Vaginal morcellation: A new strategy for large gynecological malignant tumor extraction

Transvaginal morcellation within an enclosed bag in gynecological surgeries: a comprehensive systematic review and analysis of safety, efficacy, and outcomes

PURPOSE

This systematic review aims to comprehensively assess the safety and efficacy of transvaginal morcellation within an enclosed bag in gynecological surgeries, with a focus on its benefits, potential risks, and recommendations for its use.

METHODS

We conducted a comprehensive search of Epistemonikos, Web of Science, Medline (PubMed), Scopus, and Cochrane databases for studies on transvaginal contained morcellation in adult patients undergoing gynecological surgeries. The review included 22 studies that met the inclusion criteria, encompassing diverse surgical procedures, patient profiles, and outcomes. These studies were thoroughly reviewed and analyzed to assess the safety and efficacy of the morcellation technique.

RESULTS

Key findings from the selected studies indicate that transvaginal morcellation within an enclosed bag offers several advantages in gynecological surgeries, including reduced invasiveness, shorter operative times, and minimal blood loss when compared to conventional methods. The risk of tumor recurrence or dissemination appears to be low when appropriate precautions are taken, emphasizing the technique's safety, especially when performed by experienced surgical teams. While some studies reported complications, these were generally not directly associated with the morcellation technique.

CONCLUSION

Transvaginal morcellation within an enclosed bag demonstrates potential as a safe and effective option for gynecological surgeries. The technique offers the benefits of minimally invasive procedures, including reduced bleeding, shorter recovery times, and improved cosmetic outcomes. This review also highlights the need for standardization in study methodologies and reporting, as the heterogeneity in outcomes across the selected studies poses challenges in drawing definitive conclusions.

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.

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.

Safety and feasibility of contained uterine morcellation in women undergoing laparoscopic hysterectomy

Background

Widespread concerns have been raised regarding the safety of power morcellation of uterine specimens because of the potential to disseminate occult malignancy. We sought to assess the safety and feasibility of contained manual uterine morcellation within a plastic specimen bag among women with uterine neoplasms.

Methods

A retrospective single-institution descriptive cohort study was conducted from 2003 to 2014. Patients with leiomyoma and/or uterine malignancy who underwent minimally invasive surgery with contained uterine manual morcellation were identified from surgical logs. Demographic data, pathology results, operative details and adjuvant treatments were abstracted.

Results

Eighty-eight patients were identified; 35 with leiomyoma and 53 with endometrial cancer. The mean age was 48 and 60, respectively. Uterine size/weight was greater in women with leiomyoma compared to those with cancer (15.1 weeks/448 g vs. 10.7 weeks/322 g). Mean operative time was 206 min (range 115–391) for leiomyoma cases and 238 min (range 131–399) for cancer cases. Median length of stay was 1 day (range 0–3 days). There were no cases of occult leiomyosarcoma and all specimens were successfully manually morcellated within a bag. There were no intraoperative complications. Thirty-day postoperative complications occurred in 7 patients, including one readmission for grade (G) 1 vaginal cuff separation after intercourse, G1 port-site hematoma (1), G2 port-site cellulitis (1), G2 vaginal cuff cellulitis (2), G2 bladder infection (2), G2 pulmonary edema (1), and G1 musculoskeletal injury (1).

Conclusions

Contained uterine hand morcellation is a feasible procedure with low peri-operative complication rates that allows for minimally invasive surgical procedures for women with large uterine neoplasms. Further evaluation is needed to assess survival outcomes for uterine malignancies.

Morcellation equipment: past, present, and future

PURPOSE OF REVIEW

This review was written in an effort to describe the evolution of power morcellation equipment from their creation to their current state. In addition, this review addresses the continuously evolving equipment involved with power morcellation and looks to describe where the field is headed in the future. In addition, recent professional and federal recommendations have changed the way power morcellation is being approached and has led to the development of contained morcellation systems, which, although in their infancy, are also being proven to be well tolerated options.

RECENT FINDINGS

This article will review the most current research on electronic power morcellation and the multiple attempts to prove superiority from the many different types of equipment, and also the many different approaches to morcellation. In addition, with the adaptation to contained morcellation, this review will cover research focused on optimizing a containment system and the techniques involved.

SUMMARY

In summary, this review is aimed at describing many of the currently available power morcellation products and contained morcellation systems in an effort to allow physicians to understand the different options available, and to discuss well tolerated, effective, and clinically proven techniques that can lead to improved surgical outcomes in the future.

Extraction of a specimen through an umbilical zigzag incision during laparoscopic surgery for endometrial cancer

Background

Though laparoscopic surgery has recently been applied in the treatment of early-stage endometrial cancer, the presence of a large uterus is a hindrance to specimen extraction from the abdominal cavity. We describe a laparoscopic surgical technique for endometrial cancer involving the extraction of the resected specimen through an umbilical zigzag incision.

Case presentation

A 63-year-old woman with endometrial cancer underwent a total hysterectomy and bilateral salpingo-oophorectomy that was performed laparoscopically. The surgical specimen was extracted through an umbilical zigzag incision. This umbilical zigzag incision created a larger fascial and peritoneal opening, facilitating the removal of the specimen. The final histopathologic results revealed stage 1A G1 endometrioid adenocarcinoma and multiple uterine leiomyomas. Three months after surgery, the wound in the umbilical region was inconspicuous, along with the inward movement of the umbilicus.

Conclusions

A laparoscopic surgical technique for endometrial cancer involving the extraction of the specimen through an umbilical zigzag incision seems to reduce the difficulties associated with laparoscopic surgery and maintains cosmesis. Further analyses involving larger numbers of cases and long-term follow-up periods are warranted to evaluate this surgical method.

Contained Morcellation: Review of Current Methods and Future Directions

Power morcellation of surgical specimen during laparoscopic surgery is a practical technology that provides the opportunity to perform several minimally invasive procedures. However, this technology brought forward additional risks and complications associated with dissemination of both benign and malignant tissues inside the abdominal cavity. Based on startling cases, Food and Drug Administration (FDA) announced a discouraging statement on the use of power morcellators that decreased the number of minimally invasive approaches in the following period. As a response to these concerns and negative impacts of the FDA statement, researchers developed several new approaches resulting in contained or in-bag morcellation methods. In this review, we aimed to discuss these current methods and provide an insight for future developments.

Laparoendoscopic Single-Site Total Laparoscopic Hysterectomy: Clinical Factors that Affect Operative Times and Techniques to Overcome Difficulties

STUDY OBJECTIVE

To compare surgical outcomes of patients who underwent laparoendoscopic single-site total laparoscopic hysterectomy (LESS-TLH) with operative times < 150 minutes and ≥150 minutes to determine the clinical factors that influence operative times. We also describe techniques that help overcome difficulties involved in this procedure.

DESIGN

Retrospective study (Canadian Task Force classification II-2).

SETTING

University medical center.

PATIENTS

Two hundred thirty-four patients underwent LESS-TLH for benign uterine disease and cervical disease between September 2011 and February 2015. Thirty-seven patients (15.8%) were excluded from analysis. One hundred ninety-seven patients were divided into 2 groups according to the total operative time (median, 150 minutes): <150 minutes (n = 93) and ≥150 minutes (n = 104).

INTERVENTIONS

LESS-TLH was performed using anterior, lateral, and posterolateral colpotomy techniques, and knife-in-bag morcellation was used for specimen extraction.

MEASUREMENTS AND MAIN RESULTS

Patient characteristics, except for body mass index (BMI) and age, were generally similar in the 2 groups. Age, BMI, adhesiolysis, time to completion of colpotomy, stump repair time, specimen extraction time, blood loss, and weight of the uterus showed statistically significant differences between the 2 groups. Clinical factors that affected operative time were adhesiolysis of the posterior uterus (p = .010), time to completion of colpotomy (>65 minutes; p = .000), specimen extraction time (>34.4 minutes; p = .000), and weight of the uterus (>270 g; p = .015). Conversion to additional port laparoscopy occurred in 14 patients (5.98%). Conversion to laparotomy occurred in 1 patient (.43%). The surgical complication rates were 3.2% (3 patients) in the <150 minutes group and 3.8% (4 patients) in the ≥150 minutes group. No urologic injuries occurred in either group. One postoperative ileus occurred in the ≥150 minutes group; it was relieved by conservative treatment.

CONCLUSION

Time to completion of colpotomy was influenced by adhesiolysis of the posterior uterus and specimen extraction time by weight of the uterus. Alternative methods for decreasing the time required to extract a large uterus and for approaching posterior adhesion of the uterus are needed for LESS-TLH.

Power Morcellation Using a Contained Bag System

BACKGROUND AND OBJECTIVES

The well-known advantages of minimally invasive surgery make the approach well suited for hysterectomy and other gynecological procedures. The removal of specimens excised during surgery has been a challenge that has been answered by the use of power morcellation. With this study we sought to assess the feasibility of power morcellation within a specimen bag.

METHODS

This was a retrospective cohort study including patients from a private practice in suburban Chicago, Illinois, who underwent contained electromechanical power morcellation during a laparoscopic or robot-assisted hysterectomy or myomectomy from May 2014 through December 2015. Contained power morcellation was performed with the Espiner EcoSac 230 (Espiner Medical Ltd., North Somerset, United Kingdom) specimen bag. Descriptive statistics were performed for both categorical and continuous data.

RESULTS

Of the 187 procedures performed, 73.8% were myomectomies, and 26.2% were hysterectomies. The patients' mean age was 40 (range, 25-54) years and mean body mass index was 28.7 (range, 17.3-57.6). The average specimen weight was 300 g, with the largest weighing 2134 g. Estimated blood loss averaged 98.4 mL. The postoperative admission rate was 12.3%, most of which were due to nausea and urinary retention. Seventeen patients (9.1%) had postoperative complications, most of which were minor, and 4 (2.1%) were readmitted. There were no bag failures or complications that were due to the use of the specimen bag or to power morcellation.

CONCLUSIONS

Performing electromechanical power morcellation within the Espiner EcoSac 230 specimen bag was successfully performed in 187 patients with no bag-related complications. This method of contained power morcellation is feasible, reliable, and reproducible, even for a large specimen.

Surgical Treatment of Uterine Fibroids Within a Containment System and Without Power Morcellation

Increased awareness regarding risks associated with intracorporeal electromechanical, or power, morcellation has urged surgeons to develop alternative methods for tissue extraction that may mitigate some of these risks during surgery. The use of containment systems during laparoscopic procedures has allowed surgeons to continue to offer and perform myomectomies that still benefit from being minimally invasive but which may minimize the risk of inadvertent tissue dispersion. Here, we will review techniques for performing contained tissue fragmentation without the use of a power morcellator.

The Morcellation Debate: The History and the Science

Intracorporeal electromechanical morcellation has been available for nearly 2 decades, and has allowed hundreds of thousands of women to undergo hysterectomy and myomectomy in a minimally invasive approach. Despite gains in postoperative pain, complications, quality of life, hospital stay, and return to work, it has recently come under attack. The risk of inadvertent morcellation of a uterine malignancy, and subsequent dissemination of occult cancer, must be balanced by the risks of increased numbers of laparotomies. Power morcellation should be available to appropriate surgical candidates.

[Current controversies regarding power morcellation and future directions]

Modern surgery tends to the improvement of minimally invasive strategies. Laparoscopy, rooted in practices for years, supplanted laparotomy in many directions. Regarding the extraction of large uterus, morcellation is currently the only way to externalize surgical specimens (myomas, uterine), without increasing the skin opening while allowing to reduce postoperative complications compared to laparotomy. However, in 2014, the Food and Drug Administration (FDA) discourages the use of uterine morcellation because of oncological risk. This recommendation has been challenged by a part of the profession. Our review has sought to identify the evidence for and against the use of morcellation. We also tried to quantify surgical risk and the current means of prevention. The incidence of uterine sarcomas is still poorly identified and preoperative diagnostic facilities remain inadequate. The small number of retrospective studies currently available could not enable any recommendation. The evaluation of morcellation devices and the improvement of preoperative diagnosis modalities (imaging, preoperative biopsy) are to continue to minimize the oncological risk.

Uncontained Compared With Contained Power Morcellation in Total Laparoscopic Hysterectomy

OBJECTIVE

To compare perioperative outcomes of uncontained and contained power morcellation in total laparoscopic hysterectomy.

METHODS

Women who underwent total laparoscopic hysterectomy that required utilization of power morcellation between July 2012 and January 2015 in the Division of Minimally Invasive Gynecology at an academic tertiary care center were included. In February 2014, the division began performing all power morcellation contained within a large insufflated bag in an attempt to reduce dissemination of benign and malignant uterine tissue. Data were collected from a prospective database and analyzed as a retrospective cohort. The primary outcome was operative time. Secondary outcomes included estimated blood loss, length of stay, pathology, uterine weight, and complications, including blood transfusion, conversion to open, intraoperative organ injury, pelvic infection, readmission, or reoperation.

RESULTS

A total of 152 patients were identified: 101 uncontained morcellations and 51 contained morcellations. The baseline demographic characteristics between the two groups were similar. Operative time was longer in the contained morcellation group (184 compared with 164 minutes, P=.01). There were no cases of visible bag disruption or dissemination of uterine tissue in the contained morcellation group.

CONCLUSION

Contained power morcellation at the time of total laparoscopic hysterectomy is associated with a 20-minute increase in operative time when compared with uncontained morcellation.

LEVEL OF EVIDENCE

II.

Risk, risk reduction and management of occult malignancy diagnosed after uterine morcellation: a commentary

Minimally invasive surgical techniques compared with laparotomy offer the advantages of less intraoperative blood loss, shorter hospitalization, fewer wound complications and faster return to baseline activity for both hysterectomy and myomectomy. While morcellation allows for the laparoscopic removal of large specimens, it may result in intraperitoneal dissemination of benign disease or upstaging of occult malignancy leading to compromised survival. There has been heightened scrutiny over appropriate patient selection and preoperative assessment in light of recent warnings against power morcellation issued by the US FDA. This commentary therefore summarizes the magnitude of such risks associated with uterine morcellation, current national regulatory statements and potential merits of risk-reducing approaches such as contained morcellation. The importance of patient counseling is underscored.

Laparoscopic Hysterectomy for Uterine Fibroids: Is it Safe?

As more complex cases and larger uterine specimens are able to be managed with minimally invasive surgery, the limitations of tissue retrieval with these methods are of increasing concern. Risks of morcellator-related injury, tissue dissemination, or fragmentation must be weighed against increased morbidity of abdominal approach to hysterectomy. In an effort to mitigate the risks of tissue morcellation, containment system use must be considered when fragmenting a specimen, either with power morcellation or a manual technique via the vagina or minilaparotomy.

Successful use of laparoscopic myomectomy to remove a giant uterine myoma: a case report

INTRODUCTION

Uterine leiomyomas are the most common benign neoplasms of the female reproductive tract. Myomectomy is the preferred surgical treatment in reproductive-aged women who desire to retain their fertility. The use of a laparoscopic approach for large myomas is still controversial, although there are several compelling reasons for its use. The laparoscopic removal of giant uterine myomas is rare, and only a few cases have been published in the literature.

CASE PRESENTATION

We report the case of a 33-year-old white woman who was referred to our clinic with progressive abdominal distension. An ultrasonic examination revealed a markedly enlarged uterus containing a 17 cm uterine myoma. Laparoscopic myomectomy was selected as the treatment option. The laparoscopy confirmed the 17 cm fundal intramural myoma. The myoma was totally enucleated and removed without disturbing her endometrial cavity. The myometrial defect was repaired with a continuous suture using the V-loc suture in two layers. The entire myoma was removed using a tissue morcellator. The total weight of the myoma removed was 2005g, and the operation lasted for 140 minutes. Her postoperative course was unremarkable.

CONCLUSIONS

Laparoscopic myomectomy offers many advantages compared with abdominal myomectomy. Although the use of a laparoscopic approach to treat very large myomas is controversial and technically demanding, we successfully performed a laparoscopic myomectomy in a patient with a giant myoma. This case confirms the efficiency, reliability, and safety of a minimally invasive surgical approach to treating a giant uterine myoma. Laparoscopic myomectomy can be performed by experienced surgeons regardless of the size of the myoma.

A critical assessment of morcellation and its impact on gynecologic surgery and the limitations of the existing literature

Uterine sarcomas are rare uterine malignancies that are difficult to diagnose preoperatively. Because of cases of disseminated sarcoma after laparoscopic hysterectomy, the role of power morcellators in gynecologic surgery has been questioned. Morcellation is an integral part of making laparoscopic surgery possible for the removal of large uterine leiomyomata, and the development of power morcellation has increased efficiency during these procedures. Minimally invasive surgery has demonstrated benefits that include improved pain control, decreased infection risk, and faster surgical recovery and return to work. In this review, we examine the risk of incidental sarcoma at the time of surgery, the quality of the data, the accuracy of clinical and radiologic predictors of uterine sarcoma, and the impact of morcellation on the prognosis of uterine sarcoma.

Technical update on tissue morcellation during gynaecologic surgery: its uses, complications, and risks of unsuspected malignancy

OBJECTIVE

To review the use of tissue morcellation in minimally invasive gynaecological surgery.

OUTCOMES

Morcellation may be used in gynaecological surgery to allow removal of large uterine specimens, providing women with a minimally invasive surgical option. Adverse oncologic outcomes of tissue morcellation should be mitigated through improved patient selection, preoperative investigations, and novel techniques that minimize tissue dispersion.

EVIDENCE

Published literature was retrieved through searches of PubMed and Medline in the spring of 2014 using appropriate controlled vocabulary (leiomyomsarcoma, uterine neoplasm, uterine myomectomy, hysterectomy) and key words (leiomyoma, endometrial cancer, uterine sarcoma, leiomyosarcoma, morcellation, and MRI). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date limits but results were limited to English or French language materials. Searches were updated on a regular basis and incorporated in the guideline to August 2014. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The quality of evidence in this document was rated using the criteria described in the report of the Canadian Task Force on Preventive Health Care. (Table 1) BENEFITS, HARMS, AND COSTS: Gynaecologists may offer women minimally invasive surgery and this may involve tissue morcellation and the use of a power morcellator for specimen retrieval. Women should be counselled that in the case of unexpected uterine sarcoma or endometrial cancer, the use of a morcellator is associated with increased risk of tumour dissemination. Appropriate training and safe practices should be in place before offering tissue morcellation. SUMMARY STATEMENTS: 1. Uterine sarcomas may be difficult to diagnose preoperatively. The risk of an unexpected uterine sarcoma following surgery for presumed benign uterine leiomyoma is approximately 1 in 350, and the rate of leiomyosarcoma is 1 in 500. (II-2) This risk increases with age. (II-2) 2. An unexpected uterine sarcoma treated by primary surgery involving tumour disruption, including morcellation of the tumour, has the potential for intra-abdominal tumour-spread and a worse prognosis. (II-2) 3. Uterus-sparing surgery remains a safe option for patients with symptomatic leiomyomas who desire future fertility. (II-1) RECOMMENDATIONS: 1. Techniques for morcellation of a uterine specimen vary, and physicians should consider employing techniques that minimize specimen disruption and intra-abdominal spread. (III-C) 2. Each patient presenting with uterine leiomyoma should be assessed for the possible presence of malignancy, based on her risk factors and preoperative imaging, although the value of these is limited. (III-C) 3. Preoperative endometrial biopsy and cervical assessment to avoid morcellation of potentially detectable malignant and premalignant conditions is recommended. (II-2A) 4. Hereditary cancer syndromes that increase the risk of uterine malignancy should be considered a contraindication to uncontained uterine morcellation. (III-C) 5. Uterine morcellation is contraindicated in women with established or suspected cancer. (II-2A) If there is a high index of suspicion of a uterine sarcoma prior to surgery, patients should be advised to proceed with a total abdominal hysterectomy, bilateral salpingectomy, and possible oophorectomy. (II-2C) A gynaecologic oncology consultation should be obtained. 6. Tissue morcellation techniques require appropriate training and experience. Safe practice initiatives surrounding morcellation technique and the use of equipment should be implemented at the local level. (II-3B) 7. Morcellation is an acceptable option for retrieval of benign uterine specimens and may facilitate a minimally invasive surgical approach, which is associated with decreased perioperative risks. Each patient should be counselled about the possible risks associated with the use of morcellation, including the risks associated with underlying malignancy. (III-C).

Safe vaginal uterine morcellation following total laparoscopic hysterectomy

The minimally invasive approach for hysterectomy with proven benefits and lower morbidity has become the gold standard, even in women with large uterine masses. Most women with a malignant condition present with abnormal vaginal bleeding and/or suspicious imaging such that few are diagnosed by final histopathology after surgery. However, if a malignancy is not diagnosed preoperatively, intraabdominal morcellation for uterus extraction has an increased risk for potential tumor spread and peritoneal metastases, especially in cases of unexpected leiomyosarcoma. We describe a simple method to wrap the uterus in a contained environment with a plastic bag through the posterior vaginal fornix prior to conventional coring morcellation for vaginal extraction in total laparoscopic hysterectomy. We further describe our experience with a risk stratification and treatment algorithm to implement this procedure in daily routine. A video and an illustrating sketch demonstrate the simplicity and safety of the procedure.

Surgical Methods for the Treatment of Uterine Fibroids - Risk of Uterine Sarcoma and Problems of Morcellation: Position Paper of the DGGG

The appropriate surgical technique to treat patients with uterine fibroids is still a matter of debate as is the potential risk of incorrect treatment if histological examination detects a uterine sarcoma instead of uterine fibroids. The published epidemiology for uterine sarcoma is set against the incidence of accidental findings during surgery for uterine fibroids. International comments on this topic are discussed and are incorporated into the assessment by the German Society for Gynecology and Obstetrics (DGGG). The ICD-O-3 version of 2003 was used for the anatomical and topographical coding of uterine sarcomas, and the "Operations- und Prozedurenschlüssel" (OPS) 2014, the German standard for process codes and interventions, was used to determine surgical extirpation methods. Categorical qualifiers were defined to analyze the data provided by the Robert Koch Institute (RKI), the German Federal Bureau of Statistics (DESTATIS; Hospital and Causes of Death Statistics), the population-based Cancer Register of Bavaria. A systematic search was done of the MEDLINE database and the Cochrane collaboration, covering the period from 1966 until November 2014. The incidence of uterine sarcoma and uterine fibroids in uterine surgery was compared to the literature and with the different registries. The incidence of uterine sarcoma in 2010, standardized for age, was 1.53 for Bavaria, or 1.30 for every 100 000 women, respectively, averaged for the years 2002-2011, and 1.30 for every 100 000 women in Germany. The mean incidence collated from various surveys was 2.02 for every 100 000 women (0.35-7.02; standard deviation 2.01). The numbers of inpatient surgical procedures such as myoma enucleation, morcellation, hysterectomy or cervical stump removal to treat the indication "uterine myoma" have steadily declined in Germany across all age groups (an absolute decrease of 17 % in 2012 compared to 2007). There has been a shift in the preferred method of surgical access from an abdominal/vaginal approach to endoscopic or endoscopically assisted procedures to treat uterine fibroids, with the use of morcellation increasing by almost 11 000 coded procedures in 2012. Based on international statements (AAGL, ACOG, ESGE, FDA, SGO) on the risk of uterine sarcoma as an coincidental finding during uterine fibroid surgery and the associated risk of a deterioration of prognosis (in the case of morcellation procedures), this overview presents the opinion of the DGGG in the form of four Statements, five Recommendation and four Demands.

Power morcellators: a review of current practice and assessment of risk

Power morcellation has come under scrutiny because of a highly publicized case of disseminated leiomyosarcoma following a laparoscopic hysterectomy. A recent Federal and Drug Administration safety communication discouraging use of power morcellators on presumed uterine leiomyoma further highlights the need for reexamination of uterine tissue extraction. This clinical opinion aims to summarize current approaches to uterine/fibroid tissue extraction including the associated immediate and long-term potential risks of open power morcellation. The known data about risk of uterine sarcoma is reviewed followed by a discussion of acceptable risk and informed consent in the context of shared-decision making.

Intracorporeal electromechanical tissue morcellation: a critical review and recommendations for clinical practice

Electromechanical morcellators have come under scrutiny with concerns about complications involving iatrogenic dissemination of both benign and malignant tissues. Although the rapidly rotating blade has resulted in morcellator-related vascular and visceral injuries, equally concerning are the multiple reports in the literature demonstrating seeding of the abdominal cavity with tissue fragmented such as leiomyomas, endometriosis, adenomyosis, splenic and ovarian tissues, and occult cancers of the ovaries and uterus. Alternatives to intracorporeal electric morcellation for tissue extirpation through the vagina and through minilaparotomy are feasible, safe, and have been shown to have comparable, if not superior, outcomes without an increased need for laparotomy. Intracorporeal morcellation within a containment bag is another option to minimize the risk of iatrogenic tissue seeding. Patient safety is a priority with balanced goals of maximizing benefits and minimizing harm. When intracorporeal electromechanical morcellation is planned, physicians should discuss the risks and consequences with their patients. Although data are being collected to quantify and understand these risks more clearly, a minimally invasive alternative to unenclosed intracorporeal morcellation is favored when available. It is incumbent on surgeons to communicate the risks of practices and devices and to advocate for continued improvement in surgical instrumentation and techniques.

Laparoscopic Extrafascial Hysterectomy (Completion Surgery) After Primary Chemoradiation in Patients With Locally Advanced Cervical Cancer: Technical Aspects and Operative Outcomes

Objective

This study aimed to evaluate the feasibility and safety of laparoscopic extrafascial hysterectomy and bilateral salpingo-oophorectomy after primary chemoradiation (CRT) in patients with locally advanced cervical cancer (LACC) without evidence of nodal metastasis.

Background

Currently, the standard of care for patients with advanced cervical cancer is concurrent CRT. There is an unequivocal correlation between presence of residual disease and risk of local relapse. Nevertheless, the importance of hysterectomy in adjuvant setting remains controversial.

Methods

Prospective study with patients affected by bulky LACC (International Federation of Gynecology and Obstetrics stage IB2 up to IIB) treated initially with radical CRT who underwent laparoscopic surgery 12 weeks after therapy conclusion. Inclusion criteria were absence of signs for extrapelvic or nodal involvement on initial imaging staging, as well as complete clinical and radiologic response.

Results

From January 2011 to March 2013, 33 patients were endoscopically operated. The mean age was 44 years (range, 21–77 years). Histologic finding revealed squamous cell carcinoma in 19 (60%) cases and adenocarcinoma in 14 (40%) cases. International Federation of Gynecology and Obstetrics stages distribution were as follow: 1B2, n = 3 (9%); IIA, n = 4 (11%); and IIB, n = 26 (80%). The mean pretherapeutic tumor size was 5.2 cm (range, 4–10.2 cm). Estimated blood loss was 80 mL (range, 40–150 mL), and mean operative time was approximately 104 minutes (range, 75–130 minutes). No casualty or conversion to laparotomy occurred. Hospital stay was in average 1.7 days (range, 1–4 days). Significant complication occurred in 12% of the cases; 2 vaginal vault dehiscence, 1 pelvic infection, and 1 ureterovaginal fistula. Nine (27%) patients had pathologic residual disease, and in 78% of these cases, histologic finding was adenocarcinoma (P = −0.048). All patients had free margins. After median follow-up of 16 months, all women have no signs of local recurrence.

Conclusions

Laparoscopic extrafascial hysterectomy (completion surgery) after primary CRT in patients with apparent node-negative LACC is a feasible and safe strategy to improve tumor local control mainly in cases of adenocarcinoma.