Arnold Advincula's Surgical Techniques
However, what this also means is that while it may be prudent to restrict or limit a surgical practice in select higher-risk populations or modify it in some way to make it safer, we shouldn’t necessarily completely abandon or ban a practice that has benefited hundreds of thousands of patients at low risk of harm until we have objectively reviewed all of the available science and fully understand the implications of a practice change (ie, would the risks of preventable harm be even greater for women if more of them had to undergo open abdominal surgery?). We need continued cool heads and sound scientific reasoning to decide upon health-care policy changes or treatment paradigm shifts.
At the end of the day, however, it is paramount that we mitigate patient harm. The subject of tissue extraction during minimally invasive surgery is a complex and nuanced issue that merits continued study and open-minded and intelligent dialogue between patient stakeholders, clinicians, scientists, industry, ethicists, regulatory agencies, and the press. I think we can all appreciate how humbling and challenging the morcellation issue has been for many of us, especially our patients—particularly the unfortunate women who have been diagnosed with a uterine sarcoma.
Like many of my colleagues, I have been privileged to care for a number of women with uterine leiomyosarcoma. It is a devastating disease, and the prognosis is very poor, whether it is morcellated or removed intact. We are fortunate that the vast majority of women who undergo a minimally invasive procedure for fibroids or other presumed benign indications will not be at risk for an occult malignancy. But what can we do now to continue to offer the benefits of minimally invasive surgery and tissue extraction to women while simultaneously reducing the risk to the select few who will develop a rare uterine cancer?
We can all make a greater effort to more carefully select our patients for minimally invasive surgery and tissue extraction, to limit the performance of open electromechanical morcellation and collaborate in studying the role of refined tissue-extraction techniques and containment systems, to enhance the informed consent process, to develop improved diagnostic tests for preoperative cancer detection, and to conduct higher-quality studies on minimally invasive tissue-extraction techniques for regulatory agencies to review in the near future. It also goes without saying that we need more federal funding to study rare tumors (and gynecologic cancers in general) and develop better sarcoma treatments.
Although there is no medical treatment or surgical procedure that is completely risk-free, interventions such as HRT, tamoxifen, and uterine morcellation—when used in appropriate patients and for appropriate indications—will allow preventable harm to be minimized and make it possible for countless women to continue to derive tremendous benefit.
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