Arnold Advincula's Surgical Techniques
The year 2014 marked a sea change in our approach to tissue extraction during minimally invasive surgery. The US Food and Drug Administration (FDA) initiated this transformation in April, when it issued a safety warning on the use of open power morcellation.1 A flurry of statements on the practice followed from professional societies, capped, in late November, with another statement from the FDA.2–4 The new bottom line: The use of open electromechanical (“power”) morcellation is contraindicated in perimenopausal and postmenopausal women, as well as in those who are known or suspected to have a malignancy.4
Most of the concern to date has centered on the risk that an occult leiomyosarcoma could be morcellated inadvertently during uterine surgery, an event that may worsen the prognosis for the patient. To get a gynecologic oncologist’s take on the controversy, OBG Management caught up with Amanda Nickles Fader, MD, director of the Kelly Gynecologic Oncology Service at Johns Hopkins University. Dr. Fader’s perspective is unique in that she treats a relatively high number of patients who have leiomyosarcoma and other uterine cancers.
In this Q&A, we discuss the patient population at Johns Hopkins; why Dr. Fader is especially qualified to speak to the future of electromechanical morcellation in gynecologic surgery; the benefits and risks of minimally invasive surgery, including tissue extraction; her recommendations for preoperative evaluation and counseling of patients undergoing uterine surgery; and guidance on how the specialty of gynecologic surgery should proceed in the future.
OBG Management: Dr. Fader, by way of introduction, could you characterize your patient population?
Amanda Nickles Fader, MD: Like most gynecologic oncologists, I primarily treat women with cancers of the uterus, ovary, cervix, and vulva. Many of us also have the opportunity to treat a number of women each year with complex benign gynecologic conditions that require surgery. As someone who is extremely interested in rare gynecologic tumors, I also treat a relatively high volume of women diagnosed with uterine sarcoma.
Approximately 75% of the women I see in my practice have preinvasive or invasive cancer, and 25% have a benign condition, such as enlarged fibroids or advanced-stage endometriosis.
OBG Management: How many cases of uterine sarcoma do you encounter on an annual basis?
Dr. Fader: Uterine sarcomas are very rare. They represent only 2% of all uterine cancers. Put into perspective, that means that about 0.4 cases of leiomyosarcoma occur in every 100,000 US women—most commonly postmenopausal women. Leiomyosarcoma is a biologically aggressive, high-grade malignancy that often is lethal.5
Endometrial stroma sarcoma is even less common—only 0.3 cases occur in every 100,000 US women. However, this tumor type is more indolent, often diagnosed at an earlier stage, and potentially curable with surgery (with or without hormonal therapy).6
As a referral center for rare uterine tumors, the Kelly Gynecologic Oncology Service and the Sarcoma Center at Johns Hopkins see approximately 35 to 40 new cases of uterine sarcoma annually for treatment of primary disease or recurrence. An additional 15 to 20 consult cases are reviewed from outside hospitals each year by our gynecologic pathology department.
Why a minimally invasive approach is vital
OBG Management: When it comes to uterine surgery for presumed benign conditions, why is a minimally invasive approach important?
Dr. Fader: Minimally invasive surgery clearly benefits women and is one of the greatest advances of the past half-century within our field. Randomized controlled trials and meta-analyses have demonstrated without question that women who undergo minimally invasive surgery for benign conditions or early-stage cancerous gynecologic conditions have superior clinical outcomes, compared with women who undergo surgery via laparotomy.7,8 These outcomes include fewer perioperative complications (including fewer cases of surgical site infection, venous thromboembolism, wound dehiscence, and hospital readmission), shorter hospital stays, less pain, faster recovery, and fewer adhesions. And when women with early-stage cancers undergo minimally invasive surgery, randomized controlled trials show, they have a stage-specific survival rate similar to that observed in women treated with laparotomy.9
Benefits and risks of tissue extraction in minimally invasive surgery
OBG Management: What are the main benefits of tissue extraction, including morcellation?
Dr. Fader: Tissue extraction is a practice that has allowed us to offer minimally invasive surgery to countless more women than we could have in the recent past. It is a technique in which a large specimen (typically a uterus or fibroid) is fragmented into smaller parts in order to remove it through a small laparoscopic incision or orifice (vagina, umbilicus). Without tissue-extraction practices, thousands of women who undergo myomectomy each year to conserve their fertility and hundreds of thousands of women who require hysterectomy potentially would have to undergo a more painful and risky surgery through a larger abdominal incision. That would not be desirable, as we know conclusively that laparotomy is associated with worse outcomes—and even an increased risk of mortality—compared with minimally invasive surgery performed by experienced surgeons.10
