• Nathan Riley, MD

Obgyno Wino Podcast Episode 12 - Uterine Morcellation for Presumed Leiomyomas

Updated: Jul 21, 2019

"Things need not have happened to be true. Tales and adventures are the shadow truths that will endure when mere facts are dust and ashes and forgotten." - Neil Gaiman

2016 Cabernet Sauvignon from Chateau St. Jean

CO#770 - Published February 2019

How does one remove a large, fibroid uterus surgically?

- morcellation: cutting the uterus into small chunks in order to remove it piecemeal through a small incision

- logic: keep the incisions small and do less harm to the patient

- downside: what if there is cancer hiding in there?

- in 1993, power morcellators were developed to make this process faster

- this decreased operative time, but the FDA issued a warning in 2014 that "power morcellation of presumed leiomyomas (i.e. chopping up a uterus inside the abdomen but not inside another container) could inadvertently spread undetected cancer cells within the uterus around the abdominal cavity

- as a result of this warning, laparoscopic hysterectomy and myomectomy rates decreased

- surgical complications and 30-day readmission rates also increased (open surgeries = longer, more difficult recovery)

A little diddy on leiomyosarcomas...

- incidence of leiomyosarcoma: 0.36:100000

- leiomyosarcomas are very aggressive tumors

- 5-year survival rate is 50:50 even when the tumor is confined to the uterus

- there is limited evidence describing the effect of power morcellation on prognosis when leiomyosarcoma is diagnosed

- small studies have suggested an increase risk of recurrence in patients who had undergone power morcellation

- 2017 meta-analysis suggested a trend in better survival in patients who underwent scalpel or no morcellation compared to power morcellation, but confidence intervals overlapped so the authors were unable to draw definitive conclusions

Preoperative evaluation

- imaging: endovaginal ultrasound, MRI

- cervical cancer screening: up to date, malignancy reasonably excluded, endometrial sampling to evaluate for uterine malignancy

- even non-fibroid uteruses may contain occult endometrial cancer cells; EMB is particularly important if patient reports abnormal uterine bleeding or postmenopausal bleeding at time of preoperative evaluation

- no definitive screening to rule out leiomyosarcoma; diagnosis requires histopathologic evaluation, and this usually takes place at time of analysis of surgical specimens (though it can be detected on endometrial biopsy in some patients)

- preoperative biopsy of leiomyomas is neither practical nor helpful

What does the data show?

- plenty of data to suggest that abdominal hysterectomy is associated with higher risk of infection, hemorrhage, VTE, nerve injury, genitourinary injury, and GI injury when compared to laparoscopic approaches

- furthermore, laparoscopic approaches are associated with more rapid recovery and shorter operating times

- myomectomy data showed similar risks

- additionally, laparoscopic myomectomy is associated with less postoperative pain and shorter hospital stay when compared to open myomectomy

- models have been devised to helps weigh the risks of laparoscopic power morcellation (risk for malignancy) against abdominal hysterectomy (risk for morbidity related to surgery)

- most of the studies have found that mortality between laparoscopic hyst w/ morcellation versus abdominal hyst was highly dependent on the incidence of leiomyosarcoma used in the analysis, and, as the incidence of highly variable and generally rare, it's hard to draw definititve conclusions from the data

- for women <40 years old, deaths in power morcellation group offset by deaths in abdominal hysterectomy group (opposite for remain >60 years of age)

Risks versus benefits counseling

- 2014 FDA warning: "laparoscopic power morcellators are contraindicated for removal of uterine tissue containing suspected fibroids in patients who are peri- or post-menopausal, or are candidates for en bloc tissue removal"

- risk of unexpected leiomyosarcoma is somewhere between 1:10000 to 1:770 in surgeries for presumed benign fibroids

- this risk must be weighed against the increased morbidity associated with open surgery

- in general, it seems that for women <50 years of age, laparoscopic hysterectomy or myomectomy w/ morcellation, if indicated, is reasonable when balancing the risks of occult leiomyosarcoma versus procedure-related risks

- for women 50 years of age or older, there's a higher risk for occult leiomyosarcoma, and therefore laparoscopic approach may not be outweighed by procedural risks of open surgery

Alternatives to morcellation

- ACOG maintains that a minimally invasive surgical approach to hysterectomy is recommended for benign disease

- abdominal approach may be required if the uterus is too large to be removed intact per the vagina

- if you want to avoid a larger incision, manual morcellation in a containment bag is a reasonable option, whether by vaginal route, mini-laparotomy, or the umbilical incision

Other risks of morcellation

- 2016 systematic review: w/ non-contained power morcellation, benign tissue can be spread across the peritoneal cavity (endometriosis, adenomyosis, parasitic leiomyomas, or disseminated peritoneal leiomyomatosis)

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