OBJECTIVE:
Cesarean radical hysterectomy (cesarean-RH) is performed at the time of cesarean delivery for pregnant women with early-stage cervical cancer.1 Cesarean-RH is a rare procedure and has been understudied; population statistics are lacking in the literature. This study examined the characteristics and perioperative outcomes of women with cervical cancer who underwent cesarean-RH.
STUDY DESIGN:
This is a population-based retrospective study that queried the Healthcare Cost and Utilization Project’s National Inpatient Sample from 2007–2015.2 The study start period of 2007 was chosen because of the distinction detailed surgical approaches for RH (abdominal vs other approaches). The study end period of 2015 was chosen because of the change in the International Classification of Disease coding schema. Cervical cancer cases that had both cesarean delivery and abdominal RH (cesarean-RH group) were compared with cases that had RH alone via laparotomy (open-RH; Supplemental Table). Characteristics associated with cesarean-RH and those associated with perioperative complications during the index admission for RH were assessed by fitting binary logistic regression models (conditional backward) in multivariable analyses. All analyses were based on the weighted model.2
RESULTS:
Among 22,551 cases of RH that were performed for cervical cancer during the study period, there were 267 cases (1.2%) of cesarean-RH. When compared with the open-RH group (n=15,420), women in the cesarean-RH group were more likely to be young, to be Hispanic, to have lower household income, and to have Medicaid insurance (all: P<.001; Table 1). Hospitals that performed cesarean-RH were more likely to be urban teaching hospitals and to have large bed capacity (both: P<.001). The lymphadenectomy rate in the cesarean-RH group was higher compared with the open-RH group (98.1% vs 94.1%; P=.003).
TABLE 1.
Patient demographics and inpatient perioperative outcome
| Radical hysterectomy | |||||
|---|---|---|---|---|---|
| Characteristic | Open (n = 15,420) | Cesarean (n = 267) | P value | Odds ratio (95% confidence interval)a |
P valuea |
| Age, yb | 46.8±12.8 | 32.9 (±5.1) | <.001 | 0.87 (0.86–0.89) | <.001 |
| Year, n (%) | .892c | ||||
| 2007–2009 | 7,260 (47.1) | 144 (54.1) | |||
| 2010–2012 | 5,205 (33.8) | 57 (21.4) | |||
| 2013–2015 | 2,955 (19.2) | 65 (24.4) | |||
| Race/ethnicity, n (%) | <.001 | .009d | |||
| White | 7,835 (50.8) | 130 (48.9) | 1.56 (0.95–2.58) | .082 | |
| Black | 1,557 (10.1) | 19 (7.1) | 1 | ||
| Hispanic | 2,370 (15.4) | 72 (27.1) | 2.13 (1.26–3.59) | .005 | |
| Others | 1,424 (9.2) | –e | 0.82 (0.37–1.83) | .634 | |
| Missing | 2,234 (14.5) | 35 (13.2) | 1.42 (0.80–2.53) | .234 | |
| Obesity, n (%) | .186 | ||||
| No | 13,854 (89.9) | 247 (92.5) | |||
| Yes | 1,565 (10.1) | 20 (7.5) | |||
| Charlson Index, n (%) | .080 | ||||
| 0 | 11,035 (71.6) | 207 (77.8) | |||
| 1–2 | 2,794 (18.1) | 38 (14.3) | |||
| ≥3 | 1,590 (10.3) | 21 (7.9) | |||
| Median household income, n (%) | <.0001 | <.001d | |||
| <$39,000 | 4,135 (26.8) | 116 (43.6) | 1.80 (1.22–2.63) | .003 | |
| $39,000-$47,999 | 3,649 (23.7) | 60 (22.6) | 1.15 (0.76–1.74) | 0.510 | |
| $48,000-$62,999 | 3,593 (23.3) | 39 (14.7) | 0.74 (0.47–1.16) | .190 | |
| ≥$63,000 | 3,629 (23.5) | 41 (15.4) | 1 | ||
| Missing | 414 (2.7) | –e | 2.21 (1.08–4.55) | .031 | |
| Primary expected payer, n (%) | <.001 | .034d | |||
| Medicare | 1,579 (10.2) | –e | 1.38 (0.54–3.54) | .502 | |
| Medicaid | 3,521 (22.8) | 111 (41.6) | 1.37 (1.03–1.83) | .030 | |
| Private including HMO | 8,515 (55.2) | 127 (47.6) | 1 | ||
| Others | 1,763 (11.4) | 24 (9.0) | 0.70 (0.44–1.10) | .122 | |
| Missing | 42 (0.3) | 0 | Not available | .998 | |
| Hospital bed size, n (%) | <.001 | ||||
| Small/medium | 4,061 (26.3) | 41 (15.4) | 1 | ||
| Large | 11,201 (72.6) | 225 (84.6) | 2.01 (1.43–2.83) | <.001 | |
| Missing | 157 (1.0) | 0 | |||
| Hospital teaching status, n (%) | .001 | ||||
| Rural/urban nonteaching | 2,941 (19.1) | 30 (11.2) | 1 | ||
| Urban teaching | 12,322 (79.9) | 237 (88.8) | 1.73 (1.17–2.56) | <.001 | |
| Missing | 157 (1.0) | 0 | |||
| Hospital region, n (%) | .562 | ||||
| Northeast | 2,312 (15.0) | 35 (13.2) | |||
| Midwest | 3,401 (22.1) | 53 (19.9) | |||
| South | 5,872 (38.1) | 111 (41.7) | |||
| West | 3,834 (24.9) | 67 (25.2) | |||
| Lymphadenectomy, n (%) | .003 | ||||
| No | 912 (5.9) | –e | |||
| Yes | 14,507 (94.1) | 261 (98.1) | |||
| Length of stay, df | 4 (3–5) | 5 (4–6) | <.001 | ||
| ≤7, n (%) | 14,251 (92.4) | 219 (82.0) | |||
| >7, n (%) | 1,169 (7.6) | 48 (18.0) | |||
| Total charge in US dollarsf | |||||
| Uncorrected | 37,307 (25,508–54,127) | 51,371 (38,677–68,831) | <.001 | ||
| Correctedg | 48,016 (33,209–69,016) | 67,277 (49,669–82,357) | <.001 | ||
| Complication (any), n (%) | <.001 | ||||
| No | 10,469 (67.9) | 146 (54.9) | |||
| Yes | 4,951 (32.1) | 120 (45.1) | |||
For multivariable model with a binary logistic regression model (cesarean vs open radical hysterectomy); conditional backward method was used to retain covariates with P<.05 level
Values are given as mean±standard deviation
Cochran-Armitage test (examined annual value)
For interaction
Suppressed per the Healthcare Cost and Utilization Project requirement (1–10); total number may not be 15,687 because of weighted values
Values are given as median (interquartile range) or number (percentage per column) is shown: Chi-square test, Fisher exact test, Student t test, or Mann-Whitney U test for univariable analysis
Corrected for the year 2019 value.
Cesarean-RH was associated with longer length of stay (median, 5 vs 4 days) and higher corrected-total charge (median, $67,277 vs $48,016) for the index admission compared with the open-RH group (both: P<.001). Women in the cesarean-RH group had a higher perioperative complication rate compared with those in the open-RH group (45.1% vs 32.1%; absolute difference, 13.0%; P<.001). On multivariable analysis, cesarean-RH carried an independent 2.5–fold increased risk for perioperative complications compared with open-RH (adjusted-odds ratio, 2.45; 95% confidence interval, 1.89–3.16; P<.001; Table 2).
TABLE 2.
Multivariable analysis for perioperative complications
| Characteristic | Odds ratio (95% confidence interval) | P value |
|---|---|---|
| Age, y | 1.02 (1.01–1.02) | <.001 |
| Race/ethnicity | <.001a | |
| White | 1 | |
| Black | 1.42 (1.26–1.60) | <.001 |
| Hispanic | 0.88 (0.79–0.98) | .0020 |
| Others | 1.19 (1.05–1.35) | .008 |
| Missing | 1.01 (0.91–1.13) | .805 |
| Charlson Index | <.001a | |
| 0 | 1 | |
| 1–2 | 2.59 (2.37–2.83) | <.001 |
| ≥3 | 2.69 (2.40–3.01) | <.001 |
| Median household income | <.001a | |
| <$39,000 | 1.09 (0.98–1.21) | .115 |
| $39,000–$47,999 | 1.01 (0.91–1.13) | .810 |
| $48,000–$62,999 | 1.12 (1.01–1.25) | .028 |
| ≥$63,000 | 1 | |
| Missing | 0.53 (0.41–0.68) | <.001 |
| Primary expected payer | <.001a | |
| Medicare | 0.99 (0.88–1.12) | .888 |
| Medicaid | 1.36 (1.19–1.56) | <.001 |
| Private including HMO | 1 | |
| Others | 1.17 (1.07–1.28) | .001 |
| Missing | 1.16 (0.59–2.26) | .674 |
| Hospital bed size | ||
| Small/medium | 1 | |
| Large | 1.09 (1.01–1.18) | .048 |
| Hospital teaching status | ||
| Rural/urban nonteaching | 1 | |
| Urban teaching | 1.14 (1.04–1.26) | .005 |
| Hospital region | .006a | |
| Northeast | 1.15 (1.05–1.27) | .004 |
| Midwest | 1.20 (1.08–1.35) | .001 |
| South | 1.08 (0.96–1.22) | .198 |
| West | 1 | |
| Radical hysterectomy type | ||
| Open | 1 | |
| Cesarean | 2.45 (1.89–3.16) | <.001 |
Note: A binary logistic regression model for analysis (conditional backward method). All the listed covariates were entered in the final model. Missing cases for hospital bed size and teaching status were not entered in the model because of multicollinearity.
For interaction.
More specifically, compared with open-RH, cesarean-RH was associated with an increased risk of hemorrhage (27.1% vs 13.8%), ileus/small bowel obstruction (15.8% vs 8.8%), and pyelonephritis (1.9% vs 0.1%), but a decreased risk of atelectasis (0% vs 5.6%), wound complications (0% vs 2.5%), and respiratory failure (0% vs 2.4%; all, P<.05). Surgical mortality rate was statistically similar between the 2 groups (cesarean-RH vs open-RH groups: 0% vs 0.2%; P=.999).
CONCLUSION:
Our analysis confirmed that cesarean-RH is a rare surgical procedure that accounts for approximately 1% of all RH cases. Our study found that cesarean-RH is associated with high surgical morbidity (43–45%), especially in regards to high blood loss.3-5 Because previous studies have included a limited number of cesarean-RH cases, our analysis with a larger sample size is more informative to outline the detailed characteristics and perioperative outcomes of cesarean-RH. There are several limitations in the database, which include a lack of pathological information (such as histologic type, cancer stage, and oncologic outcome). The blood loss attributable to the hysterectomy part during cesarean-RH, long-term complications, and neonatal outcome are also not available. Therefore, further studies are warranted to assess the safety and feasibility of this procedure.
Because of the high surgical morbidity, consideration should be given to performing cesarean-RH at 4–6 weeks postpartum, if this expectant delay is feasible.1 Some experts propose that <3 mm invasion with lymphovascular space invasion (±positive cone margin) as an indication for cesarean-RH, if necessary.1 Because (1) this prudent consideration of delayed surgery is not based on good-quality evidence and (2) surgical mortality rate, an ultimate outcome measure of surgery, related to cesarean-RH was similar to open-RH, well-balanced assessment and decision-making for cesarean-RH is necessary, given that delayed treatment likely requires a second laparotomy.6 Most importantly, cesarean-RH should be performed at a tertiary care center with all necessary components of perioperative care, particularly blood products.
Supplementary Material
Footnotes
The following authors report possible conflict of interest: L.D.R., consultant, Quantgene; M.K., advisory board, Tesaro, GSK; S.M., research funding, MSD; K.M., honorarium, Chugai, textbook editorial expense, Springer, and investigator meeting attendance expense, VBL therapeutics. The remaining authors report no conflict of interest.
Contributor Information
Koji Matsuo, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA.
Rachel S. Mandelbaum, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA.
Shinya Matsuzaki, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA.
Ernesto Licon, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA.
Lynda D. Roman, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA.
Maximilian Klar, Department of Obstetrics and Gynecology, University of Freiburg, Freiburg, Germany.
Brendan H. Grubbs, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA.
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