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Putting morcellation into perspective – ‘Just the facts, Ma’am, nothing but the facts’


 

Intra-abdominal (intracorporeal) morcellation, especially electronically powered morcellation, has recently come under scrutiny. Generally performed at the time of conventional laparoscopic or robotic supracervical hysterectomy, total hysterectomy for the large uterus, or myomectomy, both power and cold-knife morcellation may splatter tissue fragments in the pelvis and abdomen, leading to potential parasitizing of the tissue and ectopic growth. Recent evidence indicates inadvertent morcellation of a leiomyosarcoma may negatively affect the patient’s subsequent disease-free survival and overall survival.

Concerns about morcellation heightened after Dr. Amy J. Reed, an anesthesiologist at Beth Israel Deaconess Medical Center, Boston, and a mother of 6, underwent presumed fibroid surgery and was diagnosed, post morcellation, with leiomyosarcoma. Dr. Reed’s husband, Dr. Hooman Noorchashm, a cardiothoracic surgeon at Brigham and Women’s Hospital, Boston, where his wife’s surgery was performed, is calling for a moratorium on intra-abdominal morcellation, whether it involves the use of a power morcellator, or for that matter, the cold knife.

Images courtesy Dr. Charles E. Miller

Power morcellators are used to remove the uterus, fibroids, spleen, or kidney.

It is imperative and incumbent upon our specialty to have a detailed evaluation of the risks and benefits of morcellation. While morcellation of the rare leiomyosarcoma is a risk, banning intraabdominal/intrapelvic morcellation will certainly have a profound negative impact on patients who are able to undergo a minimally invasive gynecologic procedure. Banning morcellation would increase intraoperative risk and subsequent concern of postoperative pelvic adhesions and thus, potential impact on fertility (post myomectomy), dyspareunia, and pelvic pain. Further, a ban would incur higher costs and more loss of patient productivity (Hum. Reprod. 1998 13:2102-6). These concerns were the basis for the AAGL position statement touting a minimally invasive approach to hysterectomy (J. Minim. Invasive Gynecol. 2011;18:1-3).

Since their introduction in the mid-1990s, electronically powered morcellators have been used to remove the uterus, fibroid(s), spleen, or kidney. Varying in size from 12-20 mm, electronic morcellators generally consist of a rotating circular blade at the end of a hollow tube. A tenaculum or multitoothed grasper is placed through the tube and blade to grasp the tissue to the revolving blade. The specimen is then removed in strips. Tissue splatter is inevitable, at least until the technique evolves to allow morcellation to be performed within the confines of a bag.

Benign uterine fibroids are the most common pelvic tumor in women. Literature reviews indicate the lifetime risk is 70% for white women and 80% in women of African ancestry. Uterine sarcomas occur in 3-7 women per 100,000 (Am. J. Obstet. Gynecol. 2011;205:492.e1-5). Further, Dr. Kimberly A. Kho of the University of Texas Southwestern Medical Center, Dallas, and Dr. Ceana H. Dr. Nezhat of Atlanta Center for Minimally Invasive Surgery and Reproductive Medicine, conducted a meta-analysis of 5,666 uterine procedures, and found 13 unsuspected uterine sarcomas, for a prevalence of 0.23% (JAMA 2014 [doi:10.1001/jama.2014.1093]).

Images courtesy Dr. Charles E. Miller

Benign uterine fibroids, or leiomyomas, are the most common abnormal pelvic growths in women.

This finding is consistent with that of a previous study by Dr. W.H. Parker who also noted a 0.23% risk, based on data from 1,332 women undergoing surgery secondary to uterine fibroids. Interestingly, in Dr. Parker’s study, the risk was 0.27% among women with rapidly growing leiomyoma, often thought to be a risk factor for sarcoma development (Obstet. Gynecol. 1994;83:414-8).

Because of the difficulty of making a preoperative diagnosis of leiomyosarcoma, it is doubtful that this risk will be decreased in the near future. Risk factors have not been well established, although a twofold higher incidence of leiomyosarcomas has been observed in black women (Gynecol. Oncol. 2004;93:204-8). Increasing age would appear to increase uterine sarcoma risk, as the majority of cases are diagnosed in postmenopausal women. Tamoxifen, when used for 5 or more years, appears to be associated with higher sarcoma rates (J. Clin. Oncol. 2002;20:2758-60) as is a history of pelvic irradiation or childhood retinoblastoma.

Unless metastatic disease is present, symptoms are similar for leiomyomas and leiomyosarcomas. A rapidly growing mass, a finding associated with an increased risk of uterine sarcoma, was not seen in Parker’s study of 1,332 women undergoing hysterectomy or myomectomy for uterine leiomyoma. Similarly, size does not count; a large uterine mass or increased uterine size did not appear to be associated with a greater risk of sarcoma (Gynecol. Oncol. 2003;89:460-9).

Some contend that failed response with such therapies as gonadotropin-releasing hormone agonists and uterine artery embolization are associated with increased incidence of leiomyosarcoma, but the data are not convincing (Eur. J. Obstet. Gynecol. Reprod. Biol. 1998;76:237-40).

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