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Yoshida R, Makihara Y, Miyamoto A, Araki H, Ando S, Yoshizako T, Oride A, Kaji Y. Acute abdomen by red degeneration of a parasitic leiomyoma: A case report and literature review. Radiol Case Rep 2024; 19:1533-1536. [PMID: 38317695 PMCID: PMC10839770 DOI: 10.1016/j.radcr.2024.01.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 01/10/2024] [Indexed: 02/07/2024] Open
Abstract
A 43-year-old woman, with a history of uterine fibroids and multiple myomectomy, presented with acute lower abdominal pain. Computed tomography revealed multiple tumors, including a high-density mass in the left lower abdomen indicative of a parasitic leiomyoma undergoing red degeneration. This uncommon condition is due to acute occlusion, often caused by peripheral venous thrombosis at the fibroid edge. The diagnosis was corroborated by distinctive findings on magnetic resonance imaging and computed tomography. Notably, high signal intensity on T1-weighted images (T1WI) suggested methemoglobin presence due to hemorrhagic infarction, whereas low signal intensity on T2-weighted images (T2WI) indicated deoxyhemoglobin. Symptom improvement followed treatment with analgesics. This case underscores the significance of considering parasitic myomas in the differential diagnosis of intraperitoneal tumors after myomectomy and proposes that vascular torsion from mechanical stress on the mobile mesentery may contribute to red degeneration in such tumors. In this report, we detail the imaging characteristics and clinical progression of red degeneration in a parasitic leiomyoma, emphasizing the importance of this diagnosis in patients with a history of uterine surgery.
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Affiliation(s)
- Rika Yoshida
- Department of Radiology, Faculty of Medicine, Shimane University, Izumo, Shimane, Japan
| | - Yuko Makihara
- Department of Radiology, Faculty of Medicine, Shimane University, Izumo, Shimane, Japan
| | - Akina Miyamoto
- Department of Radiology, Faculty of Medicine, Shimane University, Izumo, Shimane, Japan
| | - Hisatoshi Araki
- Department of Radiology, Faculty of Medicine, Shimane University, Izumo, Shimane, Japan
| | - Shinji Ando
- Department of Radiology, Faculty of Medicine, Shimane University, Izumo, Shimane, Japan
| | - Takeshi Yoshizako
- Department of Radiology, Faculty of Medicine, Shimane University, Izumo, Shimane, Japan
| | - Aki Oride
- Department of Obstetrics and Gynecology, Faculty of Medicine, Shimane University, Enya-cho, 89-1, Izumo 693-8501, Shimane, Japan
| | - Yasushi Kaji
- Department of Radiology, Faculty of Medicine, Shimane University, Izumo, Shimane, Japan
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Zouzoulas D, Tsolakidis D, Pavlidi OI, Pappas PD, Theodoridis T, Pados G, Pervana S, Pazarli E, Grimbizis G. Rate of Leiomyosarcomas during Surgery for Uterine Fibroids: 8-Year Experience of a Single Center. J Clin Med 2023; 12:7555. [PMID: 38137623 PMCID: PMC10743724 DOI: 10.3390/jcm12247555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 12/04/2023] [Accepted: 12/06/2023] [Indexed: 12/24/2023] Open
Abstract
The aim of this study is to investigate the prevalence of occult malignant mesenchymal tumors in patients operated on for uterine fibroids in relation to the surgical approach and type of operation. A retrospective review of all patients that underwent surgery for uterine fibroids (January 2011-December 2018) at the 1st Department of Obstetrics & Gynecology at "Papageorgiou" Hospital. The surgical approach and clinicopathological characteristics were analyzed. A total of 803 patients were operated on: 603 (75.1%) with laparotomy, 187 (23.3%) laparoscopically, and 13 (1.6%) vaginally. Furthermore, 423 (52.7%) patients underwent hysterectomy and 380 (47.3%) myomectomies. Laparoscopy and myomectomy were offered to younger patients with fewer smaller uterine fibroids and were associated with statistically significant shorter hospitalization. The pathological reports revealed: 690 (86%) benign leiomyomas, 32 (4%) cellular leiomyomas, 29 (3.6%) degenerated leiomyomas, 22 (2.7%) adenomyomas, 18 (2.2%) atypical-bizarre leiomyomas, 1 (0.1%) STUMP, 5 (0.65%) endometrial stromal sarcomas, and 6 (0.75%) cases of leiomyosarcomas (LMS). All LMS were preoperatively characterized as suspicious and underwent abdominal hysterectomy. Morcellation was offered in two cases of atypical leiomyomas, with no morcellation-associated complication. Laparoscopy as a valuable surgical approach for young patients with fewer in number and smaller in size fibroids is associated with shorter hospitalization. The risk of unintended morcellation of LMS seems to be very low and can be reduced with careful preoperative work-up but not eliminated.
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Affiliation(s)
- Dimitrios Zouzoulas
- 1st Department of Obstetrics & Gynecology, “Papageorgiou” Hospital, Aristotle University of Thessaloniki, 56403 Thessaloniki, Greece (O.I.P.); (P.D.P.); (T.T.); (G.P.); (G.G.)
| | - Dimitrios Tsolakidis
- 1st Department of Obstetrics & Gynecology, “Papageorgiou” Hospital, Aristotle University of Thessaloniki, 56403 Thessaloniki, Greece (O.I.P.); (P.D.P.); (T.T.); (G.P.); (G.G.)
| | - Olga I. Pavlidi
- 1st Department of Obstetrics & Gynecology, “Papageorgiou” Hospital, Aristotle University of Thessaloniki, 56403 Thessaloniki, Greece (O.I.P.); (P.D.P.); (T.T.); (G.P.); (G.G.)
| | - Panagiotis D. Pappas
- 1st Department of Obstetrics & Gynecology, “Papageorgiou” Hospital, Aristotle University of Thessaloniki, 56403 Thessaloniki, Greece (O.I.P.); (P.D.P.); (T.T.); (G.P.); (G.G.)
| | - Theodoros Theodoridis
- 1st Department of Obstetrics & Gynecology, “Papageorgiou” Hospital, Aristotle University of Thessaloniki, 56403 Thessaloniki, Greece (O.I.P.); (P.D.P.); (T.T.); (G.P.); (G.G.)
| | - George Pados
- 1st Department of Obstetrics & Gynecology, “Papageorgiou” Hospital, Aristotle University of Thessaloniki, 56403 Thessaloniki, Greece (O.I.P.); (P.D.P.); (T.T.); (G.P.); (G.G.)
| | - Stavroula Pervana
- Anatomical Pathology Laboratory, “Papageorgiou” Hospital, 56403 Thessaloniki, Greece
| | - Elsa Pazarli
- Anatomical Pathology Laboratory, “Papageorgiou” Hospital, 56403 Thessaloniki, Greece
| | - Grigoris Grimbizis
- 1st Department of Obstetrics & Gynecology, “Papageorgiou” Hospital, Aristotle University of Thessaloniki, 56403 Thessaloniki, Greece (O.I.P.); (P.D.P.); (T.T.); (G.P.); (G.G.)
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Obrzut B, Kijowska M, Obrzut M, Mrozek A, Darmochwał-Kolarz D. Contained Power Morcellation in Laparoscopic Uterine Myoma Surgeries: A Brief Review. Healthcare (Basel) 2023; 11:2481. [PMID: 37761678 PMCID: PMC10531049 DOI: 10.3390/healthcare11182481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 09/05/2023] [Accepted: 09/06/2023] [Indexed: 09/29/2023] Open
Abstract
Uterine fibromas are the most common benign uterine tumors. Although the majority of leiomyomas remain asymptomatic, they can cause serious clinical problems, including abnormal uterine bleeding, pelvic pain, and infertility, which require effective gynecological intervention. Depending on the symptoms as well as patients' preferences, various treatment options are available, such as medical therapy, non-invasive procedures, and surgical methods. Regardless of the extent of the surgery, the preferred option is the laparoscopic approach. To reduce the risk of spreading occult malignancy and myometrial cells associated with fragmentation of the specimen before its removal from the peritoneal cavity, special systems for laparoscopic contained morcellation have been developed. The aim of this review is to present the state-of-the-art contained morcellation. Different types of available retrieval bags are demonstrated. The advantages and difficulties associated with contained morcellation are described. The impact of retrieval bag usage on the course of surgery, as well as the effects of the learning curve, are discussed. The role of contained morcellation in the overall strategy to optimize patient safety is highlighted.
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Affiliation(s)
- Bogdan Obrzut
- Department of Obstetrics and Gynecology, Institute of Medical Sciences, Medical College, University of Rzeszów, Rejtana 16 C, 35-959 Rzeszow, Poland
| | - Marta Kijowska
- Department of Obstetrics and Gynecology, Provincial Clinical Hospital No. 2 Rzeszow, Lwowska 60, 35-301 Rzeszow, Poland
| | - Marzanna Obrzut
- Institute of Health Sciences, Medical College, University of Rzeszow, Warzywna 1a, 35-310 Rzeszow, Poland
| | - Adam Mrozek
- Department of Obstetrics and Gynecology, Institute of Medical Sciences, Medical College, University of Rzeszów, Rejtana 16 C, 35-959 Rzeszow, Poland
| | - Dorota Darmochwał-Kolarz
- Department of Obstetrics and Gynecology, Institute of Medical Sciences, Medical College, University of Rzeszów, Rejtana 16 C, 35-959 Rzeszow, Poland
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Yuan P, Shan L, Yang X, Yu F, Ge Z, Wang M, Tan H. The merging of dual umbilical port-incisions for contained morcellation in laparoscopic myomectomy. Am J Obstet Gynecol 2023; 229:72-74. [PMID: 36933684 DOI: 10.1016/j.ajog.2023.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 02/09/2023] [Accepted: 03/13/2023] [Indexed: 03/18/2023]
Abstract
Uncontained power morcellation during laparoscopic myomectomy may spread tissue fragments or malignant cells into the abdominal cavity. Recently, various approaches to contained morcellation, have been adopted to retrieve the specimen. However, each of these methods has its own drawbacks. Intraabdominal bag-contained power morcellation adopts a complex isolation system, which prolongs the operation and increases medical costs. Contained manual morcellation via colpotomy or mini-laparotomy increases the trauma and the risk of infection. Contained manual morcellation via umbilical incision during single-port laparoscopic myomectomy may be the most minimally invasive and cosmetic approach. But the popularization of single-port laparoscopy is challenging because of technical difficulties and high costs. We have therefore, developed a surgical technique using 2 umbilical port-incisions (5 mm and 10 mm), which are merged into 1 large umbilical incision (25-30mm) for contained manual morcellation during specimen retrieval, and one 5mm incision in the lower left abdomen for an ancillary instrument. As demonstrated in the video, this technique significantly facilitates surgical manipulation using conventional laparoscopic instruments while still keeping the incisions minimal. It is also economical because the use of an expensive single-port platform and special surgical instruments is avoided. In conclusion, the merging of dual umbilical port-incisions for contained morcellation adds a minimally invasive, cosmetic, and economical option to laparoscopic specimen retrieval that would enrich a gynecologist's skill set, which is particularly relevant in a low-resource settings.
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Affiliation(s)
- Peng Yuan
- Department of Gynecology, Northwest Women's and Children's Hospital (Shaanxi Provincial Maternity and Child Health Care Hospital), Xi'an, Shaanxi, China.
| | - Li Shan
- Department of Gynecology, Northwest Women's and Children's Hospital (Shaanxi Provincial Maternity and Child Health Care Hospital), Xi'an, Shaanxi, China
| | - Xiaohua Yang
- Department of Gynecology, Northwest Women's and Children's Hospital (Shaanxi Provincial Maternity and Child Health Care Hospital), Xi'an, Shaanxi, China
| | - Fan Yu
- Department of Gynecology, Northwest Women's and Children's Hospital (Shaanxi Provincial Maternity and Child Health Care Hospital), Xi'an, Shaanxi, China
| | - Zhonghu Ge
- Department of Gynecology, Northwest Women's and Children's Hospital (Shaanxi Provincial Maternity and Child Health Care Hospital), Xi'an, Shaanxi, China
| | - Mengyao Wang
- Department of Gynecology, Northwest Women's and Children's Hospital (Shaanxi Provincial Maternity and Child Health Care Hospital), Xi'an, Shaanxi, China
| | - Hongwei Tan
- Department of Gynecology, Northwest Women's and Children's Hospital (Shaanxi Provincial Maternity and Child Health Care Hospital), Xi'an, Shaanxi, China.
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Wang J, Liu G, Yang Q. Parasitic myoma after transabdominal hysterectomy for fibroids: a case report. BMC Womens Health 2023; 23:310. [PMID: 37328846 PMCID: PMC10273530 DOI: 10.1186/s12905-023-02410-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 05/02/2023] [Indexed: 06/18/2023] Open
Abstract
BACKGROUND Parasitic myomas typically occur after a pedunculated subserosal fibroid loses its uterine blood supply and parasitizes other organs or after a surgery involving morcellation techniques. Parasitic myomas that occur after transabdominal surgery are extremely rare and may not be sufficiently documented. Here, we present a case of parasitic myoma in the anterior abdominal wall following a transabdominal hysterectomy for fibroids. CASE PRESENTATION The patient was a 46-year-old Chinese woman who had undergone surgery for uterine myomas at our hospital 1 year prior. The patient later revisited our department with a palpable mass in her abdomen, and imaging revealed a mass in the iliac fossa. The possibility of a broad ligament myoma or solid ovarian tumor was considered before surgery, and laparoscopic exploration was performed under general anesthesia. A tumor measuring approximately 4.5 × 4.0 cm was found in the right anterior abdominal wall, and a parasitic myoma was considered. The tumor was completely resected. Pathological analysis of the surgical specimens suggested leiomyoma. The patient recovered well and was discharged on postoperative day 3. CONCLUSION This case suggests that parasitic myoma should be considered in the differential diagnosis of patients presenting with abdominal or pelvic solid tumors with a history of surgery for uterine leiomyomas, even without a history of laparoscopic surgery using a power morcellator. Thorough inspection and washing of the abdominopelvic cavity at the end of surgery is vital.
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Affiliation(s)
- Jiao Wang
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, No.36 Sanhao Street, Heping District, Shenyang, Liaoning Province, 110004, China
| | - Guipeng Liu
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, No.36 Sanhao Street, Heping District, Shenyang, Liaoning Province, 110004, China.
| | - Qing Yang
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, No.36 Sanhao Street, Heping District, Shenyang, Liaoning Province, 110004, China.
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Xu T, Qiu B, Xu Q, Qu J, Zhuang D, Xu Q. Case study of colorectal endometriosis treated with endoscopic submucosal excavation. Front Physiol 2023; 14:1073241. [PMID: 37275230 PMCID: PMC10233404 DOI: 10.3389/fphys.2023.1073241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 04/17/2023] [Indexed: 06/07/2023] Open
Abstract
Colorectal endometriosis (CEM) is a rare and complicated form of deep invasive endometriosis. Its treatment methods include drug therapy and surgery. However, it is often difficult to alleviate symptoms and address problems, such as infertility, using drug treatment alone. Surgical intervention provides a histologic diagnosis, allows assessment of pelvic cysts or masses with features concerning for malignancy, and reduces pain by destroying the endometriotic implants. We consider surgery in women with the following: Persistent pain despite medical therapy; Contraindications to or refusal of medical therapy; Need for a tissue diagnosis of endometriosis; Exclusion of malignancy in an adnexal mass; Obstruction of the bowel or urinary tract. But there is no consensus about the surgical methods. With the rapid development of gastroenteroscopy technology in recent years, many local gastrointestinal tumors that previously required surgical resection can now be removed by endoscopic surgery. Herein, we report one case of CEM treated by endoscopic submucosal excavation (ESE) to provide a new treatment option for the radical resection of single CEM.
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Burde KG, Rajanbabu A, Nair IR, Keechilat P. Leiomyosarcoma Occurring After Hysterectomy for Benign Fibroids: A Case Report. J Obstet Gynaecol India 2022; 72:536-538. [PMID: 36506903 PMCID: PMC9732165 DOI: 10.1007/s13224-021-01560-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 08/19/2021] [Indexed: 12/15/2022] Open
Affiliation(s)
| | - Anupama Rajanbabu
- Dept. of Gynaecology Oncology, Amrita Institute of Medical Sciences, Kochi, Kerala India
| | - Indu R. Nair
- Dept of Pathology, Amrita Institute of Medical Sciences, Kochi, Kerala India
| | - Pavithran Keechilat
- Dept of Medical Oncology, Amrita Institute of Medical Sciences, Kochi, Kerala India
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Grignani G, Merlini A, Aliberti S. Being the ultimate travel companion of a patient with uterine leiomyosarcoma. Future Oncol 2022; 18:17-23. [PMID: 36169665 DOI: 10.2217/fon-2022-0637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Uterine fibroids are difficult to distinguish from malignant masses using standard ultrasonography; and morcellation carries the risk of disseminating occult cancer in a small but relevant group of women with an undetected uterine malignancy. In this context, we follow the progress of a woman diagnosed with uterine leiomyosarcoma after suboptimal initial surgery for an assumed fibroid. Evidence is reviewed that guided multidisciplinary tumor board decisions about optimal management approaches after local seeding and development of distant metastases, and informed treatment selection at each line of therapy. As the case study illustrates, choice of treatment for advanced soft tissue sarcomas frequently involves finding an appropriate balance between the efficacy and toxicity of available options, aiming to allow patients to maintain their normal lives.
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Affiliation(s)
- Giovanni Grignani
- Division of Medical Oncology, Candiolo Cancer Institute - FPO, IRCCS, Str. Prov. 142, km 3.95, I-10060, Candiolo (TO), Italy
| | - Alessandra Merlini
- Division of Medical Oncology, Candiolo Cancer Institute - FPO, IRCCS, Str. Prov. 142, km 3.95, I-10060, Candiolo (TO), Italy.,Department of Oncology, University of Turin, 10124 Turin, Italy
| | - Sandra Aliberti
- Division of Medical Oncology, Candiolo Cancer Institute - FPO, IRCCS, Str. Prov. 142, km 3.95, I-10060, Candiolo (TO), Italy
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Xu X, Desai VB, Schwartz PE, Gross CP, Lin H, Schymura MJ, Wright JD. Safety Warning about Laparoscopic Power Morcellation in Hysterectomy: A Cost-Effectiveness Analysis of National Impact. WOMEN'S HEALTH REPORTS 2022; 3:369-384. [PMID: 35415718 PMCID: PMC8994439 DOI: 10.1089/whr.2021.0101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 02/22/2022] [Indexed: 11/09/2022]
Abstract
Background: Following a 2014 safety warning (that laparoscopic power morcellation may increase tumor dissemination if patients have occult uterine cancer), hysterectomy practice shifted from laparoscopic to abdominal approach. This avoided morcellating occult cancer, but increased perioperative complications. To inform the national impact of this practice change, we examined the cost-effectiveness of hysterectomy practice in the postwarning period, in comparison to counterfactual hysterectomy practice had there been no morcellation warning. Materials and Methods: We constructed a decision tree model to simulate relevant outcomes over the lifetime of patients in the national population undergoing hysterectomy for presumed benign indications. The model accounted for both hysterectomy- and occult cancer-related outcomes. Probability-, cost-, and utility weight-related input parameters were derived from analysis of the State Inpatient Databases, State Ambulatory Surgery and Services Databases, data from the New York Statewide Planning and Research Cooperative System and New York State Cancer Registry, and published literature. Results: With an estimated national sample of 353,567 adult women, base case analysis showed that changes in hysterectomy practice after the morcellation warning led to a net gain of 867.15 quality-adjusted life years (QALYs), but an increase of $19.54 million in costs (incremental cost-effectiveness ratio = $22,537/QALY). In probabilistic sensitivity analysis, the practice changes were cost-effective in 54.0% of the simulations when evaluated at a threshold of $50,000/QALY, which increased to 70.9% when evaluated at a threshold of $200,000/QALY. Conclusion: Hysterectomy practice changes induced by the morcellation warning are expected to be cost-effective, but uncertainty in parameter values may affect the cost-effectiveness results.
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Affiliation(s)
- Xiao Xu
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
- Yale Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut, USA
| | - Vrunda B. Desai
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
- CooperSurgical, Inc., Trumbull, Connecticut, USA
| | - Peter E. Schwartz
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
| | - Cary P. Gross
- Yale Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Haiqun Lin
- Division of Nursing Science, Rutgers University School of Nursing, Newark, New Jersey, USA
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Newark, New Jersey, USA
| | - Maria J. Schymura
- New York State Cancer Registry, New York State Department of Health, Albany, New York, USA
| | - Jason D. Wright
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York, USA
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Hsieh YC, Kuo PY, Chiang YC. Leiomyomatosis peritonealis disseminata in laparoscopic port site and abdomino-pelvic cavity: A case report. Radiol Case Rep 2021; 17:293-297. [PMID: 34876953 PMCID: PMC8633832 DOI: 10.1016/j.radcr.2021.10.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 10/19/2021] [Accepted: 10/20/2021] [Indexed: 10/26/2022] Open
Abstract
Leiomyomatosis peritonealis disseminata (LPD) is a rare clinical condition characterized by the development of multiple smooth muscle-like nodules in the peritoneal or abdominal cavity. Here, we report a case of a patient who was diagnosed with LPD after laparoscopic myomectomy with power morcellation. Growing evidence has shown that LPD might develop after using power morcellation for hysterectomy or myomectomy, and this can worsen the prognosis if the spreading tissue contains malignancies, such as leiomyosarcoma. Thus, it is crucial to use laparoscopic morcellation for gynecologic procedures cautiously, and the use of a containment system is even better. If LPD develops without evidence of malignancy, the primary treatment is surgical intervention, and gonadotropin-releasing hormone agonists, aromatase inhibitors, and selective progesterone receptor modulators can be prescribed as adjuvant therapies for recurrent or refractory cases.
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Affiliation(s)
- Yun-Chiao Hsieh
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan
| | - Po-Yen Kuo
- Department of Pathology, National Taiwan University Hospital Yun-Lin Branch, Yunlin, Taiwan
| | - Ying-Cheng Chiang
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan.,Department of Obstetrics and Gynecology, National Taiwan University Hospital Yun-Lin Branch, Yunlin, Taiwan.,Department of Obstetrics and Gynecology, College of Medicine, National Taiwan University, 15F, No. 8, Chung-Shan South Road, Taipei, Taiwan
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Taşkın S, Varlı B, Yalçın İ, Ortaç F, Taşkıran Ç, Güngör M. Morcellation in gynecology: short review and suggestions from Turkish Society of Minimally Invasive Gynecologic Oncology. J Turk Ger Gynecol Assoc 2021; 22:53-57. [PMID: 33389928 PMCID: PMC7944225 DOI: 10.4274/jtgga.galenos.2020.2020.0107] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Morcellation allows the removal of a large uterus and fibroids through small incisions with minimally invasive surgery. It helps to prevent the complications associated with large incisions in both hysterectomy and myomectomy operations. Currently, there is much debate regarding the use of power morcellation in laparoscopic hysterectomy and myomectomy, mainly due to the risk of peritoneal dissemination of undiagnosed uterine sarcomas. Unfortunately, there is no valid pre-operative diagnostic method that can differentiate sarcomas from myomas, and the currently available scientific literature regarding morcellation is insufficient. As the Turkish Society of Minimally Invasive Gynecological Oncology, we present our consensus opinion and suggestions for the preoperative evaluation and morcellation of fibroids, in line with the recent literature.
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Affiliation(s)
- Salih Taşkın
- Department of Gynecologic Oncology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Bulut Varlı
- Department of Obstetrics and Gynecology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - İbrahim Yalçın
- Department of Gynecologic Oncology, Ondokuz Mayıs University Faculty of Medicine, Samsun, Turkey
| | - Fırat Ortaç
- Department of Obstetrics and Gynecology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Çağatay Taşkıran
- Department of Gynecologic Oncology, Koç University Faculty of Medicine, İstanbul, Turkey
| | - Mete Güngör
- Department of Gynecologic Oncology, Acıbadem University Faculty of Medicine, İstanbul, Turkey
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The Risk of Uterine Malignancy in a Population Being Evaluated for Uterine Fibroid Embolization. J Comput Assist Tomogr 2020; 44:893-900. [PMID: 33196598 DOI: 10.1097/rct.0000000000001104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of the study was to determine the frequency of uterine malignancy in patients evaluated for uterine fibroid embolization (UFE) and the role of magnetic resonance imaging in triage. METHODS Records and imaging studies of 864 UFE consult patients were reviewed for MRI findings suggestive of fibroid malignancy. Pathology was obtained for cases with suspicious baseline MRI's, and the most atypical mass was reanalyzed by an experienced radiologist, blinded to the pathological findings. RESULTS Twenty one of 864 patients had baseline MRI findings concerning for malignancy at consultation and 17 had complete records. Re-evaluation suggested that 5 were malignant. Three were confirmed malignant (0.35%). One malignancy among the 843 without suspicious baseline MRI findings was missed at consultation. CONCLUSIONS In our UFE population, uterine malignancy is rare (4/864, 0.46%), and MRI detected the majority, 3 (75%) of 4 before UFE. The observed prevalence of any malignancy was 0.35%, congruent with current Federal Drug Administration estimates.
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13
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Pepin K, Cope A, Einarsson JI, Cellini J, Cohen SL. Safety of Minimally Invasive Tissue Extraction in Myoma Management: A Systematic Review. J Minim Invasive Gynecol 2020; 28:619-643. [PMID: 32977002 DOI: 10.1016/j.jmig.2020.09.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 08/28/2020] [Accepted: 09/08/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE This review seeks to establish the incidence of adverse outcomes associated with minimally invasive tissue extraction at the time of surgical procedures for myomas. DATA SOURCES Articles published in the following databases without date restrictions: PubMed, EMBASE, Web of Science, Cochrane Database of Systematic Reviews and Trials. Search was conducted on March 25, 2020. METHODS OF STUDY SELECTION Included studies evaluated minimally invasive surgical procedures for uterine myomas involving morcellation. This review did not consider studies of nonuterine tissue morcellation, studies involving uterine procedures other than hysterectomy or myomectomy, studies involving morcellation of known malignancies, nor studies concerning hysteroscopic myomectomy. A total of 695 studies were reviewed, with 185 studies included for analysis. TABULATION, INTEGRATION, AND RESULTS The following variables were extracted: patient demographics, study type, morcellation technique, and adverse outcome category. Adverse outcomes included prolonged operative time, morcellation time, blood loss, direct injury from a morcellator, dissemination of tissue (benign or malignant), and disruption of the pathologic specimen. CONCLUSION Complications related to morcellation are rare; however, there is a great need for higher quality studies to evaluate associated adverse outcomes.
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Affiliation(s)
- Kristen Pepin
- Department of Obstetrics & Gynecology, Weill Cornell Medical Center, New York, New York (Dr. Pepin).
| | - Adela Cope
- Department of Obstetrics & Gynecology, The Mayo Clinic, Rochester, Minnesota (Drs. Cope and Cohen)
| | - Jon I Einarsson
- Department of Obstetrics & Gynecology, Brigham and Women's Hospital (Dr. Einarsson)
| | - Jacqueline Cellini
- Department of Research & Instruction, Harvard TH Chan School of Public Health (Ms. Cellini), Boston, Massachusetts
| | - Sarah L Cohen
- Department of Obstetrics & Gynecology, The Mayo Clinic, Rochester, Minnesota (Drs. Cope and Cohen)
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Dewulf K, Weyns V, Lelie B, Qasim H, Meersschaert J, Devos B. Ectopic leiomyoma as a late complication of laparoscopic hysterectomy with power morcellation: a case report and review of the literature. Acta Chir Belg 2020; 120:344-348. [PMID: 30892129 DOI: 10.1080/00015458.2019.1586396] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Introduction: Electromechanical power morcellation is a widely used technique to extract uterine fibroids during laparoscopic hysterectomy. Although the complication rate of morcellators is low, ectopic leiomyoma can appear several years after their use.Patients and methods: We present a case of an ectopic leiomyoma and a literature review of power morcellation-induced complications and ectopic leiomyoma.Results: A 49-year-old female presented with epigastric pain 12 years after laparoscopic subtotal hysterectomy with morcellation of the specimen. Radiological examinations revealed an epigastric mass of 45 mm that was laparoscopically removed. Histological examination confirmed the diagnosis of an ectopic leiomyoma. Complications of power morcellation are rarely reported and include perioperative injuries to bowel, vascular and urinary tract, spreading of ectopic leiomyoma and occult malignancy.Conclusions: Ectopic leiomyoma are a late and rare complication of a laparoscopic hysterectomy with power morcellation of the uterus.
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Affiliation(s)
- Karel Dewulf
- Department of Surgery, AZ Zeno, Knokke-Heist, Belgium
| | - Valerie Weyns
- Department of Surgery, AZ Zeno, Knokke-Heist, Belgium
| | - Bart Lelie
- Department of Pathology, AZ Zeno, Knokke-Heist, Belgium
| | - Hussain Qasim
- Department of Radiology, AZ Zeno, Knokke-Heist, Belgium
| | | | - Bart Devos
- Department of Surgery, AZ Zeno, Knokke-Heist, Belgium
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15
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Mas A, Simón C. Molecular differential diagnosis of uterine leiomyomas and leiomyosarcomas. Biol Reprod 2020; 101:1115-1123. [PMID: 30184111 DOI: 10.1093/biolre/ioy195] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 08/13/2018] [Accepted: 08/30/2018] [Indexed: 12/18/2022] Open
Abstract
Uterine leiomyomas (LM) and leiomyosarcomas (LMS) are considered biologically unrelated tumors due to their cytogenetic and molecular disparity. Yet, these tumors share morphological and molecular characteristics that cannot be differentiated through current clinical diagnostic tests, and thus cannot be definitively classified as benign or malignant until surgery. Newer approaches are needed for the identification of these tumors, as has been done for other tissues. The application of next generation sequencing enables the detection of new mutations that, when coupled to machine learning bioinformatic tools, advances our understanding of chromosomal instability. These approaches in the context of LM and LMS could allow the discovery of genetic variants and possible genomic markers. Additionally, the potential clinical utility of circulating cell-free tumor DNA could revolutionize the noninvasive detection and monitoring of these tumors. Here, we seek to provide a perspective on the molecular background of LM and LMS, recognizing their distinct molecular features that may lead to improved diagnosis and personalized treatments, which would have a measurable impact on women's reproductive health.
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Affiliation(s)
- Aymara Mas
- Reproductive Medicine Research Group, La Fe Health Research Institute, Valencia, Spain.,Igenomix Foundation/Instituto de Investigación Sanitaria Hospital Clínico (INCLIVA), Valencia, Spain
| | - Carlos Simón
- Igenomix Foundation/Instituto de Investigación Sanitaria Hospital Clínico (INCLIVA), Valencia, Spain.,Department of Pediatrics, Obstetrics and Gynecology, University of Valencia, Valencia, Spain
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Suchetha S, Sivaranjith J, Rema P, Thomas S. Prognostic Implication of Primary Treatment of Uterine Low-grade Endometrial Stromal Sarcoma: a Case Series. Indian J Surg Oncol 2020; 11:131-133. [DOI: 10.1007/s13193-020-01100-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 05/07/2020] [Indexed: 11/29/2022] Open
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Abstract
PURPOSE OF REVIEW This paper aims to review recent findings related to uterine morcellation. RECENT FINDINGS In 2014, the US Food and Drug Administration (FDA) issued a safety communication warning against the use of laparoscopic power morcellators. A risk of occult uterine sarcoma in women is 1/770 to 1/10,000. Our goal is to minimize the risk of spillage due to morcellation and balance it with other risks due to different surgical approaches. In case of a presence of sarcoma risk factors, any form of morcellation should be contraindicated. Power morcellation should be limited to myomectomies. In peri- and postmenopausal age, an endometrial biopsy is highly recommended before surgery with expected morcellation. It is important to explain to the patient the risks of morcellation and the risks and benefits of different surgical approaches. Finally, women should be informed that the prognosis of leiomyosarcoma is poor regardless of the method of removal.
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Affiliation(s)
- Michael J Halaska
- Department of Obstetrics and Gynaecology, Faculty Hospital Kralovske Vinohrady and 3rd Medical Faculty, Charles University in Prague, Šrobárova 1150/50, Praha 10, 100 34, Prague, Czech Republic.
| | - Myriam Gracia
- Gynaecologic Oncology Unit, La Paz University Hospital - IdiPAZ, Madrid, Spain
| | - Rene Laky
- Division of Gynaecology, Medical University of Graz, Graz, Austria
| | - Ignacio Zapardiel
- Gynaecologic Oncology Unit, La Paz University Hospital - IdiPAZ, Madrid, Spain
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18
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Shi X, Shi L, Zhang S. A comparative study on the short-term clinical efficacy of the modified laparoscopic uterine comminution technique and traditional methods. Mol Clin Oncol 2020; 12:237-243. [PMID: 32064100 PMCID: PMC7016613 DOI: 10.3892/mco.2020.1982] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Accepted: 12/13/2019] [Indexed: 11/06/2022] Open
Abstract
To assess the value of the modified laparoscopic uterine comminution technique in laparoscopic uterine surgery, a total of 82 cases of laparoscopic myomectomy were divided into the traditional group and modified group, according to a random number table. During the same period, 92 patients who underwent laparoscopic hysterectomy were divided into the conventional group and the modified group, according to a random number table. The patients in the conventional group and modified group who underwent laparoscopic uterine fibroid removal showed no significant differences in the operation time, blood loss or average hospitalization (P>0.05). There was no significant difference in the operative time or average length of hospital stay between patients in the conventional group and modified group who underwent laparoscopic hysterectomy (P>0.05). In laparoscopic myomectomy, the fibroid specimens were placed in a self-made specimen bag for modified uterine comminution. In laparoscopic hysterectomy, the whole uterus specimen was placed in a self-made specimen bag and viewed from the vagina. The improved comminution technique is simple and feasible, does not increase the operation time or length of hospitalization, and has value for clinical use.
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Affiliation(s)
- Xiaojun Shi
- Department of Gynecology, The First Affiliated Hospital of Jiaxing University, Jiaxing, Zhejiang 314001, P.R. China
| | - Libing Shi
- Assisted Reproduction Unit, Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, P.R. China
| | - Songying Zhang
- Assisted Reproduction Unit, Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, P.R. China
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van Zanten F, Schraffordt Koops SE, Pasker-De Jong PC, Lenters E, Schreuder HW. Learning curve of robot-assisted laparoscopic sacrocolpo(recto)pexy: a cumulative sum analysis. Am J Obstet Gynecol 2019; 221:483.e1-483.e11. [PMID: 31152711 DOI: 10.1016/j.ajog.2019.05.037] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 05/15/2019] [Accepted: 05/23/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Determination of the learning curve of new techniques is essential to improve safety and efficiency. Limited information is available regarding learning curves in robot-assisted laparoscopic pelvic floor surgery. OBJECTIVE The purpose of this study was to assess the learning curve in robot-assisted laparoscopic pelvic floor surgery. STUDY DESIGN We conducted a prospective cohort study. Consecutive patients who underwent robot-assisted laparoscopic sacrocolpopexy or sacrocolporectopexy were included (n=372). Patients were treated in a teaching hospital with a tertiary referral function for gynecologic/multicompartment prolapse. Procedures were performed by 2 experienced conventional laparoscopic surgeons (surgeons A and B). Baseline demographics were scored per groups of 25 consecutive patients. The primary outcome was the determination of proficiency, which was based on intraoperative complications. Cumulative sum control chart analysis allowed us to detect small shifts in a surgeon's performance. Proficiency was obtained when the first acceptable boundary line of cumulative sum control chart analysis was crossed. Secondary outcomes that were examined were shortening and/or stabilization of surgery time (measured with the use of cumulative sum control chart analysis and the moving average method). RESULTS Surgeon A performed 242 surgeries; surgeon B performed 137 surgeries (n=7 surgeries were performed by both surgeons). Intraoperative complications occurred in 1.9% of the procedures. The learning curve never fell below the unacceptable failure limits and stabilized after 23 of 41 cases. Proficiency was obtained after 78 cases for both surgeons. Surgery time decreased after 24-29 cases in robot-assisted sacrocolpopexy (no distinct pattern for robot-assisted sacrocolporectopexy). Limitations were the inclusion of 2 interventions and concomitant procedures, which limited homogeneity. Furthermore, analyses treated all complications in cumulative sum as equal weight, although there are differences in the clinical relevance of complications. CONCLUSION After 78 cases, proficiency was obtained. After 24-29 cases, surgery time stabilized for robot-assisted sacrocolpopexy. In this age of rapidly changing surgical techniques, it can be difficult to determine the learning curve of each procedure. Cumulative sum control chart analysis can assist with this determination and prove to be a valuable tool. Training programs could be individualized to improve both surgical performance and patient benefits.
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Leiomyosarcoma after Total Laparoscopic Hysterectomy with Power Morcellation. Case Rep Obstet Gynecol 2019; 2019:9381230. [PMID: 31662931 PMCID: PMC6791255 DOI: 10.1155/2019/9381230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 07/15/2019] [Indexed: 11/17/2022] Open
Abstract
Introduction Power morcellation is an effective and minimally invasive technique used to remove specimen tissues or the uterus in total laparoscopic hysterectomy (TLH). However, it has the risk of intraperitoneal dissemination of tissue and can cause a parasitic myoma. We report a case of leiomyosarcoma that occurred 4 years after TLH with power morcellation for fibroids. Case A 52-year-old woman was referred to our hospital with a pelvic mass. She was diagnosed to have submucosal fibroids and had undergone TLH with power morcellation 4 years previously. The uterus weighed 398 g at that time. At present, a parasitic myoma was suspected, owing to the diagnosis of fibroids on the initial pathological evaluation. She underwent laparotomy, and the tumor was removed. Although the pathological evaluation confirmed the tumor to be a leiomyosarcoma, a review of the initial tissue did not show the presence of any malignancy. Since there was no metastasis, she was followed-up without additional treatment. Conclusion Even if the initial pathologic evaluation suggests a benign mass, parasitic myoma and even sarcoma can occur after TLH with power morcellation. Considering the risk of dissemination and occult malignancy, the use of power morcellation should be avoided if there are alternative options to remove the tumor.
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21
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Cao H, Li L, Yang B, Luo G, Lou J, Xi M. Unexpected uterine sarcomas after hysterectomy and myomectomy for presumed leiomyoma: a retrospective study of 26,643 patients. Cancer Manag Res 2019; 11:7007-7014. [PMID: 31440089 PMCID: PMC6664248 DOI: 10.2147/cmar.s208405] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 06/21/2019] [Indexed: 11/23/2022] Open
Abstract
Objectives We conducted this study to explore the clinical characteristics, prognosis, and prevalence of unexpected uterine sarcoma (UUS) after hysterectomy and myomectomy for presumed leiomyoma. Study design The records of women who underwent hysterectomy or myomectomy through laparoscopy or laparotomy for preoperatively presumed uterine leiomyomas from January 2009 to December 2016 were reviewed and data were retrospectively analyzed. Results Eleven patients had morcellation of uterine sarcoma. Eighty-eight patients were diagnosed with uterine sarcomas (total prevalence: 0.33%) including 29 leiomyosarcomas (LMS), 48 endometrial stromal sarcomas (ESS), and 11 adenosarcomas. ESS patients with advanced stage were significantly associated with worse overall survival (p<0.01). Conclusion Only 0.33% of patients who underwent surgery for presumed leiomyoma experienced UUS, and advanced stage seemed to be the single prognostic factor for sarcoma. However, the time interval between initial treatment and secondary definitive surgery was not shown to impact prognosis. In addition, the small number of UUS patients having morcellation (4 LMS and 7 ESS) may be underpowered to detect differences in survival.
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Affiliation(s)
- Hanyu Cao
- Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, Chengdu City, Sichuan Province, People's Republic of China
| | - Lin Li
- Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, Chengdu City, Sichuan Province, People's Republic of China
| | - Bowen Yang
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, West China Second Hospital, Sichuan University, Chengdu City, Sichuan Province, People's Republic of China
| | - Gupo Luo
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, West China Second Hospital, Sichuan University, Chengdu City, Sichuan Province, People's Republic of China
| | - Jiangyan Lou
- Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, Chengdu City, Sichuan Province, People's Republic of China
| | - Mingrong Xi
- Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, Chengdu City, Sichuan Province, People's Republic of China
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Yoo Jung L, Lee YH, Chung DH, Shin JW. A case of acute abdominal pain caused by infarcted parasitic leiomyoma. J OBSTET GYNAECOL 2019; 40:143-144. [PMID: 31303087 DOI: 10.1080/01443615.2019.1590805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Lee Yoo Jung
- Department of Obstetrics and Gynecology, Gil Medical Center, College of Medicine, Gachon University, Incheon, South Korea
| | - Yae Heun Lee
- Department of Obstetrics and Gynecology, Gil Medical Center, College of Medicine, Gachon University, Incheon, South Korea
| | - Dong Hae Chung
- Department of Pathology, Gil Medical Center, College of Medicine, Gachon University, Incheon, South Korea
| | - Jin Woo Shin
- Department of Obstetrics and Gynecology, Gil Medical Center, College of Medicine, Gachon University, Incheon, South Korea
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Torrent-Colomer A, Reyes Claret A, Vicens-Vidal M, Martin Jiménez A. Parasitic Myomas and Leiomyomatosis Peritonealis Disseminata After Laparoscopic Surgery with Power Morcellation: A Report of Four Cases. J Gynecol Surg 2019. [DOI: 10.1089/gyn.2016.0090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Anna Torrent-Colomer
- Department of Gynecology, Son Llàtzer Hospital, Palma de Mallorca, Balearic Islands, Spain
| | - Albert Reyes Claret
- Department of Gynecology, Son Llàtzer Hospital, Palma de Mallorca, Balearic Islands, Spain
| | - Margalida Vicens-Vidal
- Department of Gynecology, Son Llàtzer Hospital, Palma de Mallorca, Balearic Islands, Spain
| | - Angel Martin Jiménez
- Department of Gynecology, Son Llàtzer Hospital, Palma de Mallorca, Balearic Islands, Spain
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24
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Occult Leiomyosarcomas in a Canadian Province: A Retrospective Cohort Study. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 41:46-51. [PMID: 30341020 DOI: 10.1016/j.jogc.2018.02.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 02/01/2018] [Accepted: 02/01/2018] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The risk of unexpected uterine leiomyosarcoma (LMS) following surgery for presumed benign leiomyoma is quoted to be between 1 in 498 and 1 in 5000. The objectives of the present study were to determine the prevalence of uterine LMS in a specific patient population and the rate of diagnosis of occult uterine LMS and to evaluate the risk of unintended morcellation of LMS in Saskatchewan. METHODS This study was a Canadian Task Force Classification II-2 multicentre retrospective cohort study in academic-affiliated tertiary care centres. All women with the histopathologic diagnosis of uterine LMS in Saskatchewan between January 2000 and December 2014 were included. Women with metastatic LMS at diagnosis or other types of uterine sarcomas were excluded. Data including patients' characteristics, clinical presentation, physical examination findings, imaging, pathology reports, surgical interventions, and survival outcomes were reviewed. RESULTS A total of 28 patients had a confirmed histopathologic diagnosis of LMS over the 15-year study period. Approximately 26 212 hysterectomies were performed in Saskatchewan over the same time frame. The prevalence of uterine LMS in this patient population over the study time frame is estimated to be one in 853. Mean age at diagnosis was 53.8 ± 10.0. Medical records of 25 patients could be retrieved, and 15 cases (60%) had an occult diagnosis. There were five cases of unintended morcellation (one power, four mechanical). Survival outcomes were comparable in women with unintended morcellation of occult disease and in those without morcellation. CONCLUSION This study contributes to the existing body of literature on morcellation of occult LMS, and it ascertains the rate of LMS in a patient population. The results of this study provide valuable information to health care professionals, policy makers, and women in Saskatchewan so that they may make more informed decisions concerning uterine masses.
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Chang Y, Kay N, Huang MR, Huang SJ, Tsai EM. Laparoendoscopic Single-Site Supracervical Hysterectomy with Manual Morcellation: A Retrospective Study. J Minim Invasive Gynecol 2018; 25:1094-1100. [DOI: 10.1016/j.jmig.2018.02.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 01/27/2018] [Accepted: 02/02/2018] [Indexed: 10/17/2022]
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Tantitamit T, Huang KG, Manopunya M, Yen CF. Outcome and Management of Uterine Leiomyosarcoma Treated Following Surgery for Presumed Benign Disease: Review of Literature. Gynecol Minim Invasive Ther 2018; 7:47-55. [PMID: 30254937 PMCID: PMC6113990 DOI: 10.4103/gmit.gmit_10_18] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Uterine leiomyosarcoma (uLMS) is a rare and aggressive cancer, usually diagnosed incidentally at the time of myomectomy or hysterectomy. There have been concerns for several years about the fact that the inadvertent disruption of occult uLMS may have a negative impact on patient outcome. This study reviews the outcome and management of patients with a diagnosis of uLMS after surgery for presumed benign disease. We conducted a literature search in which 47 published English-language articles were obtained for evaluation. A total of 23 studies with outcomes data were included. It is evidenced that patients who underwent surgery with tumor disruption resulted in poorer outcomes compared with en bloc tumor, especially by power morcellation. The power morcellation was associated with an increased risk of recurrence, shorten time to recurrence, and upstage after re-exploration. Early re-exploration and surgical staging are appreciated for better prognosis and may alter postoperative treatment. We also updated on the incidence and preoperative evaluation to assess the risk of patient and give an effective counseling.
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Affiliation(s)
- Tanitra Tantitamit
- Department of Obstetrics and Gynecology, Faculty of Medicine, Srinakharinwirot University, Nakhonnayok, Thailand
| | - Kuan-Gen Huang
- Department of Obstetrics and Gynecology, Linkou Chang Gung Memorial Hospital, Tao-Yuan, Taiwan.,Department of Obstetrics and Gynecology, Chang Gung University College of Medicine, Tao-Yuan, Taiwan
| | - Manatsawee Manopunya
- Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Chih-Feng Yen
- Department of Obstetrics and Gynecology, Linkou Chang Gung Memorial Hospital, Tao-Yuan, Taiwan.,Department of Obstetrics and Gynecology, Chang Gung University College of Medicine, Tao-Yuan, Taiwan
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28
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DiNapoli MN, Truong MD, Halfon JK, Burke WM. Unsuspected Uterine Sarcoma in an Urban Hospital: Does Surgical Approach Matter? J Minim Invasive Gynecol 2018; 25:491-497. [DOI: 10.1016/j.jmig.2017.10.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 10/08/2017] [Accepted: 10/09/2017] [Indexed: 11/16/2022]
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29
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Wong AWY, Tsaltas J, Manley TR, Ratner RT, Yim CCM, Barel O. Unsuspected uterine sarcomas undergoing morcellation: A retrospective multicenter study. JOURNAL OF ENDOMETRIOSIS AND PELVIC PAIN DISORDERS 2018. [DOI: 10.1177/2284026517748554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Objective: To evaluate the prevalence of unsuspected uterine sarcomas undergoing morcellation at the time of hysterectomy or myomectomy. Design: A retrospective cohort study. Settings: A teaching health service in Melbourne, Australia, consisting of four hospitals which provide gynecology and gynecology oncology services including one tertiary referral center. Population: All women undergoing any form of hysterectomy or myomectomy from 1998 to 2016. Methods: Patient demographics and the presence of morcellation were collected. All cases of confirmed uterine sarcomas were further examined and their histological subtype, patient demographics, preoperative investigations, and surgical indication were also identified. Results: A total of 7584 cases were studied. Overall, 33 uterine sarcomas were identified. Of these, seven cases were unsuspected malignancies. All seven cases were leiomyosarcomas. None of the malignant specimens underwent morcellation. The overall prevalence of uterine sarcomas in the total study population was 0.44%. The rate of unsuspected uterine sarcomas in women undergoing hysterectomy or myomectomy for presumed benign indications was 0.13% or 1 in 769. The rate of unintended morcellation of a uterine sarcoma in our center was 0%. The diagnosis of endometrial sarcoma was prompted by endometrial sampling in 58% of the cases when performed. Conclusion: The risk of inadvertent morcellation of unsuspected uterine sarcomas is low. Patients should be appropriately selected with adequate investigations and a detailed history and examination prior to surgery. Further studies are needed to identify effective preoperative screening methods for uterine sarcomas.
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Affiliation(s)
- Avelyn WY Wong
- Women’s and Children’s Program, Monash Health, Clayton, VIC, Australia
- Department of Obstetrics and Gynecology, Mercy Health, Heidelberg, VIC, Australia
| | - Jim Tsaltas
- Women’s and Children’s Program, Monash Health, Clayton, VIC, Australia
- Melbourne IVF, East Melbourne, VIC, Australia
| | - Tom R Manley
- Women’s and Children’s Program, Monash Health, Clayton, VIC, Australia
- Melbourne IVF, East Melbourne, VIC, Australia
| | - Roni T Ratner
- Women’s and Children’s Program, Monash Health, Clayton, VIC, Australia
| | - Cheryl CM Yim
- Women’s and Children’s Program, Monash Health, Clayton, VIC, Australia
| | - Oshri Barel
- Women’s and Children’s Program, Monash Health, Clayton, VIC, Australia
- Gynaecological Endoscopy Unit, Monash Health, Bentleigh East, VIC, Australia
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30
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Shim J, Kenton K, Abernethy MG. Pathology of Power Morcellation: A 12-Year Retrospective Analysis. J Gynecol Surg 2018. [DOI: 10.1089/gyn.2017.0117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Jessica Shim
- Department of Obstetrics and Gynecology, Northwestern Feinberg School of Medicine, Chicago, IL
| | - Kimberly Kenton
- Female Pelvic Medicine and Reconstructive Surgery, Northwestern Feinberg School of Medicine, Chicago, IL
| | - Melinda G. Abernethy
- Female Pelvic Medicine and Reconstructive Surgery, Northwestern Feinberg School of Medicine, Chicago, IL
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Undiagnosed Uterine Sarcomas Identified During Surgery for Presumed Leiomyoma at a National Tertiary Hospital in Thailand: A 10-Year Review. Int J Gynecol Cancer 2018; 27:973-978. [PMID: 28498251 DOI: 10.1097/igc.0000000000000968] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES The aim of this study was to evaluate the rate, clinical characteristics, and survival outcomes of an undiagnosed uterine malignancy in patients who underwent surgical treatment for presumed leiomyomas. METHODS Medical records of patients who underwent surgical treatment for presumed leiomyomas, from January 2004 to September 2013, were retrospectively reviewed, and the data were followed until September 2016. Demographic data, tumor characteristics, oncologic treatment, and response rate were analyzed by descriptive statistics. Kaplan-Meier method was used for survival analysis. This study includes follow-up data through December 31, 2016. RESULTS A total of 11,258 medical records of presumed leiomyoma patients undergoing hysterectomy during the studied period were reviewed. Pathology of uterine sarcoma was found in 22 patients (0.2%), all of whom were included. Nineteen patients had leiomyosarcoma, and 3 had endometrial stromal sarcoma. Mean age of patients was 48.3 ± 6.9 years. All patients underwent total abdominal hysterectomy, with 20 patients undergoing concurrent bilateral salpingo-oophorectomy. Uterine sarcoma was classified as stage IB in 21 patients and stage IIIC in 1 patient. Fifteen patients were prescribed the following adjuvant treatment: chemotherapy in 13 patients and megestrol acetate in 2 patients. Thirteen patients had recurrent disease, and 3 patients died of their disease. The mean progression-free survival was 50.1 ± 41.3 months, and overall survival was 59.3 ± 43.0 months. CONCLUSIONS One in 512 patients who underwent hysterectomy because of presumed uterine leiomyomas had inadvertent uterine sarcomas. Even with adjuvant therapy, treatment outcome was rather poor, with almost 60% recurrence rate and median progression-free survival and overall survival of less than 5 years.
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In-Bag Morcellation as a Routine for Laparoscopic Hysterectomy. BIOMED RESEARCH INTERNATIONAL 2017; 2017:6701916. [PMID: 29318153 PMCID: PMC5727682 DOI: 10.1155/2017/6701916] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 08/08/2017] [Indexed: 02/06/2023]
Abstract
Tissue morcellation during laparoscopic hysterectomy carries the risk of spreading cells from unsuspected malignancy. Contained morcellation inside a bag is supposed to minimize this risk. The present study evaluated routine use of in-bag morcellation during laparoscopic hysterectomy in a consecutive patient cohort (n = 49). The system used was More-Cell-Safe (A.M.I. Austria). Median age was 47 (35 to 76) years and BMI 25.1 (18.8 to 39.8). Indications for hysterectomy were fibroids (71.4%), adenomyosis (16.3%), prolapse (8.2%), and bleeding disorders (4.1%). 48 (98%) patients underwent supracervical hysterectomy and 1 (2%) underwent total hysterectomy. No unsuspected malignancy occurred. Median weight of extirpated tissue was 195 g (18 to 1110). Residual tissue and/or fluid in the bag amounted to 29 g (0 to 291). Median overall duration of surgeries was 100.5 min, and median time associated with the use of the bag was 10 min (5 to 28), significantly correlated with uterine volume (p = 0.0094) and specimen weight (p = 0.0002), but not with patient's BMI (p = 0.6970). Technical success rate for contained morcellation was 93.9%. Peritoneal washings after contained morcellation were all negative for malignant or smooth muscle cells.
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Wong M, De Wilde RL, Isaacson K. Reducing the spread of occult uterine sarcoma at the time of minimally invasive gynecologic surgery. Arch Gynecol Obstet 2017; 297:285-293. [PMID: 29128980 DOI: 10.1007/s00404-017-4575-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 10/19/2017] [Indexed: 12/18/2022]
Abstract
PURPOSE This review covers the most recent evidence to discuss the incidence of occult uterine sarcoma, whether morcellation increases tumor dissemination or mortality, and whether there is a difference between different types of morcellation. We will also discuss techniques to reduce the spread of an undiagnosed uterine sarcoma. METHOD A comprehensive literature search was made in Pubmed, Medline, the Cochrane Library, and Google Scholar for articles related to the incidence of occult uterine sarcoma after morcellation. RESULTS Fibroids are benign uterine tumors and are a common indication for gynecologic surgery. Increasingly, gynecologists are approaching these surgeries with minimally invasive techniques. Uterine sarcomas are rare malignant mesenchymal tumors that are difficult to distinguish preoperatively from uterine fibroids. CONCLUSION During a minimally invasive surgery, there is a risk of disseminating an occult sarcoma during tissue extraction. Minimally invasive gynecologists are tasked with balancing taking a minimally invasive approach, which is shown to result in better patient outcomes, with minimizing the risk of spreading an occult sarcoma.
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Affiliation(s)
- Marron Wong
- Newton-Wellesley Hospital, Center for Minimally Invasive Gynecologic Surgery, Harvard Medical School, Newton, MA, USA
| | - Rudy Leon De Wilde
- Department of Gynecology, Obstetrics and Gynecological Oncology at Pius Hospital, University Hospital for Gynecology-Carl von Ossietzky University, Oldenburg, Germany.
| | - Keith Isaacson
- Newton-Wellesley Hospital, Center for Minimally Invasive Gynecologic Surgery, Harvard Medical School, Newton, MA, USA
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Gerges B, Mongelli M, Casikar I, Bignardi T, Condous G. Three-dimensional transvaginal sonographic assessment of uterine volume as preoperative predictor of need to morcellate in women undergoing laparoscopic hysterectomy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 50:255-260. [PMID: 27281513 DOI: 10.1002/uog.15991] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 06/01/2016] [Accepted: 06/03/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE In light of recent statements from the United States Food and Drug Administration warning against the use of power morcellation of uterine leiomyomas during laparoscopy, we sought to evaluate the use of preoperative two- (2D) and three- (3D) dimensional transvaginal ultrasound (US) assessment of uterine volume to predict the need for morcellation in women undergoing laparoscopic hysterectomy (LH). METHODS This was a prospective observational study performed between October 2008 and November 2011 in a tertiary referral laparoscopic unit. All women scheduled to undergo LH were included and underwent detailed preoperative transvaginal US. Uterine volumes were calculated using 2D-US measurements (ellipsoid formula), and using Virtual Organ Computer-aided AnaLysis (VOCAL™) having acquired 3D-US volumes of the uterus. Age, parity, need to morcellate and final uterine dry weight at histology were recorded. The estimated uterine volumes were then incorporated into a previously published logistic regression model to predict the need to morcellate for both nulliparous and parous women. The probability threshold cut-off of 0.14 (95% sensitivity) was evaluated in terms of sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and likelihood ratios (LRs). The performance of the models incorporating 2D- and 3D-US calculations were compared with 2D- and 3D-US-generated volumes alone, using receiver-operating characteristics (ROC) curves. RESULTS Of 76 women who underwent LH during the study period, 79% (n = 60) had complete background and 3D-US data. Their mean age was 43.7 years, 91.7% were parous and 35% underwent morcellation. The greatest uterine volume that did not require morcellation was 404 mL estimated using 3D-US, which corresponded to a uterine volume of 688.8 mL using 2D-US. The smallest uterine volume that required morcellation was 118.9 mL using 3D-US, which corresponded to a uterine volume of 123.4 mL using 2D-US. The 3D-US uterine volume for parous women with a sensitivity of 95% based on ROC-curve analysis was approximately 120 mL, which equated to a predicted probability of morcellation cut-off of 0.14. For this cut-off, specificity was 55.00%, PPV was 51.35%, NPV was 95.65%, LR+ was 2.11 and LR- was 0.09. Areas under the ROC curves for the morcellation logistic regression model were 0.769 (95% CI, 0.653-0.886) and 0.586 (95% CI, 0.419-0.753) using uterine volumes obtained by 3D-US and by 2D-US, respectively, and they were 0.938 (95% CI, 0.879-0.996) and 0.815 (95% CI, 0.681-0.948) using 3D-US and 2D-US volumes alone. CONCLUSIONS The need to morcellate can be predicted preoperatively using 3D-US uterine volumes obtained by transvaginal US with a fair degree of accuracy. Uteri with volumes smaller than 120 mL at 3D-US are very unlikely to require morcellation. The incorporation of 3D-US-estimated uterine volume into the previously published logistic regression model does not seem to confer any significant improvement when compared with 3D-US uterine volume alone to predict the need to morcellate in women undergoing total LH. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- B Gerges
- Acute Gynaecology, Early Pregnancy and Advanced Endosurgery, Sydney Medical School Nepean, University of Sydney, Nepean Hospital, Penrith, NSW, Australia
| | - M Mongelli
- Nepean Medical School, Nepean Hospital, University of Sydney, Nepean Hospital, Kingswood, NSW, Australia
| | - I Casikar
- Acute Gynaecology, Early Pregnancy and Advanced Endosurgery, Sydney Medical School Nepean, University of Sydney, Nepean Hospital, Penrith, NSW, Australia
| | - T Bignardi
- Department of Obstetrics and Gynecology, A.O. Niguarda Ca' Granda, Milan, Italy
| | - G Condous
- Acute Gynaecology, Early Pregnancy and Advanced Endosurgery, Sydney Medical School Nepean, University of Sydney, Nepean Hospital, Penrith, NSW, Australia
- OMNI Gynaecological Care Centre for Women's Ultrasound and Early Pregnancy, St Leonards, NSW, Australia
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Sarcoma Risk in Uterine Surgery in a Tertiary University Hospital in Germany. Int J Gynecol Cancer 2017; 27:961-966. [DOI: 10.1097/igc.0000000000000988] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Cohen A, Tulandi T. Long-term sequelae of unconfined morcellation during laparoscopic gynecological surgery. Maturitas 2017; 97:1-5. [DOI: 10.1016/j.maturitas.2016.11.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Revised: 11/13/2016] [Accepted: 11/14/2016] [Indexed: 12/12/2022]
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Siedhoff MT, Doll KM, Clarke-Pearson DL, Rutstein SE. Laparoscopic hysterectomy with morcellation vs abdominal hysterectomy for presumed fibroids: an updated decision analysis following the 2014 Food and Drug Administration safety communications. Am J Obstet Gynecol 2017; 216:259.e1-259.e6. [PMID: 27890646 DOI: 10.1016/j.ajog.2016.11.1039] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 11/15/2016] [Accepted: 11/17/2016] [Indexed: 01/07/2023]
Abstract
Previous decision analyses demonstrate the safety of minimally invasive hysterectomy for presumed benign fibroids, accounting for the risk of occult leiomyosarcoma and the differential mortality risk associated with laparotomy. Studies published since the 2014 Food and Drug Administration safety communications offer updated leiomyosarcoma incidence estimates. Incorporating these studies suggests that mortality rates are low following hysterectomy for presumed benign fibroids overall, and a minimally invasive approach remains a safe option. Risk associated with morcellation, however, increases in women age >50 years due to increased leiomyosarcoma rates, an important finding for patient-centered discussions of treatment options for fibroids.
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Affiliation(s)
- Matthew T Siedhoff
- Center for Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA.
| | - Kemi M Doll
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Washington, Seattle, WA
| | - Daniel L Clarke-Pearson
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC
| | - Sarah E Rutstein
- Department of Health Policy and Management, School of Medicine, University of North Carolina, Chapel Hill, NC
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Is Laparoscopic Power Morcellation of Fibroids a Cardinal Sin in 2017? J Obstet Gynaecol India 2017; 67:1-6. [PMID: 28242959 DOI: 10.1007/s13224-017-0970-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 01/17/2017] [Indexed: 12/21/2022] Open
Abstract
The diagnosis of an unsuspected leiomyosarcoma after hysterectomy for the treatment of a presumed benign leiomyoma is a rare but highly clinically significant event. In order to facilitate removal of large uterine specimens using a minimally invasive surgical approach, morcellation with extraction in pieces is often performed. In the event of unsuspected malignancy, this may result in abdominal dispersion of the tumor and contribute to poorer survival. Modern surgical innovations always work toward improving minimally invasive strategies. Laparoscopy, rooted in practices for years, supplanted laparotomy for many indications. For extraction of large uteri, morcellation is currently the only way to externalize surgical specimens (myomas, uteri), without increasing the skin opening while allowing to reduce postoperative complications when compared to laparotomy. However, in 2014, the Food and Drug Administration warned against the use of uterine morcellation because of an oncological risk. Some practicing academicians have challenged this recommendation. The incidence of uterine sarcomas is still poorly identified and preoperative diagnostic facilities remain inadequate. The small number of retrospective studies currently available do not reinforce any recommendation. The evaluation of morcellation devices and the improvement of preoperative diagnostic modalities (Imaging, preoperative Biopsy) are being improvised continually so as to minimize the oncological risks. Even during conventional myomectomy, tissue spillage occurs during resection of leiomyoma(s). Adverse oncologic outcomes of tissue morcellation should be mitigated through improved patient selection, preoperative investigations, and novel techniques that minimize tissue dispersion. Preoperative endometrial biopsy and cervical assessment to avoid morcellation of potentially detectable malignant and premalignant conditions is recommended.
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Pavlakis K, Messini I, Yiannou P, Gavresea T, Chrysanthakis D, Hilaris G, Panoskaltsis T. Morcellating uterine mesenchymal tumors: The pathologist's view. J Obstet Gynaecol Res 2017; 43:580-586. [DOI: 10.1111/jog.13240] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 10/21/2016] [Indexed: 01/16/2023]
Affiliation(s)
- Kitty Pavlakis
- Pathology Department; IASO Women's Hospital; Maroussi Greece
- Pathology Department; National and Kapodistrian University of Athens; Athens, Greece
| | - Irini Messini
- Pathology Department; IASO Women's Hospital; Maroussi Greece
| | - Petros Yiannou
- Pathology Department; IASO Women's Hospital; Maroussi Greece
| | | | | | - Georgios Hilaris
- IASO Women's Hospital Athens Greece and Stanford University Hospital; Stanford California USA
- Stanford University Hospital; Stanford California USA
| | - Theodoros Panoskaltsis
- 2nd Department of Obstetrics and Gynecology; Medical School National and Kapodistrian University of Athens; Athens, Greece
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Surgical treatment: Myomectomy and hysterectomy; Endoscopy: A major advancement. Best Pract Res Clin Obstet Gynaecol 2016; 34:104-21. [DOI: 10.1016/j.bpobgyn.2015.11.021] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 11/26/2015] [Indexed: 12/12/2022]
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Skorstad M, Kent A, Lieng M. Uterine leiomyosarcoma - incidence, treatment, and the impact of morcellation. A nationwide cohort study. Acta Obstet Gynecol Scand 2016; 95:984-90. [DOI: 10.1111/aogs.12930] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 05/21/2016] [Indexed: 12/15/2022]
Affiliation(s)
- Mette Skorstad
- Department of Obstetrics and Gynecology; Vestfold Hospital; Tonsberg Norway
| | - Andrew Kent
- Department of Gynecology; Royal Surrey Hospital; Guildford UK
| | - Marit Lieng
- Department of Gynecology; Oslo University Hospital; Oslo Norway
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
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Lu B, Xu J, Pan Z. Iatrogenic parasitic leiomyoma and leiomyomatosis peritonealis disseminata following uterine morcellation. J Obstet Gynaecol Res 2016; 42:990-9. [PMID: 27125448 DOI: 10.1111/jog.13011] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2015] [Revised: 01/31/2016] [Accepted: 02/26/2016] [Indexed: 12/16/2022]
Abstract
AIM To assess the impact of morcellation on the spread of uterine leiomyoma. METHODS Cases of parasitic leiomyoma involving prior laparoscopy were collected between 2012 and 2015 in a tertiary women's hospital in China. Their clinicopathological features and the associated reports were reviewed. RESULTS All six patients with parasitic leiomyoma had laparoscopic myomectomy or hysterectomy with power morcellation 39-132 months previously. Patient 1 had widely disseminated tumors in the peritoneum and pelvis, in keeping with leiomyomatosis peritonealis disseminata (LPD). She received debulking of peritoneal tumors and lived with disease for 22 months. The implanting sites of the other parasitic tumors (patients 2-6) included the mesentery (n = 2), intestine (n = 1), pelvic parietal (n = 1), bladder (n = 1), and musculus rectus abdominis (n = 1). The diameter varied from 1 cm to 6 cm. The patients underwent abdominal subtotal hysterectomy, cervicectomy or tumor debulking and the postoperative course was unremarkable for a period of 2-32 months. Pathologically, these disseminated or parasitic leiomyomas did not show any evidence of malignancy. There were no morphological or immunohistochemical differences between the original tumor and the following seeding tumors. On literature review, 11 iatrogenic LPD have been reported after laparoscopic surgery for uterine leiomyoma. These cases may provide an alternative pathogenic mechanism for a distinct variant of LPD. CONCLUSIONS Laparoscopic hysterectomy with tumor morcellation may increase the chance of tumor implantation and dissemination. Both clinicians and pathologists should be alert to this rare complication.
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Affiliation(s)
- Bingjian Lu
- Department of Surgical Pathology, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Jing Xu
- Department of Surgical Pathology, Sir Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Zimin Pan
- Gynecologic Oncology, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
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Complication rate of uterine morcellation in laparoscopic supracervical hysterectomy: a retrospective cohort study. Eur J Obstet Gynecol Reprod Biol 2016; 199:179-82. [DOI: 10.1016/j.ejogrb.2016.02.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 02/07/2016] [Accepted: 02/11/2016] [Indexed: 11/21/2022]
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Tulandi T, Leung A, Jan N. Nonmalignant Sequelae of Unconfined Morcellation at Laparoscopic Hysterectomy or Myomectomy. J Minim Invasive Gynecol 2016; 23:331-7. [DOI: 10.1016/j.jmig.2016.01.017] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 01/12/2016] [Accepted: 01/15/2016] [Indexed: 01/12/2023]
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In-bag manual versus uncontained power morcellation for laparoscopic myomectomy: randomized controlled trial. Fertil Steril 2016; 105:1369-1376. [PMID: 26801067 DOI: 10.1016/j.fertnstert.2015.12.133] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 12/10/2015] [Accepted: 12/21/2015] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To evaluate whether manualin-bag morcellation could be efficiently proposed as alternative to the uncontained power technique. DESIGN Randomized controlled trial. SETTING Academic hospital. PATIENT(S) One hundred fifty-two premenopausal women eligible for myomectomy were screened, and 104 were randomized. INTERVENTION(S) Patients were randomized into two groups. In the experimental group, "in-bag" protected morcellation was performed. In the control group, patients were treated by uncontained power myoma removal. MAIN OUTCOME MEASURE(S) The primary endpoint was the comparison of morcellation operative time (MOT). The secondary endpoints were the comparisons of total operative time (TOT), simplicity of morcellation (as defined by the surgeon using a visual analogue scale scale), intraoperative blood loss, rate of complications, and postoperative outcomes. RESULT(S) A sample size of 51 per group (n = 102) was planned. Between March 2014 and January 2015, patients were randomized as follows: 53 to the experimental group and 51 to the control group. Most demographic characteristics were similar across groups. MOT was observed to be similar in both study groups (16.18 ± 8.1 vs. 14.35 ± 7.8 minutes, in the experimental and control groups, respectively). Fibroid size was identified as the principal factor influencing morcellation time (Pearson coefficient 0.484 vs. 0.581, in the experimental and control groups, respectively). No significant difference in TOT, simplicity of morcellation, delta Hb, postoperative pain, and postoperative outcomes were observed between groups. CONCLUSION(S) The protected manual in-bag morcellation technique represents a time-efficient and feasible alternative, which does not interfere with surgical outcomes in women undergoing laparoscopic myomectomy. CLINICAL TRIAL REGISTRATION NCT02086435.
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First clinical experiences using a new in-bag morcellation system during laparoscopic hysterectomy. Arch Gynecol Obstet 2015; 294:83-93. [PMID: 26690354 DOI: 10.1007/s00404-015-3986-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 12/08/2015] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Endoscopic techniques have successfully reduced the invasiveness of hysterectomy, when compared to open procedures. Power morcellation, as a part of the minimal invasive concept, carries the risk of disseminating cells from the tissue specimen. The present observational study reports on first experiences using a new system (More-Cell-Safe, A.M.I., Austria) for contained in-bag morcellation during laparoscopic hysterectomy. MATERIALS AND METHODS The dual opening system allows two-port access without bag puncture. The optic is protected against spread cell contamination with a disposable sleeve. Application data were prospectively recorded on the first n = 7 consecutive patients and compared to n = 7 preceding patients undergoing uncontained morcellation. RESULTS Bag system use was surgically successful in 6 of 7 cases (85.7 %). Morcellated specimen weight ranged from 205 to 638 g (mean 413.33 ± 176.85; median 413). In one patient, the uterine specimen (1050 g) proved too large to be placed into the bag. Average time associated to the bag use was 16.2 ± 7.65 min, ranging from 8.5 to 26.5 min (median 14 min). Removed bags contained bloody fluid with residual tissue fragments weighing overall between 21 and 85 g. Spread spindle cells were detected in two cases after uncontained morcellation, but not after in-bag morcellation. CONCLUSION The experiences from our small pilot series prove technical feasibility in the clinical setting.
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Nygaard I. Laparoscopic hysterectomy: weigh harms, but do not dismiss benefits. Am J Obstet Gynecol 2015; 212:553-5. [PMID: 25925627 DOI: 10.1016/j.ajog.2015.03.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 03/05/2015] [Indexed: 12/31/2022]
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