Commentary
Over one-half million hysterectomies are performed annually in the United States. Approximately one-third of them are done using minimally invasive techniques. Electromechanical morcellation was introduced to gynecologic surgery in the 1990s. This allowed for women with larger uteri to be able to undergo minimally invasive surgery (MIS). Over time, there was a shift from laparoscopic-assisted vaginal hysterectomy to laparoscopic-assisted supracervical hysterectomy using the morcellator. This is done even in cases when the uterus is small enough to be easily delivered transvaginally.
Uncontained intraperitoneal morcellation, especially with the rotating blade morcellator, carries the risk of peritoneal spread of an unsuspected malignancy. This not only upstages the cancer and impacts the need for or type of adjuvant therapy, but also worsens the prognosis.
No one argues that intraperitoneal morcellation of a known malignancy should be avoided. At present, there is no accurate way of diagnosing a uterine leiomyosarcoma in a woman thought to have leiomyoma before the specimen is evaluated in the pathology laboratory. Endometrial sampling and imaging studies have poor sensitivity for detecting this pathology prior to surgery. The symptoms associated with uterine leiomyosarcoma can be similar to those experienced by women with leiomyomas. Several studies have shown that the median age of women who undergo surgery for removal of leiomyomas but are found to have a leiomyosarcoma is 50 years. The incidence of unsuspected leiomyosarcoma in women having uterine leiomyomas surgically removed increases with age. However, the age of these women with unsuspected uterine leiomyosarcoma ranges from 18 to 95 years. Therefore, it should be noted that uterine leiomyosarcoma can occur at almost any age in a woman’s lifetime.
A Food and Drug Administration analysis released in April 2014 suggests that a uterine leiomyosarcoma can be found in 1 out of 350 women undergoing surgery for presumed leiomyomas. Leibsohn et al. (Am. J. Obstet. Gynecol. 1990;162:968-76) reviewed 1,432 cases of hysterectomy performed in women with symptoms thought to be due to uterine leiomyomas. A leiomyosarcoma was found in seven cases (0.49%). One of 511 (0.2%) women between the ages of 31 and 40 years had an unsuspected leiomyosarcoma.
We could ask, at what level of risk is peritoneal dissemination by uncontained morcellation of an unsuspected malignancy justified? Is the harm to one patient justified by the possible benefit to thousands of other patients? I will argue that any level of risk is too high if there is a way to achieve the same results without worsening the prognosis of women who harbor unsuspected leiomyosarcoma. The safe use of morcellation will not impede MIS. Women with smaller uteri can undergo transvaginal hysterectomy or laparoscopic-assisted vaginal hysterectomy. Leiomyomas could be removed intact through a colpotomy or through a small abdominal incision. Larger specimens could be morcellated within an isolation bag. In some situations the specimen may be too large or the surgeon lacks the necessary skills for MIS to be safely performed. In those cases a laparotomy is the safest approach. It is ingenuous to suggest that these cases should be referred to a gynecologist with the skill to perform these challenging procedures minimally invasively. This may be possible in some geographic locations and acceptable to some patients, but frequently it is impractical.
Dr. Enrique Hernandez is the Abraham Roth Professor and Chair of Obstetrics, Gynecology and Reproductive Sciences at Temple University, Philadelphia. Dr. Hernandez said he had no relevant financial disclosures.
