Case Study – Keysha Taylor

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A Robotic Hysterectomy and a Life Saving Decision

By Dr. Laviniu Anghel – with considerable thanks to Keysha Taylor for sharing her inspiring story. 

I vividly recall the October 2016 day that I met Keysha Taylor.

It was a chance meeting. At the time, I had been an Attending Ob-Gyn for more than six years and wasn’t scheduled to be in the office that day. However, I stopped by and Keysha’s doctor asked my advice on her case given my vast gynecological surgical experience.    

As I reviewed Keysha’s records, I saw this otherwise healthy 45 year-old woman had a four-year history of increasingly progressive perimenopausal symptoms – extreme fatigue, night sweats, weight gain, and dry skin. Like many women juggling the responsibilities of a family and a career, instead of seeking proactive medical care, Keysha had tried several home remedies for her symptoms and continued to live with these significant health changes.

Notably, in the year preceding our meeting, Keysha was diagnosed with anemia, an iron deficiency spurred on by her extremely heavy periods. She explained she was having two periods a month (often unable to contain the blood flow), and was plagued by debilitating headaches and piercing abdominal and pelvic pain. Her turning point to drive her to seek additional medical advice came on New Year’s Day 2016 as she stood in the street, with her family beside her, doubled over in pain.

Soon after the New Year’s Day episode, a transvaginal sonogram revealed a cyst on her left ovary, two pollops (which were at that point removed and benign) and three uterine fibroids.

Fibroids, non-cancerous tumors of the uterus that are common as women approach menopause, can range from the size of a pin head to larger than a watermelon. In Keysha’s case they were 5 centimeters. Nearly 70 percent of white women and more than 80 percent of African-American women have a fibroid before they are 50. Most are asymptomatic, but for some women, such as in Keysha’s case, they can cause considerable pain and substantial menstrual bleeding.

While the results of Keysha’s sonogram were not to be taken lightly, that Spring, she again put her health aside to care for her husband who had undergone emergency surgery. She was also settling two daughters into college, keeping up with the demands of a teenage son, and traveling with family. As she says, ‘life got in the way of taking care of myself.’

A Memorable Patient

What struck me upon meeting Keysha, aside from her medical history, was the warmth and caring that radiated from her. Even though fatigued, she was vibrant, and it was near impossible not to be uplifted in her presence. As I got to know Keysha, it became clear why.

Keysha and her husband, Charles, are devoted to full-time ministry. He is the Pastor of Journey Church, the Miramar–based congregation of Grace Communion International. With a piano performance degree from Miami University, Keysha is the Worship Director and leads music ministry. An accomplished musician and writer, she has done considerable adult and youth outreach, inspiring and teaching countless members of the South Florida community. 

As the consulting doctor on her case, I was of course determined to help Keysha lead a better quality of life. And, on a more personal level, I wanted to help this woman, who had done so much for others, finally take care of herself.

Outlining the Options

My patients know I spend considerable time educating them about their treatment options, and Keysha was no different. I thoroughly explained her options, although I could already see a clear path to success. These included:

• Medication
• IUD – an intrauterine device is a little, t-shaped piece of plastic inserted into the uterus to provide birth control.
• Endometrial Ablation – a laser fulguration of the lining of the uterus.
• Total Hysterectomy – the surgical removal of the uterus and cervix. Removing the uterus would ensure Keysha never menstruated again, which given the heavy bleeding was desirable. Removal of her cervix would help to ensure alleviation of the severe pelvic pain she was experiencing. I presented her with the following options for a total hysterectomy:
• Traditional Abdominal Hysterectomy – an open surgery in which the surgeon removes the uterus and cervix from one large, five to seven-inch incision in the abdomen. The average hospital stay is two to three days, the recovery period is four to six weeks, and there is a significant incision scar.

• Total Laparoscopic Hysterectomy  – a minimally invasive surgery in which the surgeon makes 4 small “keyhole” incisions in the navel and abdomen and inserts a camera into the area to ensure greater visibility. The uterus is generally dissected and removed through the incisions. Compared to traditional hysterectomy, there is less blood loss, less scarring and less post-operative pain. This is generally done as an outpatient procedure, and the patient is able to make a full recovery within one to two weeks. Nearly all women are good candidates for a laparoscopic hysterectomy.

• Robotic Hysterectomy – a minimally invasive, robotic assisted surgery. Through the da Vinci® surgical system, the surgeon is enabled enhanced vision, precision and control of surgical instruments. Compared to traditional hysterectomy, there is less blood loss, less scarring and less post-operative pain. This is generally done as an outpatient procedure, and the patient is able to make a full recovery within one to two weeks.

Recommendation – Robotic Hysterectomy

My ultimate recommendation to Keysha was to have the robotic hysterectomy, as removing her uterus and cervix would alleviate her heavy bleeding and chronic abdominal and pelvic pain. The robotic procedure was preferable. Given its enhanced precision capabilities, it would enable me easier access into a tiny space and a better view of the operation. Given Keysha had no significant growth on her ovaries, I recommended she keep her ovaries so she would not have to take hormone replacements. 

I told her to review her options, and when I saw her one month later in November 2016, a transvaginal sonogram revealed the fibroids had multiplied, but the ovarian cyst had shrunk. This further solidified my initial recommendation. 

A Life Saving Decision

Prior to Keysha’s surgery, which took place in late January 2017, I made the decision to remove her uterus whole. Instead of cutting the uterus to remove it through the small incisions; I would essentially deliver it whole through her vagina. Recent research suggested that malignant cancers known as sarcomas can masquerade as fibroids, which when cut during surgery could spread and worsen. In hindsight, my decision to remove the uterus whole quite literally, saved Keysha’s life. 

Keysha’s surgery ultimately consisted of four, one-inch incisions in her abdomen and navel. The surgery lasted 40 minutes and by late afternoon, Keysha was back at her home and able to walk that day. 

Uncovering a Monster

As is standard when removing uterine fibroids, post-surgery, Keysha’s entire uterus underwent a pathology test to check for cancer.  The results were shocking. The pathologist uncovered cancer – and more frighteningly – an extremely rare and very aggressive cancer known as leiomiosarcoma, living inside the fibroid. 

Approximately six in one million women a year will be diagnosed with leiomiosarcoma and two might survive. There isn’t much known about this cancer other than that it doesn’t respond to chemotherapy or radiation. Once it starts to spread, it is a death sentence. 

The cancer revealed to be just under one centimeter, which is significant for two reasons: 1) When examining the uterus, the pathologist’s cut marks were fortunately made in a such a way that would reveal the tumor, as he easily could have cut right through it or missed it altogether. 2) With leiomiosarcoma, when the tumor reaches one centimeter it begins to spread rapidly. Fortunately, for Keysha, we had taken the tumor out before it reached this threshold size. 

It also became apparent that the decision to remove her uterus as a whole saved her life. Had I cut the uterus during surgery, as is the norm in a laparoscopoic or robotic procedure, it would have aggravated the tumor, disseminating the cancer it into Keysha’s system.

Telling Keysha was, to say the least, very difficult. Like with all my patients, I cared about her and was concerned for not only her but her family. While the tumor was under the one centimeter mark, there was still concern that it had spread and that her ovaries were infected.

Putting the Monster to Rest

Because of the rarity of the pathology report, and upon referral through a familial connection, Keysha ultimately went for a consult at the University of Maryland under the direction of the Dean of the School of Medicine, E. Albert Reece, MD, PhD, MBA. Dr. Reece was overseeing a team specializing in sarcomas and connected Keysha to university colleague, Dr. Gautam Rao, Assistant Professor of Obstetrics & Gynecology. Dr. Rao has a special interest in chemotherapy for gynecologic malignancies. 

After undergoing additional tests and a PET/CT scan, Dr. Rao was able to report that Keysha’s ovaries and abdominal area were clear of any cancer. Ultimately, to the relief of her family, myself, her congregation and the team of doctors working with her, Keysha was confirmed cancer free.

Keysha’s case will stay with me forever. Her case highlights how one medical decision may truly be the difference between life and death. I’m grateful I had the skill, experience and foresight to remove her uterus as a whole that fateful day, and I’m grateful her friends and family will enjoy this wonderful woman for many years to come.