Tool helps with decision-making for fibroid management

Data are limited on outcomes of laparoscopic hysterectomy with morcellation in patients with unsuspected uterine sarcomas, which complicates discussions between physicians and patients about management of uterine fibroids. A shared clinical decision tool described in an article published in the European Journal of Obstetrics and Gynecology and Reproductive Biology may help in counseling patients about optimal management of large fibroids while taking into consideration risks and benefits as mandated by the Food and Drug Administration. 

Writing about their use of the tool in a hypothetical population, the authors indicate that “women and their providers can use this tool to weigh the benefits of a minimally invasive procedure against the risk of dissemination of a rare but serious cancer.” They caution, however, that the decision aid has not been validated nor is it comprehensive and not all of the incidence parameters are generalizable to all patient populations.

The objective of the research, performed by physicians from Beth Israel Deaconess Medical Center, the Institute for Technology Assessment at Massachusetts General Hospital, and Harvard Medical School, was to compare risks and benefits of laparoscopic hysterectomy with morcellation versus abdominal hysterectomy without morcellation for large fibroids. The shared clinical decision tool was designed to serve as a framework for providers to counsel patients about mode of hysterectomy to facilitate shared decision-making between patient and provider. Risks and benefits were estimated from the literature, including surgical complications (venous thromboembolism [VTE], small bowel obstruction, adhesions, hernia, surgical site infections, and transfusions), uterine sarcoma risks, and quality-of-life (QoL) endpoints.

The tool was applied to a hypothetical population of 20,000 patients with large uterine fibroids, of whom 10,000 underwent laparoscopic hysterectomies and 10,000 had abdominal hysterectomies. The authors calculated that abdominal hysterectomy would result in 50.1% more adhesions, 10.7% more hernias, 4.8% more surgical site infections, 2.8% more bowel obstructions, and 2% more VTEs than laparoscopic hysterectomy. An abdominal procedure also would result in longer hospital stays (2 days), slower return to work (13.6 days), greater postoperative day 3 narcotic requirements (48%), and lower SF-36 QoL scores (50.4 points lower).

Looking at risks associated with unsuspected cancers, the authors estimated that 0.28% of patients undergoing hysterectomy for fibroids would have occult uterine sarcomas. In these women, laparoscopic hysterectomy with morcellation would reduce 5-year overall survival rates by 27% and recurrence-free survival by 28.8 months. Because it is not possible to exclude the presence of an occult malignancy with imaging or statistical models, physicians should use their clinical judgment and consider contained tissue extraction at the time of surgery.