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Power morcellation risks increase with age

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Defining the real risks of power morcellation

In the wake of reports of dissemination of unrecognized malignancies in patients undergoing laparoscopic hysterectomy with power morcellation of the uterus, the technique has been “virtually discontinued,” despite a lack of analysis of its benefits and potential harms, according to Dr. David G. Mutch.

The work of Wright et al. is a step in the right direction as it begins to assess the real risks of dissemination of malignancy and to determine the benefits and risks to women who might choose to undergo laparoscopy, he wrote in an editorial.

The findings help to more specifically categorize the risk to patients by considering both the risks of dissemination of malignancy and those associated with abdominal hysterectomy.

“More data such as those produced here are needed to better define the real risk so that women give informed consent before undergoing a procedure. Additionally, as other techniques such as morcellation of the uterus in a containment bag become more common, we should obtain data on their safety and efficacy,” he wrote.

Dr. Mutch is with Washington University, St. Louis. He made these remarks in an accompanying editorial (J Natl Cancer Instit. 2005;107[11]:djv283 doi: 10.1093/jnci/djv283).


 

FROM THE JOURNAL OF THE NATIONAL CANCER INSTITUTE

References

Laparoscopic hysterectomy provides better overall outcomes than either laparoscopic hysterectomy with power morcellation or total abdominal hysterectomy in women with presumed benign gynecologic disease, according to a cohort simulation model.

However, age-related differences in outcomes were apparent in the modeled scenarios, suggesting a need for individualized decision making regarding surgical technique, Dr. Jason D. Wright of Columbia University, New York, and his colleagues reported.

The investigators compared outcomes with the three approaches in a hypothetical cohort of women aged 18-65 years without a preoperative diagnosis of cancer, and found that in women with an underlying malignancy, laparoscopic hysterectomy without power morcellation was the “least costly and most effective modality of hysterectomy” across all scenarios modeled.

When comparing laparoscopic hysterectomy with power morcellation to abdominal hysterectomy, they found that the use of morcellation was associated with 80.83 more intraoperative complications, 199.64 fewer perioperative complications, and 241.80 fewer readmissions per 10,000 women (J Natl Cancer Inst. 2015;109[11]:djv251 doi: 10.1093/jnci/djv251).

Among women younger than age 40 years, laparoscopic hysterectomy with morcellation was associated with 1.57 more cases of disseminated cancer and 0.94 more cancer-associated deaths, but there were 0.97 fewer overall deaths per 10,000 women, compared with abdominal hysterectomy.

The excess cases of disseminated cancer for women who underwent laparoscopy with morcellation increased with age, to 3.75, 12.97, and 47.54 per 10,000 women in those aged 40-49 years, 50-59 years, and 60 years and older, respectively. This translated into excess deaths in all age groups (0.30, 5.07, and 18.14 per 10,000 in those aged 40-49 years, 50-59 years, and 60 years and older, respectively).

Laparoscopic hysterectomy without morcellation was also the least costly approach in all age groups. When compared with abdominal hysterectomy, laparoscopic hysterectomy with morcellation increased life-years among women under age 40 (adding 4.49 years), but decreased life-years in older women (–0.47, –20.64, and –91.19 years per 10,000 women aged 49-50, 50-59, and 60 and older, respectively). But laparoscopic hysterectomy with morcellation became more favorable for those aged 40-49, compared with abdominal hysterectomy, when quality of life was taken into account, with an increase of 11.22 quality-adjusted life-years for that age group.

Although power morcellation, compared with abdominal hysterectomy, was associated with greater quality-adjusted life-years and overall life-years in younger women, the magnitude of benefit was relatively small. And in older women, the risk of electric power morcellation greatly outweighed the benefits, the investigators wrote.

The findings underscore the importance of avoiding unnecessary use of power morcellation, as well as working to detect occult malignancy prior to interventions, they wrote.

The findings are also in accord with a 2014 advisory statement from the Food and Drug Administration warning against the use of electric power morcellators in peri- and postmenopausal women, and demonstrate a need for individualizing surgical technique in all patients and informing patients of the risks of electric power morcellation, the investigators said.

“As women age, the risk of underlying occult malignancy rises, increasing the risks associated with electric power morcellation,” the investigators wrote. “For many women, this risk will outweigh the benefits of minimally invasive surgery, and the procedure should be used with caution.”

The investigators reported having no relevant financial disclosures.

sworcester@frontlinemedcom.com

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