Power morcellation for uterine fibroids: What you need to know

Dr. Cohen is Director of Research, Division of Minimally Invasive Gynecologic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts.

She reports contracted research for Ethicon.    

Tissue morcellation is by no means a new concept in laparoscopic surgery, but recent concerns regarding open power morcellation in gynecologic procedures have called the practice into question.¹ A hand-activated device for laparoscopic tissue removal was developed as early as 1973, and by 1993, the Steiner electromechanical morcellator was introduced.^2,3

Illustration by Alex Baker, DNA Illustrations, Inc.
The advent of electromechanical morcellation allowed for marked improvements in ease and speed of specimen retrieval with minimally invasive approaches.^4,5 As the field of minimally invasive gynecologic surgery has evolved to encompass increasingly challenging procedures, a number of power morcellation devices have been marketed to allow removal of large pathology via small incisions and avoid the morbidity associated with laparotomy. However, this innovation is not without risks, including potential for intraoperative injury and risk of seeding of cellular tissue during the morcellation process.

Gynecologic surgeons should give consideration to the balance of benefit and harm that accompanies laparoscopic tissue morcellation, in addition to exploring surgical alternatives and methods to mitigate complications.

Risks associated with morcellation

Rates of visceral and vascular injury associated with electromechanical morcellation devices are difficult to quantify due to limited reporting. A recent systematic review of all published articles as well as the FDA device database identified 55 morcellator-related injuries during gynecologic (hysterectomy, myomectomy) and non-gynecologic (nephrectomy, splenectomy) procedures.⁶ Vascular and bowel injuries were listed as the most common complications. In this review, surgeon inexperience was the most commonly listed risk factor for injury.

Aside from the risks inherent in surgical operation of morcellation devices, there is also concern about dissemination of tissue that can occur during an open power morcellation process. Fragments of tissue that are not retrieved may result in pain, infection and serious morbidity.^7,8 Intracorporeal morcellation has also been reported to result in seeding of benign^9-12 or malignant tissues.^13-16 The incidence of such complications is difficult to quantify; the AAGL practice guidelines for laparoscopic subtotal/supracervical hysterectomy state that uterine morcellation does not appear to increase the risk of subsequent diagnosis of endometriosis and only rarely results in leiomyomatosis.¹⁷ Reported incidence of parasitic leiomyomata following laparoscopic procedures involving morcellation has been estimated at between 0.1% and 1% based on 2 retrospective studies.^11,12

Of particular concern is the risk of morcellating an unidentified malignancy, with possible resultant upstaging of disease and worsened prognosis.^18-20 In a recent statement, the Society of Gynecologic Oncology estimated that fewer than 1 woman in 1000 who undergoes hysterectomy for a presumed leiomyomata will have an occult malignancy, and advocated for open communication with patients regarding this issue.²¹ Unlike endometrial lesions, which are characterized by more reliable risk factors, symptomatology, and screening methods, uterine leiomyosarcomas are the subject of considerable concern because they are often difficult to differentiate from benign leiomyomata preoperatively. Leiomyosarcomas also are notoriously aggressive tumors associated with poor prognosis even in the absence of tissue morcellation.

Compounding the difficulties of diagnosis is the relative rarity of uterine leiomyosarcomas; incidence in the general population is estimated at 1 in 10,000 women, or approximately 1 in 1,000 women undergoing surgery for presumed fibroids.^20,22-24 Suggested clinical factors that may heighten concern for malignancy include advancing patient age and presence of new or increasing uterine mass in a postmenopausal patient. The average age at presentation is 60 years; however, leiomyosarcomas have been reported in patients as young as their mid-20s.²⁵ The rate of uterine growth has not been demonstrated to be a reliable predictor for malignancy.²⁴ Screening techniques for uterine sarcomas are limited, but magnetic resonance imaging (MRI), particularly diffusion-weighted, and serum samples of lactate dehydrogenase (LDH) have been suggested as potential screening methods.^26,27 One small prospective study demonstrated high sensitivity and specificity with the combination of dynamic MRI and measurement of total LDH and LDH isoenzyme type 3, but the results have not been reproduced on a larger scale.²⁷

Surgical alternatives to open power morcellation

Laparotomy for hysterectomy or myomectomy is a definitive option for avoiding tissue morcellation, but it comes at the expense of increased morbidity and recovery time compared to minimally invasive approaches.^28,29 When the uterine size is such that the specimen can be delivered vaginally, performing a vaginal hysterectomy or total laparoscopic hysterectomy, rather than supracervical hysterectomy, is also an option.

Minilaparotomy is another alternative to open power morcellation for specimen retrieval.^30,31 Depending on the size of the mass, the specimen can either be removed intact via the minilaparotomy incision (typically < 4 cm in length), or it can be placed into a bag and manually morcellated to avoid spillage at the level of the abdominal wall or within the peritoneal cavity. Minilaparotomy allows for perioperative outcomes similar to that for a laparoscopic approach.^32-34 Specimen retrieval and/or contained manual morcellation also can be performed via colpotomy, even if total hysterectomy has not taken place.^35-37 A small randomized trial comparing transumblical and transvaginal specimen removal found decreased postoperative pain with the transvaginal method, but similar patient satisfaction, cosmesis and sexual function.³⁸

Contained power morcellation is another promising option whereby tissue dissemination can be avoided. In these cases, electromechanical morcellation is performed in an enclosed environment within the abdomen, such as an endobag or artificial pneumoperitoneum.³⁹

Implications for practice

The well-known benefits of minimally invasive gynecologic surgery must be measured along with the small but real risks associated with tissue morcellation. Taking into account patient-specific factors, appropriate preoperative screening for malignant conditions should be undertaken and open power morcellation avoided in cases of confirmed or likely malignancy.

Surgeons who choose to use a power morcellator should be experienced with the device operation and make an effort to retrieve all specimen fragments from the peritoneal cavity following morcellation. Strong consideration should also be given to alternative specimen retrieval options that are associated with decreased risk of retained specimen fragments or cellular seeding. In particular, a focus on innovations in preoperative screening for uterine sarcomas as well as advanced morcellating technology is critical to improve patient outcomes.

Next: Some institutions and groups defining stances on morcellation >>

Some institutions and groups defining stances on morcellation

By Susan C. Olmstead

The story of a physician in Boston who is undergoing treatment for uterine cancer that may have been spread by morcellation has been picked up by the popular press. News outlets including The Wall Street Journal, ABC News, USA Today, and The New York Times have published stories about cancer patient Amy Reed, MD, PhD, and her husband, Hooman Noorchashm, MD, PhD, who in response to his wife’s illness has begun a campaign urging a moratorium on uterine morcellation. His change.org petition had garnered more than 5000 signatures as of late February.

In response to these stories and the resulting increase in public concern over the possibility of this procedure spreading and upstaging undetected cancer, some societies and institutions are developing formal policies on morcellation.

In December 2013, the Society of Gynecologic Oncology (SGO) issued a statement that said in part, “[morcellation] is generally contraindicated in the presence of documented or highly suspected malignancy, and may be inadvisable in premalignant conditions or risk-reducing surgery.”

It went on to recommend that “patients … who might require intracorporeal morcellation should be appropriately evaluated for the possibility of coexisting uterine or cervical malignancy” while acknowledging that currently no reliable method exists to differentiate benign from malignant leiomyomas.

According to The Wall Street Journal, Temple University Hospital in Philadelphia recently set limits on morcellation. Doctors there are being told to perform hysterectomies as conservatively as possible, and open procedures are required for uterine sizes larger than 18 weeks. Three Boston-area hospitals and the Cleveland Clinic are also reviewing or creating policies regarding morcellation and doctors are being told to spell out the potential risks to patients, The Wall Street Journal reports.

The American College of Obstetricians and Gynecologists (ACOG) has not issued new guidelines for its members concerning morcellation, but says, “ACOG recently conducted a preliminary review of the literature on morcellation, and the findings are consistent with … the clinical guidance contained in existing ACOG Practice Bulletins and Committee Opinions. As ACOG updates its guidelines, we will further consider any newly available information and incorporate it at that time.”

Jon I. Einarsson, MD, PhD, MPH, Deputy Editor of Contemporary OB/GYN and the director of the division of minimally invasive gynecologic surgery at Brigham and Women’s Hospital, Boston, anticipates changes ahead in how morcellation is performed. “Electromechanical morcellation has enabled gynecologists to offer patients a minimally invasive approach for specimen extraction for over 2 decades,” he noted. “However, morcellation in its current form has drawbacks that have been highlighted by recent events. I believe that in the next few years, open electromechanical morcellation will be a thing of the past.

“Novel methods of enclosed specimen extraction are already being developed and will probably come to market within the next 2 to 3 years. I predict that this disruptive technology will dramatically change our methods for specimen extraction moving forward."

References

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