Surgical Techniques

Tissue extraction at minimally invasive surgery: Where do we go from here?

OBG Manag. 2015 March;27(3):26–28,30–35,40,44

References

1. US Food and Drug Administration. Laparoscopic uterine power morcellation in hysterectomy and myomectomy: FDA Safety Communication. http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm393576.htm. Published April 17, 2014. Accessed February 3, 2014.

2. AAGL. Morcellation during uterine tissue extraction. http://www.aagl.org/wp-content/uploads/2014/05/Tissue_Extraction_TFR.pdf. Accessed February 3, 2015.

3. American College of Obstetricians and Gynecologists. Power morcellation and occult malignancy in gynecologic surgery: a special report. http://www.acog.org/Resources-And-Publications/Task-Force-and-Work-Group-Reports/Power-Morcellation-and-Occult-Malignancy-in-Gynecologic-Surgery. Published May 2014. Accessed February 3, 2015.

4. US Food and Drug Administration. Updated Laparoscopic uterine power morcellation in hysterectomy and myomectomy: FDA Safety Communication. http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm424443.htm. Published November 24, 2014. Accessed February 2, 2015.

5. American Cancer Society. Uterine sarcoma: What is uterine sarcoma? http://www.cancer.org/cancer/uterinesarcoma/detailedguide/uterine-sarcoma-what-is-uterine-sarcoma. Updated January 12, 2015. Accessed February 3, 2015.

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7. Chittawar B, Franik S, Pouwer AW, Farquhar C. Minimally invasive surgical techniques versus open myomectomy for uterine fibroids. Cochrane Database Syst Rev. 2014;10:CD004638. doi:10.1002/14651858.CD004638.pub3.

8. Mori KM, Neubauer NL. Minimally invasive surgery in gynecologic oncology. ISRN Obstet Gynecol. 2013; article ID 312982. http://dx.doi.org/10.1155/2013/312982. Accessed February 2, 2015.

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11. Ramos A, Fader AN, Long Roche K. Surgical cytoreduction for disseminated benign disease after open power uterine morcellation. Obstet Gynecol. 2014;125(1):99–102.

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15. Pritts EA, Parker WH, Brown J, Olive DL. Outcome of occult uterine leiomyosarcoma after surgery for presumed uterine fibroids: a systematic review. J Minim Invasive Gynecol. 2015;22(1):26–33.

16. Wright JD, Tergas AI, Burke WM, et al. Prevalence of uterine pathology in women undergoing minimally invasive hysterectomy employing electric power morcellation. JAMA. 2014;312(12):1253–1255.

17. Wright JD, Tergas AI, Burke WM, et al. Uterine pathology in women undergoing minimally invasive hysterectomy using morcellation. JAMA. 2014;312(12):1253–1255.

18. Wright JD, Tergas AI, Cul R, et al. Use of electric power morcellation and prevalence of underlying cancer in women who undergo myomectomy. JAMA Oncol. 2015; published online February 19, 2015. doi:10.1001/jamaoncol.2014.206.

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OBG Management: Which is greater—the risks or benefits of tissue extraction?

Dr. Fader: Assessment of risks and benefits in medicine has everything to do with the intervention in question as applied to an individual patient. At the end of the day, there are risks and benefits to every medical or surgical treatment offered to patients in every medical and surgical discipline. But the risk of an occult uterine sarcoma is extremely low in a woman of reproductive age who has been properly selected and comprehensively evaluated for minimally invasive surgery and tissue extraction prior to surgery. And this small—though not negligible—risk must be weighed against the much higher risk of harm that may be incurred with an open abdominal procedure, compared with minimally invasive surgery.

However, in many elderly women, the risks of tissue extraction with an electromechanical morcellator may outweigh the benefits. Even so, there are exceptions in which tissue extraction may be acceptable in postmenopausal women (ie, using alternative tissue-extraction methods in those undergoing minimally invasive supracervical hysterectomy and sacral colpopexy for pelvic organ prolapse).

Few of the data published on the risks of morcellation are of very high quality in terms of scientific rigor or methodology. The best thing we can do as a gynecologic surgical community is conduct sound quality-improvement (QI) programs, disseminate our QI results, publish our data, establish guidelines for best practices in uterine tissue extraction, and collaborate readily to increase the scholarly output on this issue so that national societies and government regulatory agencies have better-quality data to inform future policy on this issue.

A case-based approach
OBG Management: How would you approach tissue extraction in the following case?

CASE: A desire for myomectomy
A 35-year-old woman (G1P1) who delivered by cesarean has an 8-cm symptomatic intramural fibroid. She has regular heavy periods that have led to anemia (hemoglobin level = 10 mg/dL). Her medical history is negative for malignancy, pelvic radiation, or tamoxifen use, and she wants to preserve her fertility. Magnetic resonance imaging (MRI) confirms an 8-cm fibroid. Endometrial biopsy results are negative.

Dr. Fader: At Johns Hopkins, as at many other centers, we use well-defined criteria to determine whether a minimally invasive approach (and tissue extraction) might be appropriate. We also individualize treatment and surgical decision-making on a case-by-case basis. Any candidate for minimally invasive surgery and tissue extraction for uterine fibroids must undergo a thorough preoperative assessment.

Johns Hopkins preoperative assessment criteria include:

endometrial biopsy
imaging (often MRI)
a detailed history and physical, with a comprehensive review of risk factors for malignancy, including family and genetic history or a personal history of malignancy, pelvic radiation, tamoxifen use, or BRCA or hereditary nonpolyposis colorectal cancer (HNPCC) deleterious mutation carrier status, among other things.
In addition, all cases are discussed at a peer-reviewed, preoperative conference to ensure that a thorough work-up has been conducted and to verify the patient’s candidacy for a minimally invasive procedure with tissue extraction. As the FDA recommends, we conduct an enhanced informed consent process and counsel patients being considered for tissue extraction about the risk of occult sarcoma.

Our top priority is patient safety, so until more data are available, we no longer perform open electromechanical morcellation. We perform all tissue extraction within a containment system and under institutional review board protocol. We primarily perform tissue extraction via scalpel morcellation.

OBG Management: How do the patient’s wishes factor into the decision to perform minimally invasive surgery with morcellation?

Dr. Fader: Our patients make their own decisions regarding surgical approach and procedure after undergoing extensive counseling about the risks and benefits of the proposed procedures. I certainly would offer a patient like the one described in this case the opportunity for a minimally invasive approach (if, after thorough preoperative evaluation, she were deemed to be at very low risk for uterine malignancy). In my experience, most women opt for the minimally invasive approach in this setting; however, if a patient declines minimally invasive surgery, I respect her decision.

Tissue extraction in perimenopause

CASE: A desire for myomectomy at age 48
OBG Management: How would you approach the same case if the patient were a 48-year-old perimenopausal woman?

Dr. Fader: In perimenopausal women, we are more selective about performing morcellation, given the recent FDA safety statement, and because the incidence of occult cancer starts to increase slightly in this patient cohort (although it doesn’t precipitously increase until well into the postmenopausal period).

In addition, myomectomy may have less value in a 48-year-old, given the lower likelihood of achieving successful fertility, although there are exceptions. US cancer statistics and studies on morcellation demonstrate that the vast majority of women in their 30s and 40s have an extremely low risk for sarcomas and other uterine malignancies.²