Hot Topic! Uterine Morcellation – What Is It All About?

Surgical options to treat uterine fibroids include hysterectomy (removal of the uterus) or myomectomy (removal of the fibroids with uterine conservation).  Depending upon the individual circumstances for each patient, these operations may be performed using different techniques, including a vaginal incision, large abdominal incision, or through small laparoscopic incisions. The vaginal approach is an excellent choice but is limited in the number of patients who qualify based on their history, size of fibroids and other factors. When we perform laparoscopic hysterectomy or myomectomy, we need to cut the uterus or fibroids into small pieces so that the small pieces can be removed through the small incisions that are used for the surgical procedure. A device called a power morcellator allows us to cut the tissue into small pieces so they can be removed through the small incisions, therefore avoiding a large incision. Laparoscopic procedures have the advantage of allowing patients to have small scars, recover faster, have less pain, less blood loss, less infection, and the ability to return to work or usual activities in a shorter period of time. This has become the preferred technique compared to an abdominal incision and has been performed successfully on very a large number of woman.

There have been some reports that the morcellation procedure can adversely affect survival in the rare instance when a patient has an uncommon type of cancer of the uterus, known as sarcoma. Uterine sarcoma occurs in about 3-7 woman out of 100,000. This is rare. In patients with a uterine mass, fibroids are by far the most common diagnosis and they are benign. Fibroids occur in about 70% of women in their lifetime, 7 out of 10. In women suspected to have fibroids needing removal, about 1 in 350 actually have a sarcoma.

Sarcoma is a particularly aggressive type of cancer and has a poor survival rate in the best of circumstances. It is very difficult to diagnose before surgery. A uterine biopsy can detect about 30% of sarcomas, and this is usually done prior to hysterectomy for fibroids. MRI of the pelvis may also be helpful, but does not always make the diagnosis. While these tests are helpful, they do not diagnose most of the sarcomas.

The U.S. Food and Drug Administration (FDA) has raised concerns that the use of power morcellation may cause harm if a woman has an undiagnosed cancer. Because the morcellator cuts up the uterus into small pieces while it is still in the body, it is possible small fragments of this type of tumor may be left in the abdomen. If this occurs, the clinical stage (spread of tumor) will increase. This can adversely affect overall prognosis and survival. One study suggests that the 5 year survival rate, if tissue is disseminated by morcellation changes from 65% to 40%. The FDA has also expressed concern that power morcellation may increase the likelihood for recurrence of other noncancerous conditions such as endometriosis and fibroids.

There are known factors that increase the risk of sarcoma. Older woman, are more at risk. Other factors include menopause, Tamoxifen use, prior pelvic radiation, history of retinoblastoma as a child and renal cell carcinoma syndrome.

Ultimately, the decision has to be made by the patient after careful research and discussion with her physician as to the necessity for hysterectomy or myomectomy and the best approach for the surgery. In the absence of risk factors, there are clearly benefits to minimally invasive surgery that must be taken into consideration. We all make decisions every day that involve risk. While this is a serious concern, it must be approached within the context of whether the risk is appropriate and acceptable to the individual. Media coverage tends to be dramatic. A detailed discussion with your doctor is the best way to make an informed decision about how you choose to be treated for any problems you may have.

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