Utility of the preoperative fiberoptic flexible sigmoidoscopy (FFS) in the evaluation of patients with suspected gynecologic malignancy

It is customary at our institution to perform standard preoperative evaluation of pelvic mass to determine the degree of intrabdominal spread, visceral involvement, and distant metastases. Fiberoptic flexible sigmoidoscopy (FFS) is routinely requested by gynecologic oncologists to exclude involvement of colon by the tumor or concurrent colonic disease (neoplasms) regardless of the presence or absence of lower gastrointestinal (GI) symptoms. The AIM of our study was to evaluate the utility of preoperative FFS for patients with suspected gynecologic malignancy. Methods: FFS was performed using a 60cm flexible sigmoidoscope. FFS and surgery findings were evaluated to determine (1) the presence of bowel involvement by the tumor, (2) extrinsic compression by the tumor, (3) presence of colonic neoplasms. The data was collected retrospectively for 14 months (n=54) and prospectively for 8 months (n=47). Results: A total of 101 women (mean age 57 years, range 32-89 years) underwent preoperative FFS and subsequent surgery. Eleven (11%) patients had lower GI symptoms. At surgery, 64% of pelvic tumors were malignant and 36% were benign. The most common abnormality at FFS was extrinsic compression by the tumor without mucosal abnormalities in 15 (14.8%) patients. Colonic adenomas (mean size 6.1 mm) were found in 11 (10%) patients (ten ≥50 yrs, 1 <50 yrs). The most common intraoperative finding was tumor adhering to the bowel in 18 patients requiring dissection, but only 1 patient required bowel resection. Eight of these 18 patients had lower GI symptoms prior to surgery. All 15 patients with extrinsic compression at FFS had tumor adhering to the bowel at surgery. Conclusions: Extrinsic compression by pelvic tumor is the most common abnormality at FFS. This finding is suggestive of tumor adherent to the bowel at surgery. However, bowel resection is rarely required due to tumor involvement. Most patients with bowel adherence by tumor have lower GI symptoms. Colonic adenomas are found in one-tenth of patients and most adenomas are in patients ≥50 years of age. Preoperative FFS does not change surgical management of pelvic tumors. Preoperative FFS is indicated in symptomatic patients ≥50 years of age.