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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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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In select cases in which a woman has undergone a comprehensive preoperative work-up, has a stable-appearing fibroid(s), and is well-educated and counseled about the pros and cons of morcellation, we would consider performing a procedure with contained tissue extraction. As a general matter, however, I would be more inclined to offer a 48-year-old in this situation a uterine artery embolization or minimally invasive hysterectomy than a myomectomy procedure, especially given the recent study by Wright and colleagues demonstrating the significantly increased risks of uterine cancer at myomectomy surgery for a woman in her late 40s or early 50s.¹⁸

Preoperative assessment should be comprehensive
OBG Management: What preoperative evaluation do you perform when tissue extraction, including morcellation, is an issue?

Dr. Fader: It is the policy at Johns Hopkins that all women being considered for minimally invasive surgery and tissue extraction must undergo a rigorous preoperative work-up that includes:

a comprehensive history and physical (to exclude malignancy and risk for occult malignancy)
an endometrial evaluation (most commonly, an endometrial biopsy)
uterine imaging (with longitudinal evaluation of imaging findings if performed previously)
discussion of each patient case at peer-reviewed, preoperative department conferences.

We have separate conferences for the gynecology and gynecologic oncology services and have employed this practice for many years at Hopkins. We are also studying the role of serum lactate dehydrogenase (LDH) isoenzyme levels in stratifying women with uterine fibroids versus cancer/sarcoma.¹⁹

OBG Management: Which patients would you exclude from the electromechanical morcellation option?

Dr. Fader: As the American College of Obstetricians and Gynecologists, the AAGL, the Society of Gynecologic Oncology, and the Society of Gynecologic Surgeons appear to agree:

When utilized in select patients of reproductive age, minimally invasive surgery and morcellation are beneficial.
Morcellation should categorically not be performed in any woman who has a known or suspected uterine (or other gynecologic) malignancy.^2,3

At our institution, we have significantly curtailed the use of electromechanical morcellation at this time and especially do not perform it in women aged 50 or older or in those with confirmed postmenopausal status. We also do not perform electromechanical morcellation in women with a personal history of uterine, cervical, or ovarian preinvasive or invasive cancer, or in women with a strong family history of gynecologic malignancy.

Other populations we exclude are women with:

a history of mitotically active or atypical fibroids (as determined at previous myomectomy)
known BRCA or HNPCC deleterious mutation, hereditary leiomyomatosis and renal cell carcinoma (HLRCC) syndrome, hereditary childhood retinoblastoma, or other genetic predisposition to uterine or ovarian cancer
a history of pelvic radiation
a history of tamoxifen use.

Counseling the patient
OBG Management: If tissue extraction is an issue, and morcellation will be necessary for a minimally invasive approach, how do you counsel the patient?

Dr. Fader: We have an informed consent protocol we use at Hopkins in this regard. We speak extensively to our patients about the fact that every procedure or intervention performed in medicine carries a benefit/risk ratio. We inform patients of the FDA morcellation safety statement—that their fibroid or fibroids may contain unexpected cancerous tissue and that laparoscopic electromechanical morcellation may spread the cancer and possibly worsen their prognosis. We also explain that, while the FDA quotes a risk of approximately 1 in 350 for occult sarcoma, that this data review was somewhat limited in scope and included postmenopausal women in the estimates. Based on the best available published systematic reviews and internal Hopkins data, we believe the risk of morcellating an occult uterine malignancy in a woman of reproductive age is more likely on the order of approximately 1 in 1,700 to 1 in 8,333.

We discuss our institution’s approach to tissue extraction (ie, that we no longer perform open electromechanical morcellation but instead perform contained tissue extraction on an institutional review board protocol). We tell patients that contained tissue-extraction practices are still experimental, although there is published literature preliminarily supporting the safety of the practice. In addition, we discuss the fact that contained tissue extraction has been used for years to safely remove large intra-abdominal specimens from laparoscopic incisions, from adnexal tissue to gallbladder, spleen, kidney, intestinal, and appendiceal specimens.

We also explain that, as physicians, we do our best to ensure that risks are minimized and reasonable in relation to anticipated benefits but that, even when we use the very best diagnostic measures, no test is 100% sensitive or specific to rule out malignancy in this setting (or in any setting, actually).

Finally, we discuss the fact that minimally invasive surgery and tissue extraction practices performed in appropriate patients by skilled surgeons conclusively benefit hundreds of thousands of women each year around the world. That is a narrative that has been somewhat lacking in the recent dialogue about tissue-extraction practices.