The literature available discusses the influence of a uterine manipulator on the success of treatment, survival, and the possibility of recurrence. A recent multi-center retrospective analysis of 2021 compared 2661 female patients from 15 centers. Of these, 1756 patients were operated endoscopically with a uterine manipulator and 905 without it. Both groups were balanced, taking into account the histology of tumor grading, myometrial invasion, disease stage, and administration of adjuvant therapy. The recurrence rate was 11.69% in the manipulator group compared to 7.4% in patients when the manipulator was not used (HR, 2.31; 95% CI, 1.27-4.20; P = 0.006). The authors emphasize the need to perform prospective measurements, although their results show a worse prognosis for patients where a uterine manipulator was used.
In our work, we did not evaluate the overall survival and recurrence rate, but the presence of the risk of a manipulator uses and a possible worsening prognosis by medical approach of female patients in terms of increasing the incidence of LVSI. The confirmation of the hypothesis would mean inadequate placing of female patients in the risk group and excessive treatment in terms of adjuvant therapy. However, this relationship has not been confirmed in our work. LVSI was positive 11.3% in the manipulator group versus 22.5% in the non-manipulator group (OR 1.92, 95% CI 0.77-4.77, P = 0.162). The difference in the groups is without statistical significance.
These conclusions are also supported by the meta-analysis of 11 retrospective studies evaluating the effect of a uterine manipulator on positive abdominal cytology (RR: 1.53, 95% CI, 0.85 to 2.77), the presence of LVSI (RR: 1.18, 95% CI, 0.66 to 2.11), and the disease recurrence rate (RR: 1.25, 95% CI, 0.89 to 1.74). The authors did not observe a negative impact of a manipulator in any of the evaluated parameters . In this stud there is the opposite conclusion to that of the authors in the previously mentioned study .
The impact of the Koch-Rumi manipulator on the presence of LVSI – the pseudo-invasion was evaluated by a team of authors from the United States of America. In a group of 37 female patients, 7 of whom underwent surgery for endometrial cancer and 30 for benign causes, they found that they observed a vascular pseudo-invasion. In malignant cases, in 71% and in benign cases, in 13%. . They expressed a suspicion of a mechanical action of positive balloon pressure in the closed uterine cavity and its possible impact on the evaluated histological specimens. In our work, we compared the influence of a type of uterine manipulator on the presence of LVSI, both expandable (Koch-Rumi) and non-expandable (Hegar dilator). In the analysis, we did not find any difference between the individual modalities (ManipKoRu 10% vs. ManipHe 14.64%, p = 0.748). (Tab. 3).
From the secondary analysis of our set, we evaluated the relationship between the degree of differentiation: the tumor grading, depth of myoinvasion, and the incidence of LVSI. In tumors on the grading scale 2 and 3 (OR 0.23; CI 95% 0.07 - 0.77; p = 0.017), and in case of tumor overgrowth of more than half of the uterine wall - T1b (OR 6.24; CI 95% 2.46 - 15.8; p <0.001), a higher incidence of LVSI with statistical significance was observed. A similar connection to a higher incidence of LVSI positive cases at higher gradings has already been documented in the literature, 43.8% versus 17.0% .
In the secondary data evaluated, we observed a significant difference in the incidence of LVSI in the female patients with histology obtained by hysteroscopy versus curettage (6.6% vs 22.4%, OR 4.27; CI 95% 1.39 - 13.07; p = 0.011). These procedures were performed in several workplaces. With the introduction of hysteroscopy as a surgical method, there has been a discussion about the safety of using a distension medium under pressure and the possible dispersal of tumor cells into the peritoneal cavity through the fallopian tubes. In their work, a group of authors observed this phenomenon in endometrial carcinomas of the second type . However, a study from 2010 did not confirm the impact on prognosis of female patients . A meta-analysis on the safety of hysteroscopy in the diagnosis of endometrial cancer in the first stage is currently registered . Our results suggest that female patients who have undergone curettage have a higher incidence of LVSI. Hypothetically, this phenomenon could occur due to the pressure of the curette on the wall of the uterine cavity and the extrusion of tumor cells into the lymphovascular spaces. In hysteroscopic examination, samples are taken in a targeted manner, often with the help of resectoscopy, without the need for increased mechanical force. Further studies will be needed to confirm our results.