“Cancer can spread much like an infection,” he maintained. “Why would you treat uterine fibroids or other masses that could be cancerous differently [than you would an infection]?”
One answer might be to reduce the risk of morcellated tissue from being disseminated in the peritoneal cavity, according to Dr. Andrew Sokol, an ob.gyn. and urologist at Georgetown University, Washington. The brother of Dr. Eric Sokol and serving on the pro side of the debate, Dr. Sokol suggested that containment bag attachments are being developed for power morcellator devices, and these appear to preserve the benefits while mitigating the risks.
Citing some early data from controlled studies indicating that surgical outcomes using containment bags are similar to those without a bag, Dr. Sokol suggested that containment bags might be the way to improve rather than abandon power morcellation.
Despite the potential risk of rupture and the need for more data, “these bags have the potential to maintain the advantages of minimally invasive surgery,” said Dr. Sokol, although he acknowledged that no containment bags have been approved by the FDA.
The final panelist in the debate rejected both minimally invasive surgery with power morcellation and open abdominal hysterectomies as a first choice in most women. Rather, Dr. Carl Zimmerman, professor of obstetrics and gynecology at Vanderbilt University Medical Center, Nashville, Tenn., maintained hysterectomies should most often be performed vaginally and morcellation of the fibroid should be performed extracorporeally.
“I was unable to find a single report of spread of malignant tumor” when morcellation of the fibroid was performed outside the body after a vaginal hysterectomy, Dr. Zimmerman reported. He expressed dismay that employing vaginal surgery has not been much discussed in any of the statements guiding clinicians to alternatives for power morcellation.
One reason vaginal hysterectomy is being overlooked, according to Dr. Zimmerman, is a decline in training for this technique. He believes that surgeons should either learn to perform vaginal hysterectomies or be prepared to refer patients to those experienced with this procedure.
“What do we need to do as surgeons? We need to have a working knowledge of all the surgical approaches to a given problem, and then we are ethically obligated to help our patients to chose the correct one in terms of safety, cost, and recovery,” Dr. Zimmerman said. For many women with fibroids, he believes the correct choice would be a vaginal hysterectomy that avoids both morcellation in the peritoneal space and the disadvantages of an open approach.
The debate was initially framed by a case. In the description, a 44-year-old woman with menorrhagia and fibroids had multiple features suggesting a low risk of uterine sarcoma, including a recent biopsy of the endometrium that proved benign. In this case, Dr. Brown described minimally invasive surgery with power morcellation as an “excellent option,” while Dr. Eric Sokol maintained the FDA advisory remained applicable.
However, for the minority of surgeons in the audience who sided with Dr. Brown, one issue may be reimbursement. Ten days after the SGS debate, a survey conducted by and published in the Wall Street Journal (April 3, 2015) found that insurance companies covering more than 90 million Americans have established or are considering restrictions on reimbursement for power morcellation. Increasingly, the choice is being taken out of the hands of both surgeons and patients.
Dr. Jubilee Brown, Dr. Andrew Sokol, Dr. Eric Sokol, and Dr. Carl Zimmerman reported no relevant financial disclosures.