Tissue extraction during minimally invasive Gyn surgery. First of 2 parts: Best practices for an environment in flux
In this roundtable discussion, five surgical experts weigh in on the state of minimally invasive gynecology and current age-based options for tissue extraction
Our expert panel
| Arnold P. Advincula, MD, is Vice-Chair of Women’s Health and Chief of Gynecology, Department of Obstetrics and Gynecology, at Columbia University Medical Center in New York, New York. He serves on the OBG Management Board of Editors. |
| Linda D. Bradley, MD, is Professor of Surgery; Vice Chairman of the Obstetrics, Gynecology and Women’s Health Institute; and Director of the Center for Menstrual Disorders, Fibroids & Hysteroscopic Services at Cleveland Clinic in Cleveland, Ohio. She serves on the OBG Management Board of Editors. |
| Cheryl Iglesia, MD, is Director of the Section of Female Pelvic Medicine and Reconstructive Surgery at MedStar Washington Hospital Center and Professor, Departments of ObGyn and Urology, at Georgetown University School of Medicine in Washington, DC. She serves on the OBG Management Board of Editors. |
| Kimberly Kho, MD, MPH, is Assistant Professor, Department of Obstetrics and Gynecology, and Director of the Southwestern Center for Minimally Invasive Surgery, Gynecology, at the University of Texas Southwestern Medical Center in Dallas, Texas. |
| Jason D. Wright, MD, is Sol Goldman Associate Professor of Obstetrics and Gynecology and Chief of the Division of Gynecologic Oncology at Columbia University College of Physicians and Surgeons and New York Presbyterian Hospital in New York, New York. |
Dr. Advincula reports that he is a consultant to Blue Endo, CooperSurgical, Intuitive Surgical, and SurgiQuest. He also receives royalties from CooperSurgical.Dr. Bradley reports that she receives grant or research support from Bayer Research as a principal investigator and contributor; is a consultant to BlueSpire, Boston Scientific, Endoceutics, Hologic, and Smith & Nephew; and is a speaker for Bayer Healthcare. Other reported financial relationships: royalties from Elsevier; as a member of the Editorial Advisory Board of MedScape and WebMD; and for articles published in Wolters Kluwer Health and UpToDate. Dr. Iglesia reports that she is a member of the FDA ObGyn Devices Panel.Dr. Kho reports no financial relationships relevant to this article. Dr. Wright reports that he receives grant or research support from Genentech.
Dr. Advincula: First, it’s important to define prevalence and incidence when discussing risks. Prevalence would be the number of patients with a leiomyosarcoma per 100,000 women, whereas incidence is the number of patients given a diagnosis of leiomyosarcoma within a year per 100,000 women. In this case, a 35-year-old woman would have a prevalence of leiomyosarcoma, in the general population, of 3 to 7 per 100,000 women and an incidence of less than 1%.
My preoperative assessment would involve MRI of the pelvis with T2 weighted images to better characterize her uterus. Although there has been much discussion lately about the use of lactate dehydrogenase (LDH) isoenzyme panels in combination with MRI to detect occult leiomyosarcoma, the reliability and reproducibility of that combined approach are not fully vetted and, as yet, are not a standard part of my workup. Endometrial sampling would certainly be warranted with any associated history of abnormal uterine bleeding.
Dr. Wright: As I mentioned earlier, most data on power morcellation have been derived from studies of women undergoing hysterectomy. To date, accurate estimates to predict the risk of occult cancer in this patient planning to undergo myomectomy are largely lacking. For women undergoing hysterectomy using power morcellation, advanced age is the strongest risk factor for occult malignancy. Although this patient’s risk of cancer likely is relatively low, she should be counseled that precise estimates are lacking.
Preoperatively, she should undergo endometrial sampling if she has abnormal bleeding. However, the reliability of endometrial sampling, as well as imaging, is limited in the detection of uterine sarcomas.
Case 2: Perimenopausal patient undergoing hysterectomy
OBG Management: How would your approach to preoperative assessment change if this patient were a 47-year-old perimenopausal woman with a single large fibroid to be removed by hysterectomy?
Dr. Bradley: It would be the same preoperative assessment—an MRI and an endometrial biopsy.
Dr. Iglesia: The risk of occult malignancy would be greater than with the first patient. Again, I would use pelvic ultrasound, endometrial biopsy, and cervical cytology to assess her, and I would perform vaginal or TLH. MRI would be indicated if there is a possibility of performing intraperitoneal morcellation. I would prefer doing any morcellation in a bag or via laparotomy.
Dr. Wright: Based on age alone, this perimenopausal patient’s risk for an underlying cancer is 0.2%.2 If the patient has any abnormal bleeding, she should undergo endometrial sampling preoperatively. The diagnostic modalities currently available—which include endometrial sampling as well as imaging, even MRI—are unreliable in the diagnosis of uterine sarcomas, and the patient should be counseled accordingly if she is considering power morcellation.
If it is technically feasible, vaginal hysterectomy or a minimally invasive hysterectomy without power morcellation are preferred. If neither modality is feasible and the patient is considering power morcellation, she should be carefully counseled about the underlying risk not only of uterine cancer but also of other adverse pathologic abnormalities.
Case 3: Postmenopausal woman scheduled for hysterectomy
OBG Management: Let’s change the details of the case again. This time she’s 55 years old and postmenopausal. She, too, has a large fibroid to be removed via hysterectomy. What is her risk of occult cancer? How would you assess her preoperatively?
Dr. Bradley: My approach would be the same as in the first two cases. However, because this patient is menopausal, morcellation would be off the table. (And it already is off the table—for any patient—at the Cleveland Clinic.) I usually prefer open hysterectomy for these patients, which is very different from what we were doing 1 year ago.
I want to expand on Dr. Wright’s comments about other pathologic abnormalities. As a woman ages, her cancer risk becomes greatest for malignancy of the endometrium rather than cancer in a fibroid. If this were my 55-year-old patient, and I had been seeing her for 20 years, and her fibroids had remained the same size but she was now having bleeding, I’d be more concerned about an endometrial problem—hyperplasia, a polyp, or cancer.
If the patient were having bulk symptoms, new pain, and imaging that shows, over 10 years between perimenopause and postmenopause, that there has been growth of the fibroids, I would be concerned about a sarcoma.
Some women who present with postmenopausal bleeding have ovarian cancer, and some studies show that a significant percentage of women with ovarian cancer present with bleeding as a primary symptom.3 So in a postmenopausal patient, I really want to know about the health of the ovaries. Are they enlarged on imaging?
There is also a bimodal distribution of human papillomavirus (HPV) infection and cervical cancer, with peaks of infection at ages 26 to 30 years and again at 46 to 50 years in some populations. The second age peak is followed by an increase in cervical intraepithelial neoplasia (CIN) 2 and 3 and invasive cervical cancer 20 years later.4 So I also want to consider the possibility of cervical cancer in this population.
