume had no independent effect on the rates of operative injury (OR 0.82; 95% CI 0.32-2.08), transfusion (OR 2.33; 95% CI 0.93-5.36), length of stay (OR 0.60; 95% CI 0.25-1.41), or readmission (OR 1.05; 95% CI 0.51-2.14). Whereas patients treated at high-volume hospitals were less likely to require ICU care (9.3% compared with 4.3%) (OR 0.44; 95% CI 025-0.77), hospital volume had no independent effect on any of the other primary outcomes of interest (P>.05 for all).Conclusion: Perioperative surgical complications, medical complications, and ICU requirements are lower in patients treated by high-volume surgeons. Hospital volume had little independent effect on outcomes. [ABSTRACT FROM AUTHOR]

BACKGROUND: Hemolytic uremic syndrome is a rare multisystem disorder that is caused by infections, preeclampsia, autoimmune disorders, or oral contraceptive agents, and rarely in association with different cancers and chemotherapeutic agents. CASE: A 34-year-old woman who presented for evaluation of a pelvic mass received a diagnosis of International Federation of Gynecology and Obstetrics (FIGO) stage 1c endodermal sinus tumor at laparotomy. Three months after receiving 3 courses of bleomycin, etoposide, and cisplatinum, she presented with renal failure, thrombocytopenia, anemia, and severe hypertension. Cancer-associated hemolytic uremic syndrome was diagnosed, and the patient was treated with plasmaphoresis, blood transfusion, and hemodialysis. CONCLUSION: Cancer-associated hemolytic uremic syndrome has a high mortality rate; thus, prompt diagnosis is critical to survival. [ABSTRACT FROM AUTHOR]

OBJECTIVE: We analyzed the content, quality, and accuracy of information provided on hospital web sites about robotic gynecologic surgery. STUDY DESIGN: An analysis of hospitals with more than 200 beds from a selection of states was performed. Hospital web sites were analyzed for the content and quality of data regarding robotic-assisted surgery. RESULTS: Among 432 hospitals, the web sites of 192 (44.4%) contained marketing for robotic gynecologic surgery. Stock images (64.1%) and text (24.0%) derived from the robot manufacturer were frequent. Although most sites reported improved perioperative outcomes, limitations of robotics including cost, complications, and operative time were discussed only 3.7%, 1.6%, and 3.7% of the time, respectively. Only 47.9% of the web sites described a comparison group. CONCLUSION: Marketing of robotic gynecologic surgery is widespread. Much of the content is not based on high-quality data, fails to present alternative procedures, and relies on stock text and images. [ABSTRACT FROM AUTHOR]

OBJECTIVE: We analyzed the effect of lymphadenectomy on the use of adjuvant radiation treatment for women with stage I-II endometrial cancer. STUDY DESIGN: Women with stage I-II endometrioid adenocarcinomas treated between 1988 and 2006 and recorded in the Surveillance, Epidemiology, and End Results database were identified. The influence of lymphadenectomy (LND) on receipt of external beam radiation and brachytherapy stratified was examined. RESULTS: We identified 58,776 women including 26,043 who underwent LND (44.3%). Among women younger than 60 years of age with stage IA (grades 1, 2, and 3) tumors, LND had no impact on the use of radiation. Patients with stage IB (grade 2 or 3) and stage IC (grade 1 or 2) tumors who underwent lymph node dissection were less likely to undergo external beam radiation and more likely to receive vaginal brachytherapy (P < .05 for all). Furthermore, the extent of lymphadenectomy influenced the receipt of radiation. CONCLUSION: Women who undergo lymphadenectomy are less likely to receive whole pelvic radiotherapy. [ABSTRACT FROM AUTHOR]

OBJECTIVE: We performed a population-based analysis to compare the clinical characteristics of women with mucinous tumors with women with other epithelial tumors. STUDY DESIGN: The Surveillance, Epidemiology, and End Results database was queried to identify all women with epithelial ovarian cancer diagnosed from 1988 to 2007. The natural history, clinical characteristics, and survival of women with serous tumors were compared with women with mucinous carcinomas. RESULTS: A total of 40,571 women including 4811 with mucinous carcinomas (11.9%) were identified. Among women with stage I neoplasms, the presence of mucinous histology had no effect on either cancer-specific survival (hazard ratio, 0.87; 95% confidence interval, 0.74-1.04). Survival was inferior in patients with advanced-stage mucinous compared with serous tumors. The hazard ratio for cancer-specific survival for women with stage III mucinous tumors was 1.55 (95% confidence interval, 1.43-1.96). CONCLUSION: Although survival for early-stage mucinous and serous tumors is similar, survival for advanced-stage mucinous neoplasms is inferior to that of serous carcinomas. [ABSTRACT FROM AUTHOR]

OBJECTIVE: We examined the influence of physician and hospital volume on the morbidity and mortality of radical hysterectomy for cervical cancer. STUDY DESIGN: Women who underwent radical hysterectomy for cervical cancer between 2003 and 2007 were examined. The effect of surgeon and hospital volume on morbidity and mortality was examined using multivariable generalized estimating equations. RESULTS: A total of 1536 women who underwent radical hysterectomy were identified. Patients treated by high-volume surgeons had fewer medical complications (odds ratio, 0.55; 95% confidence interval, 0.34-0.88) and shorter lengths of stay (odds ratio, 0.49; 95% confidence interval, 0.25-0.98). After adjustment for case mix and surgeon volume, hospital volume had no independent effect on any of the variables of interest. CONCLUSION: High-volume surgeons have fewer postoperative medical complications, shorter lengths of stay, and lower transfusion requirements. Hospital volume appears to have only a minor influence on outcomes after radical hysterectomy. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Although endometrial cancer commonly occurs in elderly women, little is known about the perioperative outcomes of the oldest women (>80 years of age) who are treated surgically. STUDY DESIGN: We performed an analysis of women >=65 years of age with endometrial cancer who underwent hysterectomy from 1998-2007 and who were registered in the Nationwide Inpatient Sample. RESULTS: A total of 25,698 women were identified. Compared with women who were 65-69 years old, women who were >=85 years old were more likely to have perioperative surgical complications (12% vs 17%), postoperative medical complications (24% vs 34%), and a longer length of stay (3 vs 5 days) and to require a transfusion (6% vs 10%; P < .05 for all). The perioperative mortality rate was 0.4% in women who were 65-69 years old compared with 1.6% in women who were >=85 years old (P < .0001). CONCLUSION: The morbidity that is associated with surgery for endometrial cancer is significantly higher in women who are >80 years old, even after medical comorbidities have been considered. [ABSTRACT FROM AUTHOR]

OBJECTIVE: We examined the prognostic significance of uterine risk factors (RF) compared to nodal metastases in endometrial cancer. STUDY DESIGN: Women with stage I-IIIC endometrioid cancer were stratified based on the presence of positive or negative lymph nodes. Each patient was characterized by the number of RF present: myoinvasion >=50%, cervical stromal involvement, and grade 3 histology. RESULTS: A total of 26,967 women were identified. In a multivariable model, uterine RF strongly influenced survival but nodal disease was a more important negative prognostic factor. Five-year overall survival was 68% (95% confidence interval [CI], 63-72%) for group 1 (node positive/no RF) vs 69% (95% CI, 66-72%) for group 5 (node negative/multiple RF). Five-year survival was lower for node-positive patients with RF (58%; 95% CI, 54-61%) than node-positive patients without RF (68%; 95% CI, 63-72%). CONCLUSION: Uterine RF strongly influenced survival both in the presence and absence of nodal metastasis. [ABSTRACT FROM AUTHOR]

At first recurrence, platinum-sensitive ovarian cancer (PSOC) is frequently treated with platinum-based chemotherapy doublets plus bevacizumab, then single-agent bevacizumab. Most patients' disease progresses within a year after chemotherapy, emphasizing the need for novel strategies. Mirvetuximab soravtansine-gynx (MIRV), an antibody-drug conjugate, comprises a folate receptor alpha (FRα)-binding antibody and tubulin-targeting payload (maytansinoid DM4). In FRα-high PSOC, MIRV plus bevacizumab previously showed promising efficacy (objective response rate, 69% [95% CI: 41-89]; median progression-free survival, 13.3 months [95% CI: 8.3-18.3]; median duration of response, 12.9 months [95% CI: 6.5-15.7]) and safety. The Phase III randomized GLORIOSA trial will evaluate MIRV plus bevacizumab vs. bevacizumab alone as maintenance therapy in patients with FRα-high PSOC who did not have disease progression following second-line platinum-based doublet chemotherapy plus bevacizumab. Clinical Trial Registration : ClinicalTrials.gov ID: NCT05445778; GOG.org ID: GOG-3078; ENGOT.ESGO.org ID: ENGOT-ov76.

Background: To assess the emotional, reproductive, sexual health, and relationship concerns of women treated for gestational trophoblastic neoplasia (GTN) and examine associations with ß-hCG surveillance., Methods: This institutional review board approved study surveyed GTN survivors (n = 51) who received treatment from 1996 to 2008. Fifty-one women, including those actively followed or formerly treated, were surveyed. The survey consisted of background/medical information, the Reproductive Concerns Scale, the Female Sexual Function Index, an item from the Abbreviated Dyadic Adjustment Scale, the Center for Epidemiologic Studies-Depression scale, the Menopausal Symptom Checklist, the Impact of Life Events Scale, and exploratory items., Results: Mean age at diagnosis was 37.1 years; 41.6 years at study enrollment. Twenty-seven patients (56%) expressed worry about treatment harm and 30 (60%) about recurrence. Twenty percent reported significant depressive symptomatology. Mild cancer-related distress, reproductive concerns, sexual dysfunction, and bothersome menopausal symptoms were noted. Nineteen patients (40%) rated their ß-hCG surveillance worry as "high." Among patients who attempted conception after treatment, 3 of 12 (25%) succeeded in the ß-hCG high-worry group versus 13 of 19 (68%) in the ß-hCG low-worry group. Survivors with high ß-hCG worry had greater reproductive concerns than those with low worry (p = 0.002) and reported less sexual desire (p = 0.025). There was no difference in the number of low-worry versus high-worry participants in active surveillance (p = 0.09)., Conclusion: Our study suggests that cancer-specific distress, sexual health, and reproductive concerns continue to impact women years after treatment. High worry about ß-hCG surveillance is negatively associated with the emotional well-being of GTN survivors and possibly influences reproductive attempts and success.

Objective: We examined the use and cost of autologous blood cell salvage in women who undergo abdominal myomectomy., Study Design: Patients who underwent abdominal myomectomy from 2007-2011 were identified. Use of the cell salvage system and reinfusion of autologous blood in women who had the system set-up were analyzed. Cost was examined by directly reported data., Results: We identified 607 patients who underwent abdominal myomectomy. Four hundred twenty-five women (70%) had the set-up of the cell salvage system. Cell-salvaged blood was processed and reinfused into 85 of these subjects (20%). In a multivariable model, performance of myomectomy by a gynecologic-specific surgeon (odds ratio [OR], 2.14; 95% confidence interval [CI], 1.28-3.59), >5 myomas (OR, 2.49; 95% CI, 1.27-4.89), and larger uterine size statistically were associated significantly with cell-salvage device set-up. Conversely, having a reproductive-endocrinology-infertility specialist as the surgeon was associated with a significant reduction in cell-salvage system set-up (OR, 0.37; 95% CI, 0.21-0.66). For the women who had cell-salvage system set-up, uterine size of >15-19 weeks of gestation (OR, 3.22; 95% CI, 1.56-8.95) or ≥20 weeks of gestation (OR, 4.62; 95% CI, 1.45-14.73), operating time of >120 minutes (OR, 3.98; 95% CI, 1.70-9.29), and intraoperative blood loss of >1000 mL (OR, 26.31; 95% CI, 10.49-65.99) were associated significantly with a higher incidence of reinfusion of cell-salvaged blood., Conclusion: The routine use of cell salvage in women who undergo abdominal myomectomy does not appear to be warranted. Cell-salvage set-up appears to be cost-effective only when reinfused, but clinical characteristics cannot predict accurately which women will require reinfusion of cell-salvaged blood., (Copyright © 2014 Mosby, Inc. All rights reserved.)

Background: Despite institutional studies that suggest that radical hysterectomy for cervical cancer is well tolerated in the elderly, little population-level data are available on the procedure's outcomes in older women. We performed a population-based analysis to determine the morbidity, mortality, and resource utilization of radical hysterectomy in elderly women with cervical cancer., Methods: Patients recorded in the Nationwide Inpatient Sample with invasive cervical cancer who underwent abdominal radical hysterectomy between 1998 and 2010 were analyzed. Patients were stratified by age: <50, 50-59, 60-69, and ≥70 years. We examined the association between age and the outcomes of interest using chi square tests and multivariable generalized estimating equations., Results: A total of 8199 women were identified, including 768 (9.4%) women age 60-69 and 462 (5.6%) women ≥70 years of age. All cause morbidity increased from 22.1% in women <50, to 24.7% in those 50-59 years, 31.4% in patients 60-69 years and 34.9% in women >70years of age (P<0.0001). Compared to women<50, those >70 were more likely to have intraoperative complications (4.8% vs. 9.1%, P=0.0003), surgical site complications (10.9% vs. 17.5%, P<0.0001), and medical complications (9.9% vs. 19.5%, P<0.0001). The risk of non-routine discharge (to a nursing facility) was 0.5% in women <50 vs. 12.3% in women ≥70 (P<0.0001). Perioperative mortality women ≥70 years of age was 30 times greater than that of women <50 (P<0.0001)., Conclusion: Perioperative morbidity and mortality are substantially greater in elderly women who undergo radical hysterectomy for cervical cancer. Non-surgical treatments should be considered in these patients., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: To perform an econometric analysis to examine the influence of procedure volume, variation in hospital accounting methodology, and use of various analytic methodologies on cost of robotically assisted hysterectomy for benign gynecologic disease and endometrial cancer., Methods: A national sample was used to identify women who underwent laparoscopic or robotically assisted hysterectomy for benign indications or endometrial cancer from 2006 to 2012. Surgeon and hospital volume were classified as the number of procedures performed before the index surgery. Total costs as well as fixed and variable costs were modeled using multivariable quantile regression methodology., Results: A total of 180,230 women, including 169,324 women who underwent minimally invasive hysterectomy for benign indications and 10,906 patients whose hysterectomy was performed for endometrial cancer, were identified. The unadjusted median cost of robotically assisted hysterectomy for benign indications was $8,152 (interquartile range [IQR] $6,011-10,932) compared with $6,535 (IQR $5,127-8,357) for laparoscopic hysterectomy (P<.001). The cost differential decreased with increasing surgeon and hospital volume. The unadjusted median cost of robotically assisted hysterectomy for endometrial cancer was $9,691 (IQR $7,591-12,428) compared with $8,237 (IQR $6,400-10,807) for laparoscopic hysterectomy (P<.001). The cost differential decreased with increasing hospital volume from $2,471 for the first 5 to 15 cases to $924 for more than 50 cases. Based on surgeon volume, robotically assisted hysterectomy for endometrial cancer was $1,761 more expensive than laparoscopy for those who had performed fewer than five cases; the differential declined to $688 for more than 50 procedures compared with laparoscopic hysterectomy., Conclusion: The cost of robotic gynecologic surgery decreases with increased procedure volume. However, in all of the scenarios modeled, robotically assisted hysterectomy remained substantially more costly than laparoscopic hysterectomy.

Background: Although a number of prohemostatic agents that are applied intraoperatively have been introduced to minimize bleeding, little is known about the patterns of use and the factors that influence use. We examined the use of hemostatic agents in patients undergoing major surgery., Methods: All patients who underwent major general, gynecologic, urologic, cardiothoracic, or orthopedic surgery from 2000-2010 who were recorded in the Perspective database were analyzed., Results: Among 3,633,799 patients, hemostatic agents were used in 30.3% (n = 1,102,267). The use of hemostatic agents increased from 28.5% in 2000 to 35.2% in 2010. Over the same period, the rates of transfusion declined for pancreatectomy (-14.4%), liver resection (-15.0%), gastrectomy (-11.7%), prostatectomy (-6.6%), nephrectomy (-4.6%), hip arthroplasty (-10.4%), and knee arthroplasty (-6.6%). Over the same time period, the transfusion rate increased for colectomy (6.0%), hysterectomy (3.7%), coronary artery bypass graft (8.4%), valvuloplasty (4.2%), lung resection (1.9%), and spine surgery (1.6%). Transfusion remained relatively stable for thyroidectomy (0.2%)., Conclusions: The use of hemostatic agents has increased rapidly even for surgeries associated with a small risk of transfusion and bleeding complications. In addition to patient characteristics, surgeon and hospital factors exerted substantial influence on the allocation of hemostatic agents., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Intraperitoneal chemotherapy is used to treat peritoneal surface-spreading malignancies. We sought to determine whether volume and surface area of the intraperitoneal chemotherapy compartments are associated with overall survival and posttreatment glomerular filtration rate (GFR) in malignant peritoneal mesothelioma (MPM) patients., Methods: Thirty-eight MPM patients underwent X-ray computed tomography peritoneograms during outpatient intraperitoneal chemotherapy. We calculated volume and surface area of contrast-filled compartments by semiautomated computer algorithm. We tested whether these were associated with overall survival and posttreatment GFR., Results: Decreased likelihood of mortality was associated with larger surface areas (p = 0.0201) and smaller contrast-filled compartment volumes (p = 0.0341), controlling for age, sex, histologic subtype, and presence of residual disease >0.5 cm postoperatively. Larger volumes were associated with higher posttreatment GFR, controlling for pretreatment GFR, body surface area, surface area, and the interaction between body surface area and volume (p = 0.0167)., Discussion: Computed tomography peritoneography is an appropriate modality to assess for maldistribution of intraperitoneal chemotherapy. In addition to identifying catheter failure and frank loculation, quantitative analysis of the contrast-filled compartment's surface area and volume may predict overall survival and cisplatin-induced nephrotoxicity. Prospective studies should be undertaken to confirm and extend these findings to other diseases, including advanced ovarian carcinoma.

Objective: To examine guideline-based use of prophylactic antibiotics in patients who underwent gynecologic surgery., Methods: We identified women who underwent gynecologic surgery between 2003 and 2010. Procedures were stratified as antibiotic-appropriate (abdominal, vaginal, or laparoscopically assisted vaginal hysterectomy) or antibiotic-inappropriate (oophorectomy, cystectomy, tubal ligation, dilation and curettage, myomectomy, and tubal ligation). Antibiotic use was examined using hierarchical regression models., Results: Among 545,332 women who underwent procedures for which antibiotics were recommended, 87.1% received appropriate antibiotic prophylaxis, 2.3% received nonguideline-recommended antibiotics, and 10.6% received no prophylaxis. Use of antibiotics increased from 88.0% in 2003 to 90.7% in 2010 (P<.001). Among 491,071, who underwent operations for which antibiotics were not recommended, antibiotics were administered to 197,226 (40.2%) women. Use of nonguideline-based antibiotics also increased over time from 33.4% in 2003 to 43.7% in 2010 (P<.001). Year of diagnosis, surgeon and hospital procedural volume, and area of residence were the strongest predictors of guideline-based and nonguideline-based antibiotic use., Conclusion: Although use of antibiotics is high for women who should receive antibiotics, antibiotics are increasingly being administered to women for whom the drugs are of unproven benefit., Level of Evidence: : III.

Objective: There is growing recognition that, in addition to occurrence of perioperative complications, the treatment of patients with complications influences outcome. We examined complications, failure to rescue (death in patients with a complication), and mortality rates for women who underwent abdominal hysterectomy., Study Design: Women who underwent abdominal hysterectomy from 1998-2010 and whose data were recorded in the Nationwide Inpatient Sample were identified. Hospitals were stratified based on risk-adjusted mortality rates into 5 quintiles, and rates of complications and failure to rescue were examined., Results: A total of 664,229 women who had been treated at 741 hospitals were identified. The overall mortality rate for the cohort was 0.17%. The risk-adjusted, hospital-level mortality rate ranged from 0-1.12%. The complication rate was 6.5% at the hospitals with the lowest mortality rates, 9.9% at the second quintile hospitals, 9.5% at both the third and fourth quintile hospitals, and 7.9% at the hospitals with the highest mortality rates. In contrast to complications, the failure-to-rescue rate increased with each successive risk-adjusted mortality quintile. The failure-to-rescue rate was 0% at the hospitals with the lowest mortality rates and increased with each successive quintile to 1.1%, 2.1%, 2.7%, and 4.4% in the hospitals with the highest mortality rates (P < .0001)., Conclusion: For women who underwent abdominal hysterectomy, hospital complication rates correlated poorly with mortality rates; failure-to-rescue is strongly associated with in-hospital mortality rates. The treatment of complications, not the actual development of a complication, is the most important factor to use to predict death after major gynecologic surgery., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Background: Little is known about the use and toxicity of antiadhesion substances such as sodium hyaluronate-carboxymethylcellulose., Objective: We analyzed the patterns of use and safety of sodium hyaluronate-carboxymethylcellulose in patients undergoing colectomy and gynecologic surgery., Design: This is a retrospective cohort study., Setting: This study covered hospitals nationwide., Patients: All patients in the Premier Perspective database who underwent colectomy or hysterectomy from 2000 to 2010 were included in the analyses., Main Outcome Measure: Hyaluronate-carboxymethylcellulose use was determined by billing codes. For the primary outcome, we used hierarchical mixed-effects logistic regression models to determine the factors associated with the use of hyaluronate-carboxymethylcellulose, whereas a propensity score-matched analysis was used to secondarily assess the association between hyaluronate-carboxymethylcellulose use and toxicity (abscess, bowel and wound complications, peritonitis)., Results: We identified 382,355 patients who underwent hysterectomy and 267,368 who underwent colectomy. For hysterectomy, hyaluronate-carboxymethylcellulose use was 5.0% overall, increasing from 1.1% in 2000 to 9.8% in 2010. Hyaluronate-carboxymethylcellulose was used in 8.1% of those who underwent colectomy and increased from 6.2% in 2000 to 12.4% in 2010. The year of diagnosis and procedure volume of the attending surgeon were the strongest predictors of hyaluronate-carboxymethylcellulose use. After matching and risk adjustment, hyaluronate-carboxymethylcellulose use was not associated with abscess formation (1.5% vs 1.5%) (relative risk = 0.97; 95% CI, 0.84-1.12) in those who underwent hysterectomy. A patient receiving hyaluronate-carboxymethylcellulose had a 13% increased risk of abscess (17.4% vs 15.0%) (relative risk = 1.13; 95% CI, 1.08-1.17) after colectomy., Limitations: This was an observational study., Conclusion: Hyaluronate-carboxymethylcellulose use has increased over the past decade for colectomy and hysterectomy. Although there is no association between hyaluronate-carboxymethylcellulose use and abscess following hysterectomy, hyaluronate-carboxymethylcellulose use was associated with a small increased risk of abscess after colectomy.

Objective: Ovarian carcinosarcomas (OCS) are rare tumors composed of both malignant epithelial and mesenchymal elements. We compared the natural history and outcomes of OCS to serous carcinoma of the ovary., Methods: Patients with OCS and serous carcinomas registered in the Surveillance, Epidemiology, and End Results (SEER) database between 1988 and 2007 were analyzed. Demographic and clinical characteristics were compared using chi square tests while survival was analyzed using Cox proportional hazards models and the Kaplan-Meier method., Results: A total of 27,737 women, including 1763 (6.4%) with OCS and 25,974 (93.6%) with serous carcinomas, were identified. Patients with carcinosarcomas tended to be older and have unstaged tumors (P<0.0001). After adjusting for other prognostic factors, women with carcinosarcomas were 72% more likely to die from their tumors (HR=1.72; 95% CI, 1.52-1.96). Five-year survival for stage I carcinosarcomas was 65.2% (95% CI, 58.0-71.4%) vs. 80.6% (95% CI, 78.9-82.2%) for serous tumors. Similarly, five-year survival for stage IIIC patients was 18.2% (95% CI, 14.5-22.4%) for carcinosarcomas compared to 33.3% (95% 32.1-34.5%) for serous carcinomas., Conclusions: Ovarian carcinosarcomas are aggressive tumors with a natural history that is distinct from serous cancers. The survival for both early and late stage carcinosarcoma is inferior to serous tumors., (© 2013.)

Objective: To determine the clinical outcomes and risk factors for persistence of ovarian cysts in pregnant women. With the increased use of ultrasound in pregnancy, the identification of incidental ovarian masses is becoming more common., Study Design: An observational study of women with ovarian masses identified before 24 weeks of pregnancy was performed. Only women who underwent follow-up imaging or surgery were included. Factors associated with persistence and outcomes of women who underwent surgery were analyzed., Results: Of the 803 women with available follow-up, the cysts resolved in 707 (88.1%) patients. Fifty (6.2%) women underwent surgical intervention. Women with persistent cysts were younger, more often Hispanic, detected at a later gestational age, had larger cysts, and more often had complex or solid components (p < 0.05 for all). Overall, 1 (0.1%) malignancy was diagnosed (a patient with a B-cell lymphoma), while 3 (0.4%) women had borderline epithelial ovarian tumors., Conclusion: Ovarian masses identified during pregnancy have a low risk of malignancy. The majority of women can be serially monitored without intervention.

Using Surveillance, Epidemiology, and End Results database we identified 43,882 (97.0%) women with endometrioid adenocarcinomas and 1,374 (3.0%) with mucinous adenocarcinomas. Women with mucinous tumors were older (P < .0001), more often white (P = .04), and more often to present at advanced stage (P = .001). Survival was similar for both histologies; the hazard ratio for cancer-specific survival for mucinous compared to endometrioid tumors was 0.90 (95% CI, 0.74-1.09) while the hazard ratio for overall survival was 0.95 (95% CI, 0.85-1.07). Five-year survival for stage I mucinous tumors was 89.9% (95% CI, 87.6-91.9%) compared to 89.0% (95% CI, 88.6-89.4%) for endometrioid tumors.

Objective: To examine the use of inpatient hysterectomy and explore changes in the use of various routes of hysterectomy and patterns of referral., Methods: The Nationwide Inpatient Sample was used to identify all women aged 18 years or older who underwent inpatient hysterectomy between 1998 and 2010. Weighted estimates of national trends were calculated and the number of procedures performed estimated. Trends in hospital volume and across hospital characteristics were examined., Results: After weighting, we identified a total 7,438,452 women who underwent inpatient hysterectomy between 1998 and 2010. The number of hysterectomies performed annually rose from 543,812 in 1998 to a peak of 681,234 in 2002; it then declined consistently annually and reached 433,621 cases in 2010. Overall, 247,973 (36.4%) fewer hysterectomies were performed in 2010 compared with 2002. From 2002 to 2010 the number of hysterectomies performed for each of the following indications declined: leiomyoma (-47.6%), abnormal bleeding (-28.9%), benign ovarian mass (-63.1%), endometriosis (-65.3%), and pelvic organ prolapse (-39.4%). The median hospital case volume decreased from 83 procedures per year in 2002 to 50 cases per year in 2010 (P<.001)., Conclusion: The number of inpatient hysterectomies performed in the United States has declined substantially over the past decade. The median number of hysterectomies per hospital has declined likewise by more than 40%., Level of Evidence: III.

Objective: While intensity-modulated radiation therapy (IMRT) allows more precise radiation planning, the technology is substantially more costly than conformal radiation and, to date, the benefits of IMRT for uterine cancer are not well defined. We examined the use of IMRT and its effect on late toxicity for uterine cancer., Methods: Women with uterine cancer treated from 2001 to 2007 and registered in the SEER-Medicare database were examined. We investigated the extent and predictors of IMRT administration. The incidence of acute and late-radiation toxicities was compared for IMRT and conformal radiation., Results: We identified a total of 3555 patients including 328 (9.2%) who received IMRT. Use of IMRT increased rapidly and reached 23.2% by 2007. In a multivariable model, residence in the western U.S. and receipt of chemotherapy were associated with receipt of IMRT. Women who received IMRT had a higher rate of bowel obstruction (rate ratio=1.41; 95% CI, 1.03-1.93), but other late gastrointestinal and genitourinary toxicities as well as hip fracture rates were similar between the cohorts. After accounting for other characteristics, the cost of IMRT was $14,706 (95% CI, $12,073 to $17,339) greater than conformal radiation., Conclusion: The use of IMRT for uterine cancer is increasing rapidly. IMRT was not associated with a reduction in radiation toxicity, but was more costly., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: Patients with locally advanced vulvar carcinoma can be treated with primary surgery or neoadjuvant chemoradiation. Neoadjuvant treatment appears to be associated with decreased morbidity and acceptable long-term outcomes. We examined the patterns of care for women with locally advanced vulvar cancer., Study Design: Data from the Surveillance, Epidemiology, and End Results (SEER) database was used to examine women with stage III-IVA vulvar cancer treated from 1988 to 2008. Primary therapy was classified as surgery or radiation. Multivariable logistic regression models were developed to examine the use of primary radiotherapy., Results: We identified a total of 2292 women including 1757 who underwent primary surgery (76.7%) and 535 treated with primary radiation (23.3%). The use of primary radiation increased with time from 18.0% in 1988 to 30.1% in 2008. In a multivariable model, older women (odds ratio [OR], 1.33; 95% confidence interval [CI], 1.03-1.72), black women (OR, 1.59; 95% CI, 1.14-2.23), and patients with stage IVA tumors (OR, 2.23; 95% CI, 1.78-2.81) were more likely to receive primary radiation. Among women treated with primary radiotherapy, only 17.8% ultimately underwent surgical resection., Conclusion: The use of primary radiation for locally advanced vulvar cancer is limited but has increased over time. Multiple patient and tumor factors influence use. The majority of patients with stage III-IVA vulvar cancer treated with primary radiation therapy did not undergo surgical resection., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Objective: To estimate trends in hospital volume and referral patterns for women with uterine and ovarian cancer., Methods: The Surveillance, Epidemiology, and End Results-Medicare database was used to identify women aged 65 years or older with ovarian and uterine cancer who underwent surgery from 2000 to 2007. "Volume creep," when a greater number of patients undergo surgery at the same hospitals, and "market concentration," when a similar overall number of patients undergo a procedure but at a smaller number of hospitals, were analyzed., Results: Among 4,522 patients with ovarian cancer, mean hospital volume increased from 3.1 cases during 2000-2001 to 3.4 cases during 2006-2007 (P=.62) suggesting minimal volume creep. Similarly, there was little evidence of market concentration. In 2000-2001, 37.8% of women were treated at the top decile by volume hospitals compared with 41.4% in 2006-2007 (P=.14). In 2006-2007, 201 (63.2%) of the hospitals had an ovarian cancer surgery volume of two or fewer cases. Among 9,908 women with uterine cancer, the mean hospital volume increased slightly from 4.5 in 2000-2001 to 5.4 in 2006-2007 (P=.10). The percentage of patients treated at the top decile by volume of hospitals increased from 40.4% in 2000-2001 to 44.7% in 2006-2007 (P<.001). In 2006-2007, 243 (49.3%) of the hospitals had a uterine cancer surgery volume of two or fewer cases., Conclusion: There have been only modest changes in the referral patterns of women with ovarian and uterine cancer. A large number of hospitals have a very low procedural volume.

Importance: Although febrile neutropenia (FN) is a major source of morbidity and mortality for patients with solid tumors, little is known about the use of guideline-based care., Objectives: To examine compliance with guideline-based recommendations for FN treatment, explore the factors that influence adherence to consensus guidelines, and analyze how the use of guideline-based care affects the outcomes., Design: The Perspective database was used to examine the treatment of cancer patients with FN from January 1, 2000, through March 31, 2010. To capture initial decision making, we examined treatment within 48 hours of hospital admission. We determined use of guideline-based antibiotics and nonguideline-based treatments, vancomycin, and granulocyte colony-stimulating factors (GCSF). Hierarchical models were developed to examine the factors associated with treatment. Patients were stratified into low- and high-risk groups, and the effect of the initial treatment on outcome (nonroutine hospital discharge and death) was examined., Setting and Participants: Twenty-five thousand two hundred thirty-one patients with solid tumors hospitalized for neutropenia., Main Outcome Measure: Use of guideline-based antibiotics, vancomycin, and GCSF and their affect on outcome., Results: Among 25 231 patients admitted with FN, guideline-based antibiotics were administered to 79%, vancomycin to 37%, and GCSF to 63%. Patients treated at high FN-volume hospitals (odds ratio [OR], 1.56; 95% CI, 1.34-1.81) by high FN-volume physicians (OR, 1.19; 95% CI, 1.03-1.38) and patients managed by hospitalists (OR, 1.49; 95% CI, 1.18-1.88) were more likely to receive guideline-based antibiotics (P < .05). Vancomycin use increased from 17% in 2000 to 55% in 2010, while GCSF use only decreased from 73% to 55%. Among low-risk patients with FN, prompt initiation of guideline-based antibiotics decreased discharge to a nursing facility (OR, 0.77; 95% CI, 0.65-0.92) and death (OR, 0.63; 95% CI, 0.42-0.95)., Conclusions and Relevance: While use of guideline-based antibiotics is high, use of the nonguideline-based treatments, vancomycin, and GCSF is also high. Physician and hospital factors are the strongest predictors of both guideline- and nonguideline-based treatment.

Objective: Emerging data suggest that oophorectomy at the time of hysterectomy for benign indications may increase long-term morbidity and mortality. We performed a population-based analysis to estimate the rates of oophorectomy in women undergoing hysterectomy for benign indications., Methods: The Perspective database was used to estimate the rate of ovarian preservation in women aged 40-64 years who underwent hysterectomy for benign indications. Hierarchical mixed-effects regression models were developed to estimate the influence of patient, procedural, physician, and hospital characteristics on ovarian conservation. Between-hospital variation in ovarian preservation also was estimated., Results: Among 752,045 women, 348,972 (46.4%) underwent bilateral oophorectomy, whereas 403,073 (53.6%) had ovarian conservation. Stratified by age, the rate of ovarian conservation was 74.3% for those younger than 40 years of age; 62.7% for those 40-44 years of age; 40.8% for those 45-49 years of age; 25.2% for those 50-54 years of age; 25.5% for those 55-59 years of age; and 31.0% for those 60-64 years of age. Younger age and more recent year of surgery had the strongest association with ovarian conservation. The observed patient, procedural, physician, and hospital characteristics accounted for only 46% of the total variation in the rate of ovarian conservation; 54% of the variability remained unexplained, suggesting a large amount of intrinsic between-hospital variation in the decision to perform oophorectomy., Conclusion: The rate of ovarian conservation is increasing, particularly among women younger than 50 years old. Although demographic and clinical factors influence the decision to perform oophorectomy, there appears to be substantial between-hospital variation in performance of oophorectomy that remains unexplained by measurable patient, physician, or hospital characteristics., Level of Evidence: II.

Background: Hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC) is used to treat peritoneal surface-spreading malignancies to maximize local drug concentrations while minimizing systemic effects. The pharmacokinetic advantage of HIPEC is defined as the intraperitoneal to intravascular ratio of drug concentrations. We hypothesized that body surface area (BSA) would correlate with the pharmacokinetic advantage of HIPEC. Because oxaliplatin is administered in 5 % dextrose, we hypothesized that BSA would correlate with glycemia., Methods: We collected blood and peritoneal perfusate samples from ten patients undergoing HIPEC with a BSA-based dose of 250 mg/m(2) oxaliplatin, and measured drug concentrations by inductively coupled plasma mass spectrophotometry. We monitored blood glucose for 24 h postoperatively. Areas under concentration-time curves (AUC) were calculated by trapezoidal rule. Pharmacokinetic advantage was calculated by (AUC[peritoneal fluid]/AUC[plasma]). We used linear regression to test for statistical significance., Results: Higher BSA was associated with lower plasma oxaliplatin AUC (p = 0.0075) and with a greater pharmacokinetic advantage (p = 0.0198) over the 60-minute duration of HIPEC. No statistically significant relationships were found between BSA and blood glucose AUC or peak blood glucose levels., Conclusions: Higher BSA is correlated with lower plasma drug levels and greater pharmacokinetic advantage in HIPEC, likely because of increased circulating blood volume with inadequate time for equilibration. Plasma glucose levels after oxaliplatin HIPEC were not clearly related to BSA.

Importance: Although robotically assisted hysterectomy for benign gynecologic conditions has been reported, little is known about the incorporation of the procedure into practice, its complication profile, or its costs compared with other routes of hysterectomy., Objectives: To analyze the uptake of robotically assisted hysterectomy, to determine the association between use of robotic surgery and rates of abdominal and laparoscopic hysterectomy, and to compare the in-house complications of robotically assisted hysterectomy vs abdominal and laparoscopic procedures., Design, Setting, and Patients: Cohort study of 264,758 women who underwent hysterectomy for benign gynecologic disorders at 441 hospitals across the United States from 2007 to 2010., Main Outcome Measures: Uptake of and factors associated with utilization of robotically assisted hysterectomy. Complications, transfusion, reoperation, length of stay, death, and cost for women who underwent robotic hysterectomy compared with both abdominal and laparoscopic procedures were analyzed., Results: Use of robotically assisted hysterectomy increased from 0.5% in 2007 to 9.5% of all hysterectomies in 2010. During the same time period, laparoscopic hysterectomy rates increased from 24.3% to 30.5%. Three years after the first robotic procedure at hospitals where robotically assisted hysterectomy was performed, robotically assisted hysterectomy accounted for 22.4% of all hysterectomies. The rates of abdominal hysterectomy decreased both in hospitals where robotic-assisted hysterectomy was performed as well as in those where it was not performed. In a propensity score-matched analysis, the overall complication rates were similar for robotic-assisted and laparoscopic hysterectomy (5.5% vs 5.3%; relative risk [RR], 1.03; 95% CI, 0.86-1.24). Although patients who underwent a robotic-assisted hysterectomy were less likely to have a length of stay longer than 2 days (19.6% vs 24.9%; RR, 0.78, 95% CI, 0.67-0.92), transfusion requirements (1.4% vs 1.8%; RR, 0.80; 95% CI, 0.55-1.16) and the rate of discharge to a nursing facility (0.2% vs 0.3%; RR, 0.79; 95% CI, 0.35-1.76) were similar. Total costs associated with robotically assisted hysterectomy were $2189 (95% CI, $2030-$2349) more per case than for laparoscopic hysterectomy., Conclusions and Relevance: Between 2007 and 2010, the use of robotically assisted hysterectomy for benign gynecologic disorders increased substantially. Robotically assisted and laparoscopic hysterectomy had similar morbidity profiles, but the use of robotic technology resulted in substantially more costs.

Although the contemporary management of endometrial cancer is straightforward in many ways, novel data has emerged over the past decade that has altered the clinical standards of care while generating new controversies that will require further investigation. Fortunately most cases are diagnosed at early stages, but high-risk histologies and poorly differentiated tumors have high metastatic potential with a significantly worse prognosis. Initial management typically requires surgery, but the role and extent of lymphadenectomy are debated especially with well-differentiated tumors. With the changes in surgical staging, prognosis correlates more closely with stage, and the importance of cytology has been questioned and is under evaluation. The roles of radiation in intermediate-risk patients and chemotherapy in high-risk patients are emerging. The therapeutic index of brachytherapy needs to be considered, and the best sequencing of combined modalities needs to balance efficacy and toxicities. Additionally novel targeted therapies show promise, and further studies are needed to determine the appropriate use of these new agents. Management of endometrial cancer will continue to evolve as clinical trials continue to answer unsolved clinical questions.

Purpose: Although the association between high surgical volume and improved outcomes from procedures is well described, the mechanisms that underlie this association are uncertain. There is growing recognition that high-volume hospitals may not necessarily have lower complication rates but rather may be better at rescuing patients with complications. We examined the role of complications, failure to rescue from complications, and mortality based on hospital volume for ovarian cancer., Patients and Methods: The Nationwide Inpatient Sample was used to identify women who underwent surgery for ovarian cancer from 1988 to 2009. Hospitals were ranked on the basis of their procedure volume. We determined the risk-adjusted mortality, major complication rate, and "failure to rescue" rate (mortality in patients with a major complication) for each tertile. Univariate and multivariate associations were then compared., Results: We identified 36,624 patients. The mortality rate for the cohort was 1.6%. The major complication rate was 20.4% at low-volume, 23.4% at intermediate-volume, and 24.6% at high-volume hospitals (P < .001). However, the rate of failure to rescue (death after a complication) was markedly higher at low-volume (8.0%) compared with high-volume hospitals (4.9%; P < .001). After accounting for patient and hospital characteristics, women treated at low-volume hospitals who experienced a complication were 48% more likely (odds ratio [OR], 1.48; 95% CI, 1.11 to 1.99) to die than patients with a complication at a high-volume hospital., Conclusion: Mortality is lower for patients with ovarian cancer treated at high-volume hospitals. The reduction in mortality does not appear to be the result of lower complications rates but rather a result of the ability of high-volume hospitals to rescue patients with complications.

Objective: We examined the use, safety, and economic impact of same-day discharge for women undergoing laparoscopic hysterectomy., Study Design: We identified women in the Perspective database who underwent laparoscopic hysterectomy from 2000 through 2010. Discharge was classified as same-day, 1 day, and ≥2 days. Multivariable models were used to examine predictors of same-day discharge, reevaluation, and cost., Results: Among 128,634 women, 34,070 (26.5%) were discharged on the day of surgery. Same-day discharge increased from 11.3% in 2000 to 46.0% by 2010 (P < .0001). The rate of reevaluation within 60 days was 4.0% for those discharged same day, 3.6% after a 1-day stay, and 5.1% for patients whose stay was ≥2 days (P < .0001). In a multivariable model, patients discharged on postoperative day 1 were less likely to require reevaluation (risk ratio, 0.89; 95% confidence interval, 0.82-0.96), but costs were $207 (95% confidence interval, $179-234) greater., Conclusion: Same-day discharge after laparoscopic hysterectomy is safe and associated with decreased cost., (Copyright © 2012 Mosby, Inc. All rights reserved.)

Objective: We analyzed the uptake, morbidity, and cost of laparoscopic and robotic radical hysterectomies for cervical cancer., Methods: We identified women recorded in the Perspective database with cervical cancer who underwent radical hysterectomy (abdominal, laparoscopic, robotic) from 2006 to 2010. The associations between patient, surgeon, and hospital characteristic and use of minimally invasive hysterectomy as well as complications and cost were estimated using multivariable logistic regression models., Results: We identified 1894 patients including 1610 (85.0%) who underwent abdominal, 217 (11.5%) who underwent laparoscopic, and 67 (3.5%) who underwent robotic radical hysterectomy were analyzed. In 2006, 98% of the procedures were abdominal and 2% laparoscopic; by 2010 abdominal radical hysterectomy decreased to 67%, while laparoscopic increased to 23% and robotic radical hysterectomy was performed in 10% of women (p<0.0001). Patients treated at large hospitals were more likely to undergo a minimally invasive procedure (OR=4.80; 95% CI, 1.28-18.01) while those with more medical comorbidities (OR=0.60; 95% CI, 0.41-0.87) were less likely to undergo a minimally invasive surgery. Perioperative complications were noted in 15.8% of patients who underwent abdominal surgery, 9.2% who underwent laparoscopy, and 13.4% who had a robotic procedure (p=0.04). Both laparoscopic and robotic radical hysterectomies were associated with lower transfusion requirements and shorter hospital stays than abdominal hysterectomy (p<0.05). Median costs were $9618 for abdominal, $11,774 for laparoscopic, and $10,176 for robotic radical hysterectomy (p<0.0001)., Conclusion: Uptake of minimally invasive radical hysterectomy for cervical cancer has been slow. Both laparoscopic and robotic radical hysterectomies are associated with favorable morbidity profiles., (Copyright © 2012. Published by Elsevier Inc.)

Background: Cervical cancer is common in the elderly. The authors examined the patterns of care, treatment, and outcomes of elderly women with cervical cancer., Methods: Women with cervical cancer diagnosed between 1988 and 2005 and registered in the Surveillance, Epidemiology, and End Results database were analyzed. Patients were stratified by age: <50, 50 to 59, 60 to 69, 70 to 79, and ≥80 years. Multivariate logistic regression models were constructed to examine treatment; cancer-specific survival was examined using Cox proportional hazards models., Results: A total of 28,902 women were identified, including 2543 women 70 to 79 years old and 1364 ≥80 years. For women with early stage (IB1-IIA) tumors, primary surgery was performed in 82.0% of women <50 years old compared with 54.5% of those 70 to 79 years old and 33.2% of those ≥80 years old (P < .0001). For women treated surgically, lymphadenectomy was performed in 66.8% of women <50 years old versus 9.1% of patients ≥80 years old (P < .0001). Compared with patients <50 years old, those >80 years old were less likely to undergo radical hysterectomy (odds ratio [OR], 0.10; 95% confidence interval [CI], 0.07-0.14) and lymphadenectomy (OR, 0.11; 95% CI, 0.08-0.16) and to receive adjuvant radiation therapy (OR, 0.06; 95% CI, 0.01-0.35). Among women with stage IIB-IVA disease, use of brachytherapy declined with age (P < .0001). For women with stage IB1-IIA tumors, the hazard ratio for death from cancer was 1.35 (95% CI, 1.16-1.58) for women 70 to 79 years old and 2.08 (95% CI, 1.72-2.48) for those ≥80 years old compared with younger women., Conclusions: Elderly women with cervical cancer are less likely to undergo surgery, receive adjuvant radiation, and receive brachytherapy. After adjusting for treatment disparities, cancer-specific mortality is higher in older women., (Copyright © 2011 American Cancer Society.)

Objectives: We performed a population-based analysis to determine the effect of histology on survival for women with invasive cervical cancer., Methods: The Surveillance, Epidemiology and End Results database was used to identify women with stage IB-IVB cervical cancer treated from 1988 to 2005. Patients were stratified by histology (squamous, adenocarcinoma, and adenosquamous). Clinical characteristics, patterns of care, and outcomes were analyzed using multivariable logistic regression and Cox proportional hazards models., Results: A total of 24,562 patients were identified including 18,979 (77%) women with squamous cell carcinomas, 4103 (17%) with adencarcinomas, and 1480 (6%) with adenosquamous tumors. Women with adenocarcinomas were younger, more often white, and more frequently married than patients with squamous cell tumors (p<0.0001 for all). Patients with adenocarcinomas were more likely to present with early-stage disease (p<0.0001). At diagnosis, 26.7% of women with adenocarcinomas had stage IB1 tumors compared to 16.9% of those with squamous cell carcinomas. Among women with early-stage (IB1-IIA) tumors, patients with adenocarcinomas were 39% (HR=1.39; 95% CI, 1.23-1.56) more likely to die from their tumors than those with squamous cell carcinomas. For patients with advanced-stage disease (stage IIB-IVA) women with adenocarcinomas were 21% (HR=1.21; 95% CI, 1.10-1.32) more likely to die from their tumors than those with squamous neoplasms. Five-year survival for stage IIIB neoplasms five-year survival was 31.3% (95% CI, 29.2-33.3%) for squamous tumors vs. 20.3% (95% CI, 14.2-27.1%) for adenocarcinomas., Conclusion: Cervical adenocarcinomas are more common in younger women and white patients. Adenocarcinoma histology negatively impacts survival for both early and advanced-stage carcinomas., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Purpose: Use of robotics in oncologic surgery is increasing; however, reports of safety and efficacy are from highly experienced surgeons and centers. We performed a population-based analysis to compare laparoscopic hysterectomy and robotic hysterectomy for endometrial cancer., Patients and Methods: The Perspective database was used to identify women who underwent a minimally invasive hysterectomy for endometrial cancer from 2008 to 2010. Morbidity, mortality, and cost were evaluated using multivariable logistic and linear regression models., Results: We identified 2,464 women, including 1,027 (41.7%) who underwent laparoscopic hysterectomy and 1,437 (58.3%) who underwent robotic hysterectomy. Women treated at larger hospitals, nonteaching hospitals, and centers outside of the northeast were more likely to undergo a robotic hysterectomy procedure, whereas black women, those without insurance, and women in rural areas were less likely to undergo a robotic hysterectomy procedure (P < .05 for all). The overall complication rate was 9.8% for laparoscopic hysterectomy versus 8.1% for robotic hysterectomy (P = .13). The adjusted odds ratio (OR) for any morbidity for robotic hysterectomy was 0.76 (95% CI, 0.56 to 1.03). After adjusting for patient, surgeon, and hospital characteristics, there were no significant differences in the rates of intraoperative complications (OR, 0.68; 95% CI, 0.42 to 1.08), surgical site complications (OR, 1.49; 95% CI, 0.81 to 2.73), medical complications (OR, 0.64; 95% CI, 0.40 to 1.01), or prolonged hospitalization (OR, 0.85; 95% CI, 0.64 to 1.14) between the procedures. The mean cost for robotic hysterectomy was $10,618 versus $8,996 for laparoscopic hysterectomy (P < .001). In a multivariable model, robotic hysterectomy was significantly more costly ($1,291; 95% CI, $985 to $1,597)., Conclusion: Despite claims of decreased complications with robotic hysterectomy, we found similar morbidity but increased cost compared with laparoscopic hysterectomy. Comparative long-term efficacy data are needed to justify its widespread use.

Purpose: The volume of surgical procedures performed by hospitals and surgeons has a strong influence on outcomes for a number of surgeries. We examined the influence of surgeon and hospital case volume on morbidity, mortality, and resource utilization for women with endometrial cancer undergoing laparoscopic hysterectomy., Methods: Perspective, a nationwide inpatient database developed to measure utilization and quality, was used to examine women with endometrial cancer who underwent laparoscopic hysterectomy with or without lymphadenectomy from 2000 to 2010. Perioperative morbidity, mortality, and cost were compared using Chi-square tests and multivariable generalized estimating equations., Results: A total of 4,137 patients were identified. The overall complication rate was 9.8% for low-volume vs. 10.4% for high-volume surgeons [multivariable odds ratio (OR) = 0.71; 95% confidence interval (CI), 0.41-1.22]. The rates of intraoperative complications, surgical-site complications, medical complications, transfusion, and reoperation were similar for patients treated by low- and high-volume surgeons (p > 0.05 for all). The adjusted estimate for hospital cost for patients treated by high- compared with low-volume surgeons was 219 USD (95% CI, -790 to 1,228 USD). The odds ratio for any complication in high- compared with low-volume hospitals was 1.24 (95% CI, 0.78-1.96). The average cost for patients treated in high- compared with low-volume facilities was -815 USD (95% CI, -1,641 to 11 USD). Neither physician nor hospital volume had a statistically significant effect on perioperative mortality., Conclusion: Laparoscopic hysterectomy for endometrial cancer is well tolerated and associated with an acceptable morbidity profile. Surgeon and hospital volume appear to have little effect on perioperative morbidity, mortality, and resource utilization.

Objective: We compared the outcomes of microinvasive squamous cell carcinoma and adenocarcinoma of the cervix and examined the safety of fertility-conserving treatment., Study Design: The Surveillance, Epidemiology, and End Results database was used to identify all women with stage IA1 and IA2 cervical carcinoma diagnosed from 1988 to 2005. The treatment and outcomes of women with adenocarcinomas were compared with squamous cell carcinomas., Results: A total of 3987 women including 988 with adenocarcinomas (24.8%) were identified. Women with adenocarcinoma were more often white and were younger (P < .05 for all). Survival for stage IA1 adenocarcinomas (hazard ratio, 0.79; 95% confidence interval, 0.21-2.94) was similar to that of women with squamous cell tumors. For stage IA2 tumors, survival was similar for squamous cell and adenocarcinomas (hazard ratio, 0.51; 95% confidence interval, 0.18-1.47). For stage IA1 and IA2 adenocarcinomas, survival was similar for conization and hysterectomy., Conclusion: Survival is similar for microinvasive adenocarcinomas and squamous cell carcinomas. Conization appears to be adequate treatment for microinvasive adenocarcinoma., (Copyright © 2012 Mosby, Inc. All rights reserved.)

Background: Endometrial polyps commonly affect premenopausal and postmenopausal women and carry a small risk of cancer. Consensus guidelines to direct the management of women with endometrial polyps are lacking. We examined the risk of malignancy in symptomatic and asymptomatic women with endometrial polyps., Methods: Institutional databases were analyzed to identify women with pathologically confirmed endometrial polyps diagnosed from 2002 to 2007. Demographic, clinical, and pathologic outcomes were reviewed. The most significant pathologic diagnosis was recorded for each subject. Endometrial hyperplasia and cancer were characterized as arising in the polyp or the adjacent endometrium. Factors associated with atypical hyperplasia and cancer were analyzed., Results: A total of 1011 women with endometrial polyps were identified. On pathology review, 964 (95.4%) polyps were reported as benign, 13 (1.3%) as hyperplasia without atypia, 5 (0.5%) as hyperplasia with atypia, and 13 (1.3%) as endometrial cancer. The only clinical or demographic factor associated with atypical hyperplasia and cancer was menopausal status (P = .02). Among premenopausal women the risk of cancer or atypical hyperplasia was 0.9% in patients without bleeding and 1.0% in women with bleeding. In postmenopausal women cancer or atypical hyperplasia was found in 1.9% of patients without bleeding and in 3.8% of women with bleeding., Conclusions: The risk of endometrial cancer in women with endometrial polyps is 1.3%, while cancers confined to a polyp were found in only 0.3%. The risk is greatest in postmenopausal women with vaginal bleeding.

Objective: Despite significant morbidity, surgical cytoreduction is the standard of care for ovarian cancer. We examined the outcomes of cytoreductive surgery to determine if there are groups of patients in which the morbidity is so substantial that alternate treatment strategies are warranted., Methods: The Nationwide Inpatient Sample was used to identify women who underwent surgery for ovarian cancer from 1998 to 2007. The effect of age, number of radical procedures performed, and clinical characteristics on morbidity and mortality were examined., Results: A total of 28,651 women were identified. The complication rates increased with age from 17.1% in those <50 years of age to 29.7% in women age 70-79 and to 31.5% in those ≥ 80 (p<0.05). The number of extended procedures performed was also a predictor of morbidity; complications increased from 20.4% for women with 0 procedures to 34.0% for 1 and 44.0% for ≥ 2 procedures (p<0.0001). In multivariable analysis age, comorbidity, and the number of procedures performed were the strongest predictors of outcome. The morbidity associated with additional procedures was greatest in the elderly. Medical complications in women <50 years of age occurred in 10.2% of those who underwent 0 radical procedures vs. 23.7% in those who underwent 2 or more procedures. For women ≥ 80 years, complications were noted in 18.3% for 0 procedures, and 33.3% for 2 or more procedures., Conclusion: The morbidity of cytoreduction is greatest in elderly women where the effects of age and the number of radical procedures performed have an additive effect on complication rates., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Objective: Despite the fact that endometrial cancer commonly occurs in elderly women, little is known about the outcome of the oldest old, those > 80 years of age. We examined the patterns of care and outcome of the oldest old women with endometrial cancer., Methods: An analysis of women > 65 years of age with endometrioid adenocarcinoma of the uterus diagnosed between 1988 and 2006 and registered in the Surveillance, Epidemiology, and End Results database was performed. Patients were stratified by age into the following groups: 65-69, 70-74, 75-79, 80-84, and ≥ 85 years of age. Multivariable logistic regression models were constructed to examine treatment while adjusting for other confounders. Cancer-specific survival was examined using Cox proportional hazards models., Results: A total of 37,718 women including 5289 aged 80-84 and 3446 ≥ 85 years of age were identified. Older women had higher grade tumors (p<0.0001) and more advanced stage disease (p<0.0001). After adjusting for tumor characteristics, patients ≥ 85 years of age were less likely to undergo hysterectomy (OR=0.14; 95% CI=0.12-0.16) and lymphadenectomy (OR=0.48; 95% CI=0.44-0.54) and less likely to receive radiation (OR=0.41; 95% CI=0.36-0.46). After adjustment for treatment and prognostic factors, cancer-specific mortality was 53% (HR=1.53; 95% CI=1.39-1.67) greater in women 80-84 and 89% (HR=1.89; 95% CI= 1.71-2.08) greater in those ≥ 85 years of age than in women 65-69 years old., Conclusion: Women > 80 years of age receive less aggressive care than younger women. Even after adjusting for treatment differences, cancer-specific mortality is higher in the oldest old women., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Objective: We examined predictors of massive blood loss for women with placenta accreta who had undergone hysterectomy., Study Design: A retrospective review of women who underwent peripartum hysterectomy for pathologically confirmed placenta accreta was performed. Characteristics that are associated with massive blood loss (≥ 5000 mL) and large-volume transfusion (≥ 10 units packed red cells) were examined., Results: A total of 77 patients were identified. The median blood loss was 3000 mL, with a median of 5 units of red cells transfused. There was no association among maternal age, gravidity, number of previous deliveries, number of previous cesarean deliveries, degree of placental invasion, or antenatal bleeding and massive blood loss or large-volume transfusion (P > .05). Among women with a known diagnosis of placenta accreta, 41.7% had an estimated blood loss of ≥ 5000 mL, compared with 12.0% of those who did not receive the diagnosis antenatally with ultrasound scanning (P = .01)., Conclusion: There are few reliable predictors of massive blood loss in women with placenta accreta., (Copyright © 2011 Mosby, Inc. All rights reserved.)