Benefits and pitfalls of open power morcellation of uterine fibroids
The current practice of open power morcellation is being scrutinized by those within and outside of the ObGyn community. We need to re-examine our current use of this procedure.
Sequelae of open power morcellation
Video courtesy of Javier F. Magrina, MD, Professor, Obstetrics-Gynecology, Mayo Clinic, Phoenix, Arizona; Immediate Past President, AAGL
Vaginal approach to open hand morcellation using a colpotomy incision during hysterectomy
Video courtesy of Javier F. Magrina, MD, Professor, Obstetrics-Gynecology, Mayo Clinic, Phoenix, Arizona; Immediate Past President, AAGL
Vaginal approach to open hand morcellation of a large uterus using a colpotomy incision during hysterectomy
Video courtesy of John B. Gebhart, MD, MS, Associate Professor of Obstetrics and Gynecology, and Fellowship Program Director, Mayo Clinic, Rochester, Minnesota
- imaging studies such as MRI or sonography,
- endometrial biopsy in cases with abnormal uterine bleeding
- cervical cytology.
These studies are recommended because they may identify an occult cervical or endometrial cancer or precancer. If the preoperative evaluation detects an occult cervical or endometrial cancer it is best to avoid open power morcellation of the uterus. These standard preoperative studies are unlikely to detect an occult leiomyosarcoma. There are currently no established imaging studies that can reliably detect a uterine sarcoma preoperatively,26,27 and endometrial biopsy has a low sensitivity for detecting leiomyosarcoma.
Related Article: Tips and techniques for robot-assisted laparoscopic myomectomy Arnold P. Advincula, MD, and Bich-Van Tran, MD (Surgical Technique, August 2013)
During the surgical consent process the issue of power morcellating an occult leiomyosarcoma and the consequences of causing the spread of cancer cells should be discussed with the patient. The patient may decide that the small risk of power morcellating an occult leiomyosarcoma is sufficiently worrisome that she would prefer an alternative procedure. These alternatives include abdominal hysterectomy, vaginal hysterectomy, or a hybrid operation involving removal of the uterine tissue through a mini-laparotomy or colpotomy incision.
Morcellation in a bag and removal of the bag through an abdominal or vaginal incision
Open power morcellation of uterine tumors creates the potential pitfall of spreading cells with enhanced growth potential around the peritoneal cavity. One approach to reducing the pitfall of open power morcellation is to place the uterine tumor in a bag, hand morcellate the tissue within the bag, and remove the bag and tissue through an abdominal incision (mini-laparotomy) or a colpotomy.28,29
If transabdominal removal of the tumor tissue is planned, the surgical port incision typically would need to be enlarged to permit hand morcellation and removal of the tissue. If a supracervical hysterectomy is planned, it may be difficult to remove a very large tumor through a small colpotomy.
Development of new technology
A major advance in gynecology would be the development of imaging studies that would permit the identification of uterine leiomyosarcomas prior to hysterectomy using open power morcellation. A preliminary study reported that diffusion-weighted imaging may be capable of differentiating leiomyosarcomas and leiomyomas30 but this study would require replication in multiple centers before it could be reliably utilized in surgical planning.
Another advance would be to develop power morcellation technology that occurs within a bag, with the removal of the bag and the enclosed morcellated tumor through a laparoscopy port. Morcellation of tissue within a bag would reduce the risk of spreading bits of tumor tissue around the peritoneal cavity.
The pitfalls of open morcellation are less likely to be clinically significant when surgery is planned for women who are aged 35 years and younger because leiomyosarcoma rarely occurs in young women. The pitfalls of open morcellation are more likely to occur when the woman is perimenopausal or postmenopausal with a very large uterus. This is because the incidence of uterine leiomyosarcoma increases with age, with the diagnosis often being made between 40 and 60 years of age.21,31
Open power morcellation has enhanced the ability of surgeons to remove large tumors through small incisions. The benefits to the patient are faster healing, faster postoperative recovery, and more rapid return to full activities. Hundreds of thousands of women have benefited from these advances in gynecologic surgery.
However, for an occasional woman, open power morcellation may be associated with the intraperitoneal spread of an occult leiomyosarcoma. This may result in the upstaging of the cancer and may cause premature death. The benefits and risks of open power morcellation need to be weighed carefully with each woman.
INSTANT POLL
Do you think that open power morcellation of uterine tumors thought to be fibroids can result in the dissemination of cancer cells throughout the peritoneal cavity, should an occult leiomyosarcoma be present?
Tell us—at rbarbieri@frontlinemedcom.com. Please include your name and city and state.
