Morcellation during Uterine Tissue Extraction: An Update

Safely Introducing New Surgical Devices in Minimally Invasive Gynecologic Surgery: An Argument for Use of the IDEAL Framework

OBJECTIVE

To review the Food and Drug Administration (FDA) premarket regulatory and postmarket surveillance processes for 2 minimally invasive gynecologic surgery case studies-the laparoscopic power morcellator and the Essure permanent birth control device-and to introduce the IDEAL (Idea, Development, Exploration, Assessment, Long-term) framework for safely introducing and monitoring minimally invasive gynecologic surgery devices.

DATA SOURCES

News media publications, agency websites, legal articles, and scientific papers.

METHODS OF STUDY SELECTION

Articles and papers were selected that described events leading to FDA approval of these devices and subsequent complications.

TABULATION, INTEGRATION, AND RESULTS

Based on current FDA premarket regulatory processes, 67% of devices do not currently require premarket review and only 1% are subject to clinical trial requirements. The IDEAL framework delineates 5 phases for safe introduction of medical devices: idea, development, exploration, assessment, and long-term study.

CONCLUSION

The laparoscopic power morcellator and Essure cases illustrate possible shortcomings in our device approval system that could be improved upon using the IDEAL framework, which limits device use until safety and efficacy data have been established and recommends postmarket surveillance.

Care Delivery for Patients with Leiomyomas: Failures, Real-Life Experiences, Analysis of Barriers, and Proposed Restorative Remedies

In this narrative review, we describe historical and contemporary influences that prevent patients with fibroids from getting appropriate medical care. Using patient stories as examples, we highlight how misogyny on all levels hurts patients and prevents medical teams from doing their best. Importantly, inequity and disparities result in massive gaps in care delivery. We suggest that we, as gynecologists and surgeons, must join public discourse on this topic to highlight the inadequacies of care delivery and the reasons behind it, suggest potential solutions, and join patients and communities in formulating and implementing remedies.

Mechanical and leakage integrity testing considerations for evaluating the performance of tissue containment systems

Tissue containment systems (TCS) are medical devices that may be used during morcellation procedures during minimally invasive laparoscopic surgery. TCS are not new devices but their use as a potential mitigation for the spread of occult malignancy during laparoscopic power morcellation of fibroids and/or the uterus has been the subject of interest following reports of upstaging of previously undetected sarcoma in women who underwent a laparoscopic hysterectomy. Development of standardized test methods and acceptance criteria to evaluate the safety and performance of these devices will speed development, allowing for more devices to benefit patients. As a part of this study, a series of preclinical experimental bench test methods were developed to evaluate the mechanical and leakage performance of TCS that may be used in power morcellation procedures. Experimental tests were developed to evaluate mechanical integrity, e.g., tensile, burst, puncture, and penetration strengths for the TCS, and leakage integrity, e.g., dye and microbiological leakage (both acting as surrogates for blood and cancer cells) through the TCS. In addition, to evaluate both mechanical integrity and leakage integrity as a combined methodology, partial puncture and dye leakage was conducted on the TCS to evaluate the potential for leakage due to partial damage caused by surgical tools. Samples from 7 different TCSs were subjected to preclinical bench testing to evaluate leakage and mechanical performance. The performance of the TCSs varied significantly between different brands. The leakage pressure of the TCS varied between 26 and > 1293 mmHg for the 7 TCS brands. Similarly, the tensile force to failure, burst pressure, and puncture force varied between 14 and 80 MPa, 2 and 78 psi, and 2.5 N and 47 N, respectively. The mechanical failure and leakage performance of the TCS were different for homogeneous and composite TCSs. The test methods reported in this study may facilitate the development and regulatory review of these devices, may help compare TCS performance between devices, and increase provider and patient accessibility to improved tissue containment technologies.

Laparoscopic subtotal hysterectomy followed by in-bag transvaginal corpus uteri morcellation and extraction: A case series

OBJECTIVES

Laparoscopic subtotal hysterectomy (LSH) is a possible treatment for patients with benign uterine disease. Once the hysterectomy has been completed, morcellation and extraction of the corpus uteri is a crucial step of the procedure. We here present a case series to evaluate the feasibility of the in-bag transvaginal specimen retrieval following LSH.

STUDY DESIGN

We report a case series of consecutive patients who underwent LSH followed by in-bag transvaginal specimen retrieval. LSH was accomplished in a standard fashion. Once the uterus was detached from the cervix, a 2 cm posterior colpotomy was performed laparoscopically with a monopolar hook under direct view to insert a specimen retrieval bag into the abdomen. The corpus uteri was placed into the bag and transvaginal contained manual morcellation was performed. The colpotomy was then sutured transvaginally. Baseline patients' characteristics and surgical data were collected. Postoperative complications, same-hospital readmissions, and reoperations were registered if occurred within 30 days from surgery.

RESULTS

Patients' median age and BMI were 45,5 and 22,7, respectively. Median operative time was 71.5 min (range 34-143) and uterus weight ranged from 60 g to 470 g (median 210 g). The estimated blood loss was 100 mL (median) and no blood transfusion was required. No conversions to open surgery, nor intraoperative complications occurred. Median hospital stay was 2 days (1-3) and no postoperative complications within 30 days from surgery were recorded.

CONCLUSIONS

LSH followed by in-bag transvaginal specimen extraction is a promising technique and might be considered a reliable and safe option to further reduce the invasiveness of the procedure.

Inbag Morcellation Applied to the Laparoscopic Surgery of Leiomyoma: A Randomized Controlled Trial

Objective

To evaluate the efficacy and safety of an endoscopic bag during laparoscopic morcellation of leiomyoma or myomatous uterus.

Materials and Methods

A total of 48 patients with symptomatic leiomyoma were randomized for laparoscopic morcellation in two groups: group A with a specific endoscopic bag or group B without any bag. The primary outcome measure was the detection of smooth muscle cells from washing after power morcellation determined by peritoneal cytology and immunohistochemistry (IHC).

Results

Cytology and IHC from group A did not revealed any smooth muscle cells, while 29% of cases (7/24) from group B were positive (p = .009). The duration of the surgical procedure was the same in both groups. The duration of positioning the bag did not change significantly during the study. Only in one case the use of the bag was difficult due to a low pneumoperitoneum.

Conclusions

The use of a morcellation bag is efficient to prevent the spread of smooth muscle cells during the morcellation of leiomyoma or myomatous uterus. This study confirms the feasibility and the safety of the laparoscopic inbag morcellation versus open morcellation.

Specificity of the lactate dehydrogenase isoenzyme index as a preoperative screen for uterine sarcoma before myomectomy

OBJECTIVE

To evaluate the applicability of the Uterine mass Magna Graecia (UMG) risk index (elevation defined by a lactate dehydrogenase isoenzyme index >29) in women undergoing surgery for benign fibroids and to determine whether other factors were associated with an elevated index. An elevated UMG index has been reported to be associated with an increased risk of uterine sarcoma in Italian women.

DESIGN

Retrospective cohort study.

SETTING

University fibroid center.

PATIENTS

All women presenting from July 1, 2013, through June 30, 2019, with fibroids who had lactate dehydrogenase isoenzymes collected and surgery performed.

INTERVENTIONS

Calculation of UMG index.

MAIN OUTCOME MEASURE

Applicability of UMG index.

RESULTS

Of 272 patients initially identified, 179 met inclusion criteria, 163 with UMG index ≤29 and 16 with UMG index >29. There were no cases of uterine sarcoma. Race, age, and presence of endometriosis, adenomyosis, or degenerating fibroids were not predictors of elevated UMG index. Body mass index (BMI) was positively associated with elevated UMG index. Specificity of UMG index to exclude uterine sarcoma was 91.1% (163/179) and higher in non-obese (BMI<30; 95.1%) than obese women (85.5%).

CONCLUSION

A previously reported UMG index cutoff of 29 had a specificity of 91.1% (higher with normal BMI and lower when obese) in our patient population. Although lower than previously reported, the index could be a useful initial method of preoperative screening of women with symptomatic fibroids. Higher BMI appears to be associated with elevated UMG indices, increasing the false-positive rate in obese women.

Laparoscopic Myomectomy - Converting to Laparotomy for a Suspicious Intraoperative Appearance with Subsequent Benign Histology - a Pre- and Intra-Operative Dilemma

Background

Although the most common uterine tumour is leiomyoma, the differential diagnoses also include the rarer adenomyoma and leiomyosarcoma. A lack of clear reliable clinical and radiological features makes the triage of uterine masses to the appropriate surgical procedure difficult. In the case of suspicious appearance of a presumed leiomyoma, an open surgical approach is recommended and morcellation is avoided.

Case

We present a case of a woman undergoing an elective laparoscopic myomectomy for a fibroid that appeared benign on ultrasound but had suspicious features intraoperatively. The operation was converted to a laparotomy to avoid the risk of morcellation-related seeding in the event that the histology was malignant. The histology was subsequently a benign exophytic adenomyoma.

Conclusion

The assessment of the nature of fibroids can be difficult both pre- and intraoperatively, and the need for difficult decision making to convert to open surgery during a laparoscopic myomectomy but with subsequent benign histology should be part of patient counselling.

Minimally Invasive Surgical Techniques for Tissue Extraction

STUDY OBJECTIVE

Morcellation is a technique to remove large specimens by means of small incisions and is commonly used in gynecologic procedures [1]. In this video, we demonstrate contained manual morcellation techniques in benign gynecologic surgeries.

DESIGN

Stepwise demonstration of 4 techniques with narrated video footage.

SETTING

Tertiary academic teaching hospital.

INTERVENTIONS

This video showcases 4 contained manual morcellation techniques: abdominal extraction through an umbilical "mini-laparotomy" incision, abdominal extraction through a suprapubic "mini-laparotomy" incision, transvaginal extraction through the colpotomy, and transvaginal extraction through the posterior cul-de-sac with the uterus in place. A particular strategy should be selected on the basis of appropriate patient characteristics and surgical factors [2].

CONCLUSION

Minimizing risk during tissue extraction is critical to minimally invasive procedures. The morcellation techniques displayed in this video allow for tissue extraction through small incisions while reducing the risk of spreading an undiagnosed malignancy.

Association of uterine dimensions and route of contained morcellation following laparoscopic hysterectomy

BACKGROUND

The aim of this study was to determine if uterine dimensions on preoperative imaging are associated with route of contained morcellation during laparoscopic hysterectomy.

METHODS

This is a prospective cohort study of patients undergoing laparoscopic hysterectomy and requiring morcellation for specimen extraction from March 2017 through August 2019. A contained extraction system was inserted and manual morcellation was performed vaginally, abdominally, or via a combination of both methods in cases of failed vaginal extraction.

RESULTS

A total of 47 patients were treated. Median age was 47 (range 38-70). Morcellation was performed vaginally for 29 patients (61.7%), abdominally for 13 patients (27.7%), and via combined approach for 5 patients (10.6%). The combined group had the highest frequency of patients who were black (vaginal: 24%, abdominal: 31%, combined: 100%; P=0.005), the longest median total operating time (vaginal: 167 minutes, abdominal: 183 minutes, combined: 268 minutes; P=0.006) and the longest median time of uterine morcellation (vaginal: 14 minutes, abdominal: 37 minutes, combined: 85 minutes; P<0.001). There was strong evidence of a positive correlation with time of uterine morcellation for both largest uterine diameter (Spearman's r: 0.62, P<0.001) and uterine volume (Spearman's r: 0.70, P<0.001). These associations remained consistent after multivariable linear regression models that were adjusted for route of morcellation, hysterectomy type, and BMI (both P<0.001).

CONCLUSIONS

Larger uterine dimensions are associated with increased total operating and morcellation times. Uterine size and volume on preoperative imaging were not associated with route of morcellation, but there was a trend towards failed vaginal extraction when uterine dimensions exceeded 16 centimeters.

Tissue Extraction in Gynecologic Surgery: Past, Present, and Future

Fibroid tissue extraction during hysterectomy and myomectomy has become increasingly controversial. A wave of research has tried to clarify difficult questions around the prevalence of occult malignancies, the effect of morcellation on cancer outcomes, proper informed consent, and surgical options for tissue extraction. This review examines the history of these controversies and discusses tissue extraction techniques and continued areas of debate in the field.

Google searches and medical publication trends since the 2014 US Food and Drug Administration position on power morcellation: Do these translate into patient awareness?

OBJECTIVES

Our primary objective was to assess patient awareness by observing Google Trends comparing search terms used in relation to morcellation rather than morcellation alone. Our secondary objective was to review trends and locations of publications on leiomyosarcoma and morcellation following the US Food and Drug Administration (FDA) position statement.

STUDY DESIGN

To assess Internet trends, we obtained the relative search volume (RSV) for each month from 1 January 2004 to 1 March 2019 from Google Trends using the terms 'fibroid', 'morcellation', and 'fibroid cancer'. RSV ranges from 0 to 100 with 100 being peak popularity for the term, and all other monthly search activity relative to the peak. To assess academic trends, we performed a systematic review of published literature discussing fibroid morcellation within the same time period. We used a two-way independent t-test to compare median RSV, and chi-squared test to compare academic output. P < 0.05 was considered statistically significant.

RESULTS

Search volume for 'morcellation' peaked during the FDA statement (RSV 0.5 to 2.9, t = 17.5, p < 0.05) but was not sustained. There is an increase in 'fibroid' activity post-FDA statement (RSV 68.8 to 76.3, t = 3.9, p < 0.05). 'Fibroid cancer' remained static throughout (t = 1.5, p = 0.1 and t=-0.5, p = 0.6). Afro-Caribbean countries had the highest RSV for 'fibroid', whereas 'morcellation' RSV was highest in predominantly Western countries. There was a significant increase in the rate of papers published on the subject following the FDA statement (6.8 vs 55.6 papers per year, 95% CI -53.96 to -43.64, p < 0.0001). No academic papers on morcellation were published from countries with the highest RSV for 'fibroid'.

CONCLUSION

Our study suggests that interest in uterine fibroids has increased since the FDA statement, but the public are perhaps unaware or not concerned of the consequent potential risk of leiomyosarcoma following morcellation. Countries where fibroid interest is highest are not necessarily those that can offer power morcellation. Further studies are required to address how the Internet influences patient choice and informed consent, and how medical professionals can use it to further educate patients on the risks and benefits of laparoscopic myomectomy and power morcellation.

Association Between Power Morcellation and Mortality in Women With Unexpected Uterine Cancer Undergoing Hysterectomy or Myomectomy

PURPOSE

Despite concerns that power morcellation may adversely affect prognosis of patients with occult uterine cancer, empirical evidence has been limited and inconclusive. In this study, we aimed to determine whether uncontained power morcellation at the time of hysterectomy or myomectomy is associated with increased mortality risk in women with occult uterine cancer.

METHODS

By linking statewide hospital discharge records with cancer registry data in New York, we identified 843 women with occult endometrial carcinoma and 334 women with occult uterine sarcoma who underwent a hysterectomy or myomectomy for presumed benign indications during the period October 1, 2003, through December 31, 2013. Within this cohort, we compared disease-specific and all-cause mortality of women who underwent laparoscopic supracervical hysterectomy/laparoscopic myomectomy (LSH/LM), a surrogate indicator for uncontained power morcellation, with women who underwent supracervical abdominal hysterectomy and total abdominal hysterectomy (TAH), which did not involve power morcellation. Multivariable Cox regressions and propensity score method were used to adjust for patient characteristics.

RESULTS

Among women with occult uterine sarcoma, LSH/LM was associated with a higher risk for disease-specific mortality than TAH (adjusted hazard ratio [aHR], 2.66, 95% CI, 1.11 to 6.37; adjusted difference in 5-year disease-specific survival, -19.4%, 95% CI, -35.8% to -3.1%). In the subset of women with leiomyosarcoma, LSH/LM was associated with an increased risk for disease-specific mortality compared with supracervical abdominal hysterectomy (aHR, 3.64, 95% CI, 1.50 to 8.86; adjusted difference in 5-year disease-specific survival, -31.2%, 95% CI, -50.0% to -12.3%) and TAH (aHR, 4.66, 95% CI, 1.97 to 11.00; adjusted difference in 5-year disease-specific survival, -37.3%, 95% CI, -54.2% to -20.3%). Among women with occult endometrial carcinoma, there was no significant association between surgical approach and disease-specific mortality.

CONCLUSION

Uncontained power morcellation was associated with higher mortality risk in women with occult uterine sarcoma, especially in those with occult leiomyosarcoma.

Incidence of Leiomyosarcoma at Surgery for Presumed Uterine Myomas in Different Age Groups

STUDY OBJECTIVE

To evaluate the incidence of leiomyosarcoma (LMS) at surgery for presumed uterine myomas according to different age groups.

DESIGN

A retrospective cohort study.

SETTING

A tertiary referral hospital.

PATIENTS

All women undergoing surgery for presumed uterine myomas between January 1, 2006, and December 31, 2016.

INTERVENTIONS

Laparoscopic myomectomy, laparotomic myomectomy, total hysterectomy, or hysteroscopic myomectomy.

MEASUREMENTS AND MAIN RESULTS

A total of 1398 patients underwent surgery for presumed uterine myomas. The incidence of LMS was 2.15 per 1000 surgeries (n = 3, 1/466, 0.2%). In women under 40 years old, the incidence of occult LMS was 0 (0/561). In women between 40 and 49 years old, 190 myomectomies were performed (28% of the surgeries), and the rate of LMS was 1.49 per 1000 (n = 1, 1/673, 0.15%). In women over 49 years old, a total hysterectomy was performed in 82.3% of the cases, and the incidence of LMS was 12.2 per 1000 surgeries (n = 2, 1/82, 1.2%).

CONCLUSION

The incidence of occult LMS in patients under 40 years old undergoing surgery for presumed uterine myomas was 0. These findings are suggestive that the use of power morcellation in this population may be safe.

Cell Spillage after Contained Electromechanical Morcellation Using a Specially Designed In-Bag System for Laparoscopic Myomectomy: Prospective Cohort Pilot Study

STUDY OBJECTIVE

Few reports have investigated the use of endoscopic retrieval bags in the context of laparoscopic myomectomy with electromechanical morcellation. We performed a leak test of a specially designed endoscopic bag system in women undergoing laparoscopic myomectomy with contained electromechanical morcellation.

DESIGN CLASSIFICATION

Prospective study.

SETTING

University hospital.

PATIENTS

Thirty-one women undergoing laparoscopic myomectomy with contained electromechanical morcellation.

INTERVENTIONS

Electromechanical morcellation was introduced for large specimen extraction during laparoscopic procedures. Complications such as retained/disseminated parasitic tissue were documented.

MEASUREMENTS AND MAIN RESULTS

Systematic peritoneal washings were performed at 3 specific times: at baseline, T1, once the peritoneal cavity was accessed laparoscopically; T2, when the myometrial incision was closed after myomectomy; and T3, after contained electromechanical morcellation. After retrieval of the endoscopic bag from the abdominal cavity, visual inspection and water test on the bag with NaCl infiltration were performed to detect leaks attributed to intraoperative perforations. A pathologist performed cytologic analyses on the 3 washings. The mean endoscopic bag procedure duration was 9 minutes. The use of a specially designed endoscopic bag system was found to be easy in 45% of cases, and no complications were reported. Cytologic washings were positive for smooth muscle cell detection in 8 cases (25.8%) at T2 and 3 cases (9.7%) at T3. All positive cases at T3 already had detectable smooth muscle cells at T2. After retrieval from the abdominal cavity, perforations on the optic access of the endoscopic bag were observed in 3 cases.

CONCLUSION

The results from this pilot study are encouraging. The use of a specially designed endoscopic bag system could be an adjuvant to reduce the risk of disseminating cells during myomectomy.

Non-malignant Sequelae after Unconfined Power Morcellation

STUDY OBJECTIVE

To identify the incidence of repeat surgery and subsequent findings after the performance of unconfined uterine power morcellation.

DESIGN

A retrospective descriptive study (Canadian Task Force classification II-2).

SETTING

Southern California Kaiser Permanente Medical Centers.

PATIENTS

Women (N = 5154) who underwent laparoscopic supracervical hysterectomy with unconfined power morcellation.

MEASUREMENTS AND MAIN RESULTS

Of the 5154 cases, 279 (5.41%) underwent subsequent reoperation with a median of 24 months after index surgery. The most common clinical complaint leading to laparoscopic supracervical hysterectomy was symptomatic leiomyoma (n = 135, 48.4%) and abnormal uterine bleeding (n = 94, 33.7%). The most common indication for reoperation was a symptomatic adnexal mass (n = 87, 31.2%) followed by pelvic pain (n = 83, 29.7%). The majority (n = 128, 60.4%) of subsequent non-urogynecologic-related reoperations resulted in benign pathology. Endometriosis was the primary pathologic diagnosis in 65 of 279 (23.3%) of the reoperative cases; this was not previously documented in 86% (n = 57/65) of these cases. The overall frequency of subsequent pathology was endometriosis (65/5154, 1.26%), disseminated leiomyomatosis (18/5154, 0.35%), and new malignancy (11/5154, 0.21%).

CONCLUSION

Morcellation of nonmalignant tissue is not without consequence. Pathology confirmed endometriosis was documented for the first time in 20.4% of patients who underwent a second surgery. This finding raises the suspicion that morcellation and dispersion of the uterine specimen may be associated in the development of endometriosis.