Uterine Morcellation: Can We and Should We?

By Stephanie Ricci, MD

Uterine tissue extraction using open electromechanical morcellation has been called into question in recent years.

Much of the controversy surrounding use of a laparoscopic power morcellation device stemmed from the concern that selected women with presumed benign disease may undergo a uterine and tissue extraction procedure that results in disruption, and possible dissemination, of a malignant tumor.

In April 2015 the Food and Drug Administration (FDA) issued a safety communication discouraging the use of the technique for minimally invasive hysterectomy and myomectomy in patients with benign conditions. An advisory committee continues to examine the issue.

In the meantime, unanswered questions

Does uterine morcellation of an occult leiomyosarcoma (LMS) increase recurrence risk and reduce survival? Several small studies have attempted to answer this question. Most compared women with uterine-confined LMS at the time of surgery, divided into intact versus fragmented removal. It is important to note that all methods of fragmentation were used in these studies, including vaginal and abdominal hand morcellation as well as electromechanical morcellation.

One study compared 25 patients who underwent morcellation to 31 patients with intact tumor removal. They found a higher rate of abdominopelvic dissemination (44 percent versus 12.9 percent, P = 0.032) and poorer overall survival on multivariate analysis in the morcellated cohort.

Another study compared 19 women with fragmented uterine removal and 39 with intact removal and reported a threefold increase in risk of recurrence in the morcellation cohort. Researchers did not, however, note a difference in overall survival.

Interestingly, a third study, which included hysteroscopic myomectomy in its “tumor injury” cohort, similarly found significantly better survival rates and decreased recurrence rates for women undergoing intact removal of the uterus. Another study demonstrated a high rate of recurrence (70.8 percent) for women with apparent uterine-confined, non-morcellated LMS that rivaled the recurrence rates noted in the studies above in morcellated cases.

Given that existing studies are retrospective and not powered to detect differences in recurrence or survival for women with LMS who have their uteri removed intact versus morcellated, no conclusions can be made regarding the impact of open electromechanical morcellation on the survival outcomes of these women.

At Cleveland Clinic

At our institution, we have taken a cautious and conservative approach to morcellation. We still perform hand assisted uterine fragmentation, either through the vagina or a mini-laparotomy, in carefully selected women after extensive counseling, comprehensive preoperative workup and informed consent.

We employ the following patient-selection criteria:

• Imaging (MRI for fibroids)
• Endometrial evaluation
• Exclusion criteria for morcellation

– Age > 50

– History of tamoxifen use

– Pelvic radiation

– BRCA mutation carrier status

– Hereditary cancer syndromes

• Enhanced surgical consent
• High-volume surgeons only
• Hand morcellation only

We feel these guidelines help produce safe, low-risk, excellent outcomes for our patients.