Hospital variation in responses to safety warnings about power morcellation in hysterectomy

BACKGROUND

Safety warnings about power morcellation in 2014 considerably changed hysterectomy practice, especially for laparoscopic supracervical hysterectomy that typically requires morcellation to remove the corpus uteri while preserving the cervix. Hospitals might vary in how they respond to safety warnings and altered hysterectomy procedures to avoid use of power morcellation. However, there has been little data on how hospitals differ in their practice changes.

OBJECTIVE

This study aimed to examine whether hospitals varied in their use of laparoscopic supracervical hysterectomy after safety warnings about power morcellation and compare the risk of surgical complications at hospitals that had different response trajectories in use of laparoscopic supracervical hysterectomy.

STUDY DESIGN

This was a retrospective analysis of data from the New York Statewide Planning and Research Cooperative System and the State Inpatient Databases and State Ambulatory Surgery and Services Databases from 14 other states. We identified women aged ≥18 years undergoing hysterectomy for benign indications in the hospital inpatient and outpatient settings from October 1, 2013 to September 30, 2015. We calculated a risk-adjusted utilization rate of laparoscopic supracervical hysterectomy for each hospital in each calendar quarter after accounting for patient clinical risk factors. Applying a growth mixture modeling approach, we identified distinct groups of hospitals that exhibited different trajectories of using laparoscopic supracervical hysterectomy over time. Within each trajectory group, we compared patients' risk of surgical complications in the prewarning (2013Q4-2014Q1), transition (2014Q2-2014Q4), and postwarning (2015Q1-2015Q3) period using multivariable regressions.

RESULTS

Among 212,146 women undergoing benign hysterectomy at 511 hospitals, the use of laparoscopic supracervical hysterectomy decreased from 15.1% in 2013Q4 to 6.2% in 2015Q3. The use of laparoscopic supracervical hysterectomy at these 511 hospitals exhibited 4 distinct trajectory patterns: persistent low use (mean risk-adjusted utilization rate of laparoscopic supracervical hysterectomy changed from 2.8% in 2013Q4 to 0.6% in 2015Q3), decreased medium use (17.0% to 6.9%), decreased high use (51.4% to 24.2%), and rapid abandonment (30.5% to 0.8%). In the meantime, use of open abdominal hysterectomy increased by 2.1, 4.1, 7.8, and 11.8 percentage points between the prewarning and postwarning periods in these 4 trajectory groups, respectively. Compared with the prewarning period, the risk of major complications in the postwarning period decreased among patients at "persistent low use" hospitals (adjusted odds ratio, 0.88; 95% confidence interval, 0.81-0.94). In contrast, the risk of major complications increased among patients at "rapid abandonment" hospitals (adjusted odds ratio, 1.48; 95% confidence interval, 1.11-1.98), and the risk of minor complications increased among patients at "decreased high use" hospitals (adjusted odds ratio, 1.31; 95% confidence interval, 1.01-1.72).

CONCLUSION

Hospitals varied in their use of laparoscopic supracervical hysterectomy after safety warnings about power morcellation. Complication risk increased at hospitals that shifted considerably toward open abdominal hysterectomy.

Disseminated ovarian granulosa cell tumor after laparoscopic surgery: Two case reports

RATIONALE

Granulosa cell tumors (GCT) have an incidence of 0.6 to 0.8/100,000. Short-term relapsed ovarian GCT is extremely rare. Herein, this report aims to present 2 rare cases of disseminated ovarian GCT and analyze the causes of recurrence.

PATIENT CONCERNS

The 2 patients presented with abdominal pain.

DIAGNOSIS

Both the patients were diagnosed with relapsed ovarian GCT (IIIc stage) in the adult type.

INTERVENTIONS

The 2 patients had a medical history of surgery for ovarian GCT by using laparoscopic with power morcellators (LPM). They experienced relapsed ovarian GCT postoperatively. Subsequently, they received a repeated operation through a laparotomy approach. Numerous malignant metastasis neoplasms were detected at the port-sites. Then, tumor resection was performed.

OUTCOMES

The postoperative pathologies of both case 1 and case 2 reported ovarian GCT (IIIc stage) in adult type. The 2 patients presented disease-free survival for more than 33 months follow-up period.

LESSONS

The application of LPM may be a risk factor of disseminated ovarian GCT. However, laparoscopic surgery is still an optimal treatment strategy for ovarian tumors. Besides, gynecologists should comply with the tumor-free principle during surgery.

Ectopic leiomyoma as a late complication of laparoscopic hysterectomy with power morcellation: a case report and review of the literature

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.

Reasons to Reconsider Risk Associated With Power Morcellation of Uterine Fibroids

Our insights into the molecular pathogenesis of uterine smooth muscle tumors have improved significantly. Accordingly, in the present review, we advocate a more refined risk assessment for patients considering surgical removal of fibroids or hysterectomy, respectively, requiring morcellation. For this procedure, the risk estimates given for the iatrogenic spread of a previously unexpected malignancy considerably vary among different studies. Nearly all previous studies conducted retrospectively refer to the risk of a patient having an unexpected malignancy at the time of surgery. We feel that, more appropriately, risk should refer to the number of tumors because, as a rule, every single nodule arises independently and, thus, carries an independent risk of being malignant or not. Furthermore, whether so-called parasitic fibroids carry an underestimated risk of stepwise malignant transformation is discussed.

The impact of recent power morcellator risk information on inpatient surgery and patient outcomes

Aim: We examine the impact of the new risk information about a surgical device on surgery and patient outcomes for hysterectomy in the inpatient setting. Methods: We utilize a difference-in-differences approach to assess the impact of new risk information on patient outcomes in the inpatient setting between 2009 and 2014. The inpatient data come from a nationally representative sample of hospitalizations in the USA. We use the likelihood of laparoscopic surgery, measures of resource use and surgical complications as outcome variables. Results: We estimate a three-percentage point decrease in the likelihood of receiving laparoscopic hysterectomy, a one-percentage point increase in the likelihood of experiencing a surgical complication and no impact on resource use, relative to pre-existing means. Conclusion: Our findings show that there was movement away from laparoscopic surgery in the months following the dissemination of new risk information. These changes had limited effect on patient outcomes.

Occult uterine malignancy during laparoscopic supracervical hysterectomy

OBJECTIVES

To estimate the incidence of occult uterine malignancies during laparoscopic supracervical hysterectomy (LSH).

MATERIAL AND METHODS

Retrospective cohort study based on archival data (2010-2016) of the Department of Gynecology and Oncology, Jagiellonian University.

RESULTS

Medical records of 696 women, who underwent LSH were analyzed. Two occult sarcomas (2/696; 0.29%, 0.003, 95% CI: 0.001 to 0.01), including one case of low-grade endometrial stromal sarcoma (ESS) with co-occurring atypical endometrial hyperplasia (AH) and one case of high-grade ESS were found postoperatively. One case of invasive primary fallopian tube cancer (1/696; 0.14%, 0.001, 95% CI: 0.00 to 0.008) and additional three cases of AH (3/696; 0.57%, 0.004, 95% CI: 0.001 to 0.013) were also identified. No case of EC was documented. One hundred sixty nine (24.3%) women of 696 had an endometrial sampling prior LSH including these with ESS. We did not observe worsening of the prognosis and all patients with confirmed malignancy are still alive and free from recurrence in 2-5 years of observations.

CONCLUSIONS

Most commonly the occult malignancy would have not been recognized if the surgery had not been conducted. When appropriate diagnostics is conducted, rare incidents of malignant tissue morcellation should not be considered as a professional misconduct but as a possible adverse event. Patients should be informed about the risk of malignancy according to available estimations and that endometrial sampling cannot eliminate such a risk. A consensus regarding safe indications, required diagnostics, and justifiability of mandatory use of contained morcellation for LSH should be developed.

A case of disseminated peritoneal leiomyomatosis after two laparoscopic procedures due to uterine fibroids

Disseminated peritoneal leiomyomatosis (DPL) is a rare disorder characterized by the presence of multifocal nodules and tumors composed of proliferating smooth muscle tissue, spread throughout the peritoneum. Estrogens and progesterone are considered to be the main factors initiating the formation of disseminated leiomyomatosis. Disseminated peritoneal leiomyomatosis is often asymptomatic, and acyclic vaginal bleeding or pain in the lower abdomen is associated with leiomyomatous rebuilt uterus corpus. Disseminated peritoneal leiomyomatosis can have other ambiguous presentation. The difficulty in DPL diagnosis is that it is not always accompanied by scattered leiomyomas and can occur after menopause. Some cases of DPL are associated with surgical procedures on uterine fibroids, especially with the use of a morcellator. We present the case of a 39-year-old woman with DPL who underwent laparoscopic myomectomy and laparoscopic supracervical hysterectomy before the final diagnosis of DPL. After the complete surgical treatment performed in our center the patient is free of symptoms.

In-bag manual vs 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]

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.

Uterine sarcomas and parasitic myomas after laparoscopic hysterectomy with power morcellation

OBJECTIVE

The purpose of this study was to describe the incidence and risk factors for uterine sarcomas and parasitic myomas at the time of power morcellation.

STUDY DESIGN

We performed a retrospective review of 3523 women who underwent laparoscopic hysterectomy from 2001-2012. Univariate analyses were used for the morcellation cases to identify potential risk factors. Multivariable logistic regression was performed.

RESULTS

Nine hundred forty-one patients underwent power morcellation at the time of hysterectomy; 10 of 941 patients (1.1%) were diagnosed subsequently with uterine sarcomas or parasitic myomas. The overall incidence of uterine sarcoma was 6 of 941 (0.6%), with a median age of 47 years (range, 41-52 years). There was no association among any of the factors analyzed and uterine sarcoma. Three of 6 patients had sarcoma diagnosed on initial pathologic evaluation of the morcellated specimen; 3 patients had delayed diagnosis of sarcoma with benign disease at the time of the initial procedure (median time to second evaluation, 6 years). For parasitic myomas (n=4), the median age was 35 years (range, 32-40 years), and the median time to second evaluation was 5 years. On multivariate analysis, age<40 years (odds ratio, 26; 95% confidence interval, 2.7015-261.9; P≤.01) was associated with higher risk of the development of parasitic myomas.

CONCLUSION

Uterine sarcoma was found in 0.6% of patients who underwent power morcellation but was not found to be associated significantly with any preoperative factors. All 6 cases were noted to have apparent fibroid tumors as an indication for their hysterectomy. Age<40 years was a risk factor for parasitic myomas after power morcellation. Patients should be counseled about these complications before power morcellation.