Arnold Advincula's Surgical Techniques
Tissue extraction can be approached in a variety of ways. It can be performed with a scalpel, with a resectoscope, or with an electromechanical morcellator. Tissue extraction can be performed within the uterine cavity, through the vagina, within the abdominal compartment, or within a containment system in any of those compartments.
OBG Management: What are the risks of tissue extraction?
Dr. Fader: The risks of tissue extraction with electromechanical morcellation include potential injury to intra-abdominal organs and vasculature and risk of dissemination of an occult (ie, undiagnosed) uterine cancer. A report by our research group also demonstrated the risks of dissemination of benign uterine tissue requiring subsequent surgery in the setting of open electromechanical morcellation.11 The risk of these events occurring in the hands of a thoughtful and experienced surgeon who conducts comprehensive preoperative patient evaluations is extremely low. However, recent evidence demonstrates that a handful of women worldwide are diagnosed with an occult uterine cancer each year during a morcellation procedure.12–14 Although it is a very rare event (given that most women undergoing hysterectomy and myomectomy procedures are of reproductive age and unlikely to have uterine cancer), this risk is a serious issue. There is an exigent need for the gynecologic surgical community to develop better approaches to tissue extraction that minimize preventable harm in women.
Needed: high-quality data on the risks of morcellation
OBG Management: How does the recent FDA statement urging caution with the use of open power morcellation factor into this equation? The most recent FDA statement noted that open power morcellation is contraindicated in perimenopausal and postmenopausal women.4
Dr. Fader: The FDA’s concern is legitimate. However, the magnitude of the risk of occult uterine sarcoma in women undergoing presumed benign gynecologic surgery has been scrutinized and debated. The FDA panel quoted a risk that roughly 1 in 350 women undergoing presumed benign gynecologic surgery for fibroids will have an occult leiomyosarcoma diagnosed. However, more recent systematic reviews and a review of the prospective published literature demonstrate that the risk is more likely on the order of 1 in 1,700 to 1 in 8,333 women.15 The risk may be even lower in gynecologic surgery practices that see a high volume of hysterectomy/myomectomy cases and utilize meticulous preoperative patient selection criteria to establish a woman’s candidacy for tissue-extraction procedures.
I am concerned with how “occult sarcoma” discovered during surgery for “presumed benign gynecologic disease is being defined in the literature. There is no uniform definition being used. A cancer in this setting is only truly occult or undiagnosed if the physician was thinking about it and made every effort to rule out cancer preoperatively, and the morcellation procedure was performed in a low-risk population (but cancer was still diagnosed on final pathology in this population). However, in the majority of the morcellation studies in the literature, it is not clear that thorough preoperative evaluations occurred in patients to rule out uterine malignancy—in fact, there is a paucity of published information regarding establishing appropriate patient candidacy for morcellation procedures. So we can’t derive any conclusions regarding whether “occult” sarcomas were truly undetectable or not in the published literature.
In addition, the literature is very clear that advancing age and postmenopausal status are risk factors for uterine malignancy.16 The vast majority of uterine sarcoma cases are diagnosed in postmenopausal women. Yet, in one large US population-based hysterectomy study, 20% of the morcellated cases (and the overwhelming majority of the “occult” morcellated uterine cancers) occurred in postmenopausal women!17
Further, in a more recent study by the same authors, again the risks of morcellating a uterine cancer in a population undergoing myomectomy was significantly higher in a postmenopausal population and occurred only rarely in women younger than age 40. But it should come as no surprise that a greater incidence of uterine cancer was identified in these older cohorts—cancer risk increases precipitously with age. That’s not “occult”; that’s basic cancer epidemiology.
In other words, we cannot assume from population-based administrative claims data that morcellation performed in inappropriate populations at higher risk of uterine malignancy (in which we do not know whether patients were properly screened for the procedure preoperatively or whether they had risk factors for uterine cancer but were presumably poor candidates for morcellation due to age alone) helps us define the true incidence of “occult” sarcoma or cancer in a population.
These studies are provocative, however, and do inform us that, as women get older, we are apt to see a greater incidence of uterine cancer. We cannot safely assume that a postmenopausal or elderly woman with symptomatic or enlarging fibroids has “presumed benign disease”—it is cancer until proven otherwise, and we need to be looking for it preoperatively. Therefore, we need to be particularly careful with our surgical practices in this population—ie, the basis for the FDA’s recommendation to avoid morcellation in older women. And I agree with the FDA that open electromechanical morcellation generally is contraindicated in postmenopausal women. However, we need better data from large prospective studies to inform our understanding of the true incidence of undiagnosed or “occult” uterine sarcoma in women undergoing surgery for presumed benign disease. These future studies are likely to demonstrate what we already know—that in young, well-screened, well-selected candidates for minimally invasive hysterectomy or myomectomy, the risk of occult cancer is going to be exceptionally low.
