Incidence and Outcomes of Occult Uterine Cancer in Uteri Removed for Prolapse

Introduction and Hypothesis To identify the incidence of occult endometrial cancer diagnosed following hysterectomy for the repair of pelvic organ prolapse, and compare patient outcomes to a control cohort of preoperatively diagnosed endome- trial cancer patients.

A retrospective cohort study of patients ≥50 years with endometrial cancer between 2010 and 2020 was performed. Demographic, clinical, surgical, and oncologic variables were compared between occult endometrial cancer and preopera- tively diagnosed endometrial cancer cohorts.

One thousand seventy-two patients were included, of which 30 (2.8%) had occult endometrial cancer diagnosed after prolapse surgery and 1042 (97.2%) were in the preoperatively diagnosed historic cohort. The incidence of occult endometrial cancer was 0.56% for all hysterectomies performed for pelvic organ prolapse. Patients in the occult endometrial cancer cohort were more likely to have grade I disease (85.2% vs. 52.1%, p 50% myometrial invasion (11.1% vs. 24.0%, p = 0.004) compared to the preopera- tively diagnosed patients. Ten occult endometrial cancer patients (33.3%) underwent a second staging procedure; 83.3% (n = 25) of patients received care in compliance with comprehensive national cancer guidelines. Five-year recurrence free survival was 95.0% (95% CI 85.4–100%) and 66.8% (95% CI 59.3–74.4%) for preoperatively diagnosed cohort and occult endometrial cancer cohort, respectively, while 5-year overall survival was 90.9% (95% CI 78.9–100%) and 83.0% (95% CI 75.5–90.5%), respectively.

The rate of incidental endometrial cancer after hysterectomy for pelvic organ prolapse was 0.56% in our cohort. Most occult diagnosed patients are diagnosed with early-stage and low-grade disease. The majority received care concurrent with National Comprehensive Cancer Network recommendations.

Hysterectomy · Occult endometrial carcinoma · Pelvic organ prolapse · Uterine cancer Abbreviations EC Endometrial cancer POP Pelvic organ prolapse CPT Current Procedural Terminology NCCN National Comprehensive Cancer Network LVSI Lymphovascular space invasion Handling Editor: Catherine Matthews Editor in Chief: Maria A. Bortolini * Mariam AlHilli [email protected] 1 Obstetrics, Gynecology, Women’s Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195, USA 2 Cleveland Clinic Lerner College of Medicine of Case Western Reserve University School of Medicine, Cleveland, OH 44195, USA 3 Department of Qualitative Health Sciences, Cleveland Clinic, Cleveland, OH 44195, USA 4 Division of Urogynecology, Department of Subspeciality Care for Women’s Health, Obstetrics and Gynecology Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195, USA 5 Division of Gynecologic Oncology, Department of Subspeciality Care for Women’s Health, Obstetrics and Gynecology Institute, Cleveland Clinic, 9500 Euclid Ave., Cleveland, Ohio 44195, USA 2298 International Urogynecology Journal (2025) 36:2297–2304 MMI Myometrial invasion FIGO International Federation of Gynecology and Obstetrics

Endometrial cancer (EC) is the most common gynecologic malignancy in women with approximately 66,200 estimated new cases diagnosed in 2023 and 13,030 expected deaths in the United States [1, 2]. The 5-year relative survival rate is 81.1%, and approximately 3.1% of women will be diagnosed with uterine cancer at some point during their lifetime [2 ]. Risk factors for EC include age, obesity, estrogen hormone replacement therapy, nulliparity, and a family history of EC [3]. A woman’s lifetime risk of undergoing a procedure for urinary incontinence or pelvic organ prolapse (POP) by the age of 80 is estimated to be 11% [4 ]. Analysis of the National Hospital Discharge Summary estimated that over 200,000 and 100,000 inpatient surgical procedures are performed in the United States annually for POP and female urinary incontinence, respectively [5 , 6]. Pro- lapse is the most common indication for hysterectomy in women greater than 55 years of age [7 ]. The risk of an incidental finding of uterine pathology in women under - going hysterectomy for prolapse is overall low, studies quote percentages ranging from 0.5–2.6% [8 –10]. An incidental diagnosis of malignancy after surgery for pro- lapse or other benign indication can result in deviations from standard management that may potentially alter patients’ outcomes. Knowing the incidence of uterine malignancy at the time of surgery for prolapse can help guide preoperative evalua- tions to identify patients at risk and direct preoperative coun- seling. Our study aim was to identify the incidence of occult endometrial cancer identified on pathology specimens from surgeries performed for POP at our institution. In addition, we sought to evaluate the oncologic outcomes of patients with an occult diagnosis of EC in comparison to women with a known preoperative diagnosis of EC.

Study Design We performed an institutional review board approved, ret - rospective cohort study of patients aged 50 years and older who had an incidental diagnosis of EC during primary sur - gery for POP at a single, tertiary care institution between January 1, 2010 and December 31, 2020. Patients were excluded if hysterectomy of any route (vaginal, laparoscopic, or open) was not performed. Patients were identified using Current Procedural Ter - minology (CPT) codes for prolapse surgery. This cohort was then cross-referenced with patients who had Interna- tional Classification of Diseases-9 or −10 codes identify - ing endometrial malignancy. Procedures for POP repair for which CPT codes were used included colpopexy, uterosa- cral ligament suspension, paravaginal repair, colpocleisis, Le Forte colpocleisis, sacrospinous ligament suspension, anterior colporrhaphy, combined anterior/posterior colp- orrhaphy, posterior colporrhaphy, colpoperineorrhaphy, colpoperineorrhaphy with repair of rectocele, burch or Marshall–Marchetti–Krantz procedure (primary or repeat), laparoscopic burch or Marshall–Marchetti–Krantz, fascia or synthetic sling, or laparoscopic sling. Identified patients were reviewed by two independent persons to verify con- cordance with inclusion criteria. Most procedures were performed by a urogynecologist with a few completed by either a general OBGYN or urologist. This cohort was compared to the preoperatively diag- nosed group, who had a diagnosis of EC prior to hyster - ectomy and completed definitive surgery at the Cleveland Clinic Foundation between January 1, 2004 and August 1, 2016 as previously described by Son et al. [11]. Patients undergoing fertility sparing treatment were excluded. Data Collection We queried the electronic medical record for patient, sur - gical, and oncologic parameters. All data was collected and stored in a secure REDCap database [12]. Patient char- acteristics, including age at primary surgery, race, body mass index, history of smoking, comorbidities, and parity were included. Data specific to the prolapse surgery was collected, including hysterectomy approach and additional proce- dures performed. Oncologic parameters specific to the occult cohort collected included patient presentation at our institutional tumor board, and requirement for subsequent surgical staging. Time to a secondary surgical procedure was defined as days elapsed between the date of primary prolapse surgery and staging procedure. Optimal manage- ment of disease per the National Comprehensive Cancer Network (NCCN) guidelines for uterine cancer was noted [13]. Oncologic parameters collected for both the occult and preoperatively diagnosed cohorts included stage and grade at diagnosis, histology, lymphovascular space inva- sion (LVSI), tumor size, and depth of myometrial inva- sion (MMI). Adjuvant therapy, including chemotherapy, 2299International Urogynecology Journal (2025) 36:2297–2304 extended beam radiation therapy, and vaginal brachyther - apy was documented. Statistical Analysis Approximately normally distributed continuous meas- ures were summarized using means and standard devia- tions and compared using two-sample t -tests. Continuous measures that demonstrated departure from normality and ordinal measures were summarized using medians and quartiles or frequencies and percentages and compared using Wilcoxon rank sum tests. Categorical factors were summarized using frequencies and percentages and were compared using Pearson’s chi-square tests or Fisher’s exact tests. Owing to the different follow-up durations between the two cohorts and the low event rates in the occult cohort, only descriptive survival analysis was done. Survival starting date was set to be the surgery date, and month was defined as 30 days. Data analysis was performed using SAS software (version 9.4; SAS Institute, Cary, NC). P values of < 0.05 were considered significant.

Patient Demographics A total of 1072 patients were included in this analysis of which 30 (2.8%) patients were in the occult cohort and 1042 (97.2%) were in the preoperatively diagnosed cohort. Patient characteristics comparing the two cohorts are illustrated in Table  1. The age at surgery was similar between the occult and preoperatively diagnosed cohorts (mean 67.2 years ± SD 9.1 vs. 63.9 years ± 9.2, p = 0.054). Patients in the occult cohort had a lower body mass index (kg/m2) in com- parison to the preoperatively diagnosed cohort (30.1 ± 6.4 vs. 34.7 ± 9.3, p < 0.001) and higher rate of smoking his- tory (40.0% vs. 0.29%, p <0.001). The distribution of race differed significantly between the two cohorts as the occult cohort had fewer African American patients (3.3% vs. 9.4%) and more Asian/Pacific Islander patients (6.7% vs. 1.9%) (p = 0.006) in comparison to the preoperatively diagnosed cohort. The two cohorts had similar rates of hypertension diabetes mellitus pulmonary disease, cardiac disease, other cancers, and Lynch syndrome (Table  1). Table 1 Demographics comparing the occult endometrial cancer to preoperative endometrial cancer cohorts Statistics presented as mean ± SD, median [P25, P75], N (column %) p values: a1 t-test, a2 Satterthwaite t-test, b Wilcoxon Rank Sum test, c Pearson’s chi-square test, d Fisher’s Exact test Occult (N = 30) Preoperative (N = 1 042) Factor Total (N=1,072) N Statistics N Statistics p value Age at surgery 64.0 ± 9.3 30 67.2 ± 9.1 1042 63.9 ± 9.2 0.054a1 Body mass index (kg/m2) 34.6 ± 9.3 30 30.1 ± 6.4 1031 34.7 ± 9.3 <0.001a2 Race 30 1024 0.006d      Non-Hispanic White 935 (88.7) 26 (86.7) 909 (88.8)      Hispanic 1 (0.09) 1 (3.3) 0 (0.00)      Black/African American 97 (9.2) 1 (3.3) 96 (9.4)      Asian/Pacific Islander 21 (2.0) 2 (6.7) 19 (1.9) Comorbidities      Hypertension 628 (58.6) 30 22 (73.3) 1042 606 (58.2) 0.096c      Diabetes 304 (28.4) 30 6 (20.0) 1042 298 (28.6) 0.30c      Pulmonary disease 174 (16.2) 30 3 (10.0) 1042 171 (16.4) 0.46d      Cardiac disease 229 (21.4) 30 4 (13.3) 1042 225 (21.6) 0.28c      Other cancer history 150 (14.1) 30 3 (10.0) 1032 147 (14.2) 0.79d History of Lynch syndrome 30 1042 0.99d      Yes 5 (0.47) 0 (0.00) 5 (0.48)      No 1,061 (99.0) 30 (100.0) 1031 (98.9)      Unknown 6 (0.56) 0 (0.00) 6 (0.58) Smoking history 15 (1.4) 30 12 (40.0) 1042 3 (0.29) <0.001d Parity 2.0 [1.00, 3.0] 29 2.0 [2.0, 3.0] 993 2.0 [1.00, 3.0] 0.091b 2300 International Urogynecology Journal (2025) 36:2297–2304 Urogynecologic Surgery Parameters A total of 5376 unique POP surgeries occurred between January 1, 2010 and December 30, 2020 at our institution. A total of 30 patients had an incidental diagnosis of EC confirmed postoperatively after prolapse surgery for an overall incidence of EC of 0.56%. No patients diagnosed with EC demonstrated signs or symptoms of EC preopera- tively, particularly postmenopausal bleeding. The surgical parameters for the occult cohort are described in Table  2. Most patients had a vaginal hysterectomy ( n = 22, 75.9%). Ten percent (n = 3) had a unilateral salpingectomy, 40.0% (n = 12) had a bilateral salpingectomy, 6.7% (n = 2) had a unilateral oophorectomy, 33.3% (n = 10) had a bilateral oophorectomy, and 3.3% (n = 1) had a colpocleisis. The median uterine weight for all hysterectomies performed in the occult cohort was 59.3 grams [Interquartile range (IQR) 42.5–99.0]. Of the 30 patients diagnosed with occult EC, no patients underwent lymph node assessment during prolapse surgery, 13.3% ( n = 4) of patients were presented at a multidisci - plinary tumor board, and 33.3% (n = 10) underwent a sec- ond staging procedure. The median time to second staging procedure was 52.0 days [IQR 28.0–64.0]. In 26.7% (n = 8) patients, a second staging procedure was documented as discussed with the patient in the medical record but was deferred due to either patient preference or low risk status. For 40.0% (n = 12) of patients, a second staging procedure was not recommended. Adnexal involvement was present in 15.8% (n = 3) of patients who had an oophorectomy either at initial surgery or at secondary staging. Overall, 83.3% (nn = 25) of patients received care in compliance with NCCN guidelines for uterine cancer. Oncologic Parameters for Occult Endometrial Cancer Versus Preoperative Diagnosed Cohorts There was no difference in stage or histology at diagnosis with the majority of patients presenting with stage I or II (87.5% vs. 83.7%, p = 0.78) and endometrioid histology (90.0% vs. 80.1%, p = 0.44) in the occult and preoperatively diagnosed cohorts, respectively (Table  3). Patients in the occult cohort were more likely to present with International Federation of Gynecology and Obstetrics (FIGO) grade 1 disease (85.2% vs. 52.1%, p 50% (11.1% vs. 24.0%, p = 0.004). Patients in the occult cohort had smaller median tumor sizes on pathology (2.0 cm IQR [0.60–2.7] vs. median 3.0 cm IQR [1.1–4.5], p = 0.005) in comparison to the control cohort and were less likely to receive any form of adjuvant therapy (24.1% vs 48.9%, p = 0.008), including chemotherapy (13.3% vs. 30.7%, p = 0.041) and vaginal brachytherapy (10.0% vs. 32.9%, p = 0.008). However, no differences in likelihood of receiving external beam radiotherapy between cohorts was noted ( p = 0.11). With a median follow-up duration of 72.0 months [IQR 32.3–94.5], two recurrences (6.7%) and 5 deaths (16.7%) were observed in the occult cohort. As is seen in Fig.  1A/B, the 5-year recurrence free survival was 95.0% (95% CI 85.4% −100%) and 5-year overall sur - vival was 90.9% (95% CI 78.9%–100%). The preoperatively diagnosed cohort had a median follow-up duration of 18.0 months [IQR 8.9–26.4] with 5-year recurrence-free survival of 66.8% (95% CI 59.3–74.4%), and 5-year overall survival of 83.0% (95% CI 75.5–90.5%). Table 2 Characteristics of surgical variables for occult endometrial cancer cohort NCCN National Comprehensive Cancer Network Statistics presented as Median [P25, P75], N (column %). Total (N = 30) Factor N Statistics Hysterectomy approach 29      Abdominal 2 (6.9)      Laparoscopic 5 (17.2)      Vaginal 22 (75.9) Type of urogynecology surgery      Tension free vaginal tape sling 30 5 (16.7)      Transobturator tape sling 30 7 (23.3)      Anterior colporrhaphy 30 21 (70.0)      Posterior colporrhaphy 30 18 (60.0)      Sacrocolpopexy 30 5 (16.7)      Uterosacral ligament suspension 30 16 (53.3)      Perineorrhaphy 30 5 (16.7)      Sacrospinous ligament suspension 30 2 (6.7)      Unilateral salpingectomy 30 3 (10.0)      Bilateral salpingectomy 30 12 (40.0)      Unilateral oophorectomy 30 2 (6.7)      Bilateral oophorectomy 30 10 (33.3)      Colpocleisis 30 1 (3.3) Uterus weight (g) 28 59.3 [42.5, 99.0] Staging at urogynecology surgery 30 0 (0) Adnexal involvement 19 3 (15.8) Cervical involvement 27 0 (0) Patient presented at tumor board 30 4 (13.3) Second staging procedure required 30      Yes 10 (33.3)      No 12 (40.0)      Yes but not performed 8 (26.7) Time to second staging procedure (days) 10 52.0 [28.0, 64.0] Compliance with NCCN guidelines 30 25 (83.3) 2301International Urogynecology Journal (2025) 36:2297–2304

Mortality rates for EC have increased by 1.8% overall and 2.7% for non-endometrioid subtypes in recent years [14]. With hysterectomy being one of the most common gyneco- logic procedures performed, the importance of preoperative evaluation for malignancy is of utmost importance. The Fed- eral Drug Administration warning against the use of power morcellation due to possible dissemination of occult malig- nancy has made for more robust preoperative cancer screen- ing practices in patients with large uteri or abnormal uterine bleeding [15, 16]. Despite increased screening efforts, occult uterine malignancy is still identified in patients undergo- ing benign surgery. The incidence of occult EC was 0.56% in our study, which is consistent with previously reported data. In our study, patients with occult EC were more likely to have FIGO grade 1 disease, and less likely to have LVSI, larger tumor size, and deep MMI than the preoperatively diagnosed cohort. Furthermore, occult patients had a sig- nificantly lower body mass index and were less likely to be of African American race than the preoperatively diagnosed cohort. Overall, 83.3% (n = 25) patients received care in compliance with NCCN guidelines for uterine cancer. Given recent increases in rates of hysteropexy [17], awareness of risk factors for occult endometrial pathology is important. While the literature does not consistently deline- ate risk factors, as outlined above, there are established con- traindications to uterine preservation. Patients with genetic predisposition for malignancy and those with a personal his- tory of an estrogen receptor positive breast cancer, especially if on tamoxifen, should not be offered uterine preserving prolapse repair. Other contraindications include endome- trial hyperplasia and post-menopausal bleeding, even if the endometrial biopsy is negative. Obesity is cited as a relative contraindication to uterine preservation, given that this is a risk factor for development of endometrial cancer [18]. Identifying and understanding risk factors for inciden- tal uterine pathology at time of hysterectomy is essential for optimizing preoperative screening and patient coun- seling in women undergoing hysterectomy for benign indications. Several studies have reviewed this topic. Reported rates of incidental EC or hyperplasia range from Table 3 Oncologic variables comparing occult endometrial cancer to preoperative endometrial cancer cohorts Statistics presented as median [P25, P75], N (column %) p values: b Wilcoxon rank sum test, c Pearson’s chi-square test, d Fisher’s exact test Occult (N=30) Preoperative (N = 1042) Factor Total (N=1,072) N Statistics N Statistics p value Stage at diagnosis 24 1014 0.78d      I/II 870 (83.8) 21 (87.5) 849 (83.7)      III/IV 168 (16.2) 3 (12.5) 165 (16.3) Grade 27 936 <0.001b      FIGO 1 511 (53.1) 23 (85.2) 488 (52.1)      FIGO 2 272 (28.2) 4 (14.8) 268 (28.6)      FIGO 3 180 (18.7) 0 (0.00) 180 (19.2) Histology 30 1,037 0.44d      Endometrioid 858 (80.4) 27 (90.0) 831 (80.1)      Serous 77 (7.2) 1 (3.3) 76 (7.3)      Clear cell 17 (1.6) 0 (0.00) 17 (1.6)      Mixed 71 (6.7) 0 (0.00) 71 (6.8)      Other 44 (4.1) 2 (6.7) 42 (4.1) LVSI 331 (31.3) 28 3 (10.7) 1030 328 (31.8) 0.017c Tumor size (cm) 3.0 [1.1, 4.5] 19 2.0 [0.60, 2.7] 1034 3.0 [1.1, 4.5] 0.005b Depth of myometrial invasion 27 964 0.004c      0% 272 (27.4) 15 (55.6) 257 (26.7)      50% 234 (23.6) 3 (11.1) 231 (24.0) Adjuvant therapy 517 (48.3) 29 7 (24.1) 1042 510 (48.9) 0.008c      Chemotherapy 324 (30.2) 30 4 (13.3) 1042 320 (30.7) 0.041c      External beam 189 (17.6) 30 2 (6.7) 1042 187 (17.9) 0.11c      Vaginal brachytherapy 346 (32.3) 30 3 (10.0) 1042 343 (32.9) 0.008c 2302 International Urogynecology Journal (2025) 36:2297–2304 0.3 to 2.6% [8 , 9, 19]. Some notable risk factors in these studies include age >60 years, a concomitant diagnosis of hypertension or diabetes, and uterine weight > 250 grams. However, these factors were not found to be predictive of occult EC in our cohort [ 19]. In our study, the occult cohort had significantly different body mass index, race, and smoking history compared to the preoperatively diag- nosed cohort. Previously published occult EC rates after surgery for varying benign indications were consistent with our findings. Fig. 1 A/B: Oncologic out- comes in occult endometrial cancer versus preoperatively diagnosed endometrial cancer cohorts 2303International Urogynecology Journal (2025) 36:2297–2304 Our study is also one of the few to report and compare oncologic descriptors and treatment outcomes after an occult EC diagnosis, and compare these women to a similar cohort of patients with preoperatively diagnosed EC. The inciden- tal diagnosis of EC after surgery creates a dilemma in the absence of prognostic information that lymph node status provides [13]. In our study, ten patients (33.3%) underwent a second staging procedure and in eight (26.7%) patients, a second staging procedure was documented as discussed with the provider in the medical record, but was deferred due to patient preference or low risk status. Ambiguity regarding adjuvant care in situations when EC is identified on pathol- ogy specimens can be mitigated by the use of clinical criteria to estimate risk of recurrence and lymph node metastasis or use of a risk scoring system that has been described pre- viously [20]. These tools can allow patients to receive the most appropriate surgery or adjuvant therapy for their can- cer, and optimize oncologic outcomes even when cancer is incidentally diagnosed. Additionally, NCCN provides guide- lines for patients with incidentally diagnosed EC who are incompletely staged which may include observation, vaginal brachytherapy, surgical restaging, or further imaging with treatment decisions altered on the basis of positive or suspi- cious imaging results [13]. Less than 25% of women in our study required adju- vant therapy. The majority of our patients had early-stage and low-grade disease and thus were able to be safely and appropriately observed. Emerging data regarding molecu- lar classification of EC and its prognostic role may further simplify risk stratification and support evidence-based treat- ment decisions according to molecular subtypes [21]. These criteria are anticipated to enhance oncologic care, and allow women to avoid undertreatment or overtreatment of their disease. The incidental diagnosis of EC is very low in patients undergoing hysterectomy for benign indications, with varying estimates ranging from 0.5–2.6% [8 –10]. The incidental finding of uterine malignancy at time of hys- terectomy for prolapse repair highlights continued diffi- culty with preoperative screening and diagnosis of EC, as most patients in this population were asymptomatic and had no identifiable risk factors. Despite the excellent out- comes and diagnosis of early-stage low-grade disease, an incidental diagnosis of EC is alarming to patients. The lifetime risk of an American woman developing EC is approximately 2.8%, and rising in recent years as previ- ously described [22]. Our study contributes to the pub- lished literature, in providing support that the incidence of incidentally diagnosed EC at the time of hysterectomy for POP is lower than a woman’s lifetime risk of devel- oping the disease. Future research is needed, especially in regard to cost effectiveness of preoperative screening with transvaginal ultrasound or endometrial biopsy in the setting of low risk patients and a rare primary outcome of incidentally diagnosed EC at time of surgery for benign indications. The main strength of our study is that it includes data from a large volume academic institution with special - ized gynecologic pathology review. Only two reviewers performed the chart review to minimize selection bias and standardize data collection. In addition, we were able to conduct a comparison of oncologic parameters to a similar cohort at the same institution with known EC at the time of primary surgery. There are several limitations to our study that must be considered. The retrospective study design, the possibility of bias in patient selection by different staff surgeons, and the availability of medical records data cannot be disre- garded. Furthermore, with the small sample size of the occult EC cohort and overall low incidence of postopera- tive complications, it is possible that the study was not adequately powered to detect significance with respect to specific associations. The patients in this study were treated at a high-volume tertiary care center and the major - ity identified as white, which may limit generalizability. The study also occurred over a 10-year study period with discrepancy in duration of study between the occult and preoperatively diagnosed cohort due to data availability, which may not account for practice or societal guidelines changes. In summary, in this single institution retrospective cohort study of women incidentally diagnosed with EC at time of POP repair, the incidence of EC was similar to published rates in the literature. The majority of our patients received care concurrent with NCCN recommen- dations for EC despite their incidental diagnosis. Author Contributions Morgan Gruner: Conceptualization, data cura- tion, writing—original draft, writing—review and editing, project administration. Surabhi Tewari: Conceptualization, data curation, writing—original draft, writing—review and editing. Meng Yao: Methodology, statistical analysis, data curation, writ- ing—original draft, writing—review and editing. Katie Propst: Conceptualization, Data curation, writing—original draft, writing—review and editing. Mariam AlHilli: Conceptualization, methodology, investigation, data curation, writing—original draft, writing—review and editing, project administration, project supervision. Funding There has been no financial support for this work. Declarations Ethical Approval IRB Number 21-538. IRB approval obtained from Cleveland Clinic Foundation IRB. Conflict of Interest The authors have no known conflicts of interest. 2304 International Urogynecology Journal (2025) 36:2297–2304 Open Access This article is licensed under a Creative Commons Attri- bution 4.0 International License, which permits use, sharing, adapta- tion, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

1. Centers for Disease Control and Prevention. Gynecologic Cancer Incidence, United States–2012–2016. U.S. Cancer Statistics data brief, no 11. Atlanta: Centers for Disease Control and Prevention, US Department of Health and Human Services; 2019. 2. National Cancer Institute Surveillance, epidemiology, and End

Program. Cancer Stat Facts: Uterine Cancer. 2022. Accessed 19 Oct 2022. https:// seer. cancer. gov/ statf acts/ html/ corp. html 3. Division of Cancer Prevention and Control, Centers for Disease Control and Prevention. Uterine Cancer: What are the risk factors? Published online August 30, 2022. Accessed 19 Oct 2022. https:// www. cdc. gov/ cancer/ uteri ne/ basic_ info/ risk_ facto rs. htm 4. Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epide- miology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol. 1997;89(4):501–6. https:// doi. org/ 10. 1016/ S0029- 7844(97) 00058-6. 5. Shah AD, Kohli N, Rajan SS, Hoyte L. The age distribution, rates, and types of surgery for stress urinary incontinence in the USA. Int Urogynecol J Pelvic Floor Dysfunct. 2008;19(1):89–96. https:// doi. org/ 10. 1007/ s00192- 007- 0392-y 6. Oliphant SS, Wang L, Bunker CH, Lowder JL. Trends in stress urinary incontinence inpatient procedures in the United States, 1979–2004. Am J Obstet Gynecol. 2009;200(5):521.e1-6. https:// doi. org/ 10. 1016/j. ajog. 2009. 01. 007 7. Whiteman MK, Hillis SD, Jamieson DJ, et al. Inpatient hysterec- tomy surveillance in the United States, 2000–2004. Am J Obstet Gynecol. 2008;198(1):34.e1-7. https:// doi. org/ 10. 1016/j. ajog. 2007. 05. 039 8. Frick AC, Walters MD, Larkin KS, Barber MD. Risk of unan - ticipated abnormal gynecologic pathology at the time of hys- terectomy for uterovaginal prolapse. Am J Obstet Gynecol. 2010;202(5):507.e1-4. https:// doi. org/ 10. 1016/j. ajog. 2010. 01. 077 9. Ackenbom MF, Giugale LE, Wang Y, Shepherd JP. Incidence of occult uterine pathology in women undergoing hysterectomy with pelvic organ prolapse repair. Female Pelvic Med Reconstr Surg. 2016;22(5):332–5. https:// doi. org/ 10. 1097/ SPV. 00000 00000 000283. 10. Desai VB, Wright JD, Gross CP, et al. Prevalence, characteris- tics, and risk factors of occult uterine cancer in presumed benign hysterectomy. Am J Obstet Gynecol. 2019;221(1):39.e1-39.e14. https:// doi. org/ 10. 1016/j. ajog. 2019. 02. 051 11. Son J, Carr C, Yao M, et al. Endometrial cancer in young women: prognostic factors and treatment outcomes in women aged ≤40 years. Int J Gynecol Cancer. 2020;30(5):631–9. https:// doi. org/ 10. 1136/ ijgc- 2019- 001105. 12. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377– 81. https:// doi. org/ 10. 1016/j. jbi. 2008. 08. 010. 13. National Comprehensive Cancer Network (NCCN). NCCN Clini- cal Practice Guidelines in Oncology. Uterine Neoplasms version 1.2023. 2022, Dec 22; National Comprehensive Cancer Network. Available from: https:// www. nccn. org/ profe ssion als/ physi cian_ gls/ pdf/ uteri ne. pdf. Accessed June 2022 14. Clarke MA, Devesa SS, Hammer A, Wentzensen N. Racial and ethnic differences in hysterectomy-corrected uterine corpus can- cer mortality by stage and histologic subtype. JAMA Oncol. 2022;8(6):895. https:// doi. org/ 10. 1001/ jamao ncol. 2022. 0009. 15. Laparoscopic Uterine Power Morcellation in Hysterectomy and Myomectomy: FDA Safety Communication. 2014. Accessed 14 Apr 2022. https:// wayba ck. archi ve- it. org/ 7993/ 20170 40418 2209/ https:/ www. fda. gov/ Medic alDev ices/ Safety/ Alert sandN otices/ ucm42 4443. htm 16. FDA. UPDATE: The FDA recommends performing contained morcellation in women when laparoscopic power morcellation is appropriate: FDA safety communication. 2020. Accessed 14 Apr 2022. https:// www. fda. gov/ medic al- devic es/ safety- commu nicat ions/ update- fda- recom mends- perfo rming- conta ined- morce llati on- women- when- lapar oscop ic- power- morce llati on. 17. Madsen AM, Raker C, Sung VW. Trends in hysteropexy and api- cal support for uterovaginal prolapse in the United States from 2002 to 2012. Female Pelvic Med Reconstr Surg. 2017;23(6):365– 71. https:// doi. org/ 10. 1097/ SPV. 00000 00000 000426. 18. Gan ZS, Roberson DS, Smith AL. Role of hysteropexy in the management of pelvic organ prolapse. Curr Urol Rep. 2022;23(9):175–83. https:// doi. org/ 10. 1007/ s11934- 022- 01101-0 19. Andiman SE, Bui AH, Hardart A, Xu X. Unanticipated uterine and cervical malignancy in women undergoing hysterectomy for uterovaginal prolapse. Female Pelvic Med Reconstr Surg. 2021;27(6):e549–54. https:// doi. org/ 10. 1097/ SPV. 00000 00000 000990 20. AlHilli MM, Podratz KC, Dowdy SC, Bakkum-Gamez JN, Weaver AL, McGree ME, et al. Risk-scoring system for the individualized prediction of lymphatic dissemination in patients with endome- trioid endometrial cancer. Gynecol Oncol. 2013;131(1):103–8. https:// doi. org/ 10. 1016/j. ygyno. 2013. 06. 037. 21. Talhouk A, McConechy MK, Leung S, Yang W, Lum A, Senz J, et al. Confirmation of promise: a simple, genomics-based clinical classifier for endometrial cancer. Cancer. 2017;123(5):802–13. https:// doi. org/ 10. 1002/ cncr. 30496. 22. Mahdy H, Casey MJ, Crotzer D. Endometrial Cancer. In: Stat- Pearls Internet. Treasure Island: StatPearls; 2023. Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.