Risk of Undetected Cancer at the Time of Laparoscopic Supracervical Hysterectomy and Laparoscopic Myomectomy: Implications for the Use of Power Morcellation

Abstract

BackgroundPower morcellation during gynecological procedures may cause seeding of undiagnosed cancers. We used a national database to determine the prevalence of malignant and premalignant conditions that were present but undetected at the time of laparoscopic supracervical hysterectomy and laparoscopic myomectomy, surgeries in which morcellation is commonly used. MethodsData from 2007 to 2012 were obtained from MarketScan, an administrative database of diagnostic and treatment data for 55.7 million commercially insured women in the United States. Because power morcellation is not captured with billing codes, we limited our analysis to women undergoing procedures that typically use morcellation and that are contraindicated in the case of suspected malignancy to describe the rates at which undetected cancers occur, thus potentially putting patients at risk for seeding of malignant tissue. We defined the rate of preoperative endometrial biopsy and postoperative cancers and hyperplasia by manually reviewing inpatient and outpatient International Classification of Disease, 9th edition, and Current Procedural Terminology codes for all suspected cases. ResultsIn all, 17,903 women underwent laparoscopic supracervical hysterectomy and 1,603 underwent laparoscopic myomectomy. The rate of uterine cancer among women undergoing hysterectomy was 2.96 per 1000 and increased with age from 0 per 1,000 at age younger than 35 to 9.07 per 1,000 at ages 55 to 64 (p < .05 for age ≥45 compared with <45). Preoperative endometrial biopsy was documented in 47% of women subsequently diagnosed with uterine cancer. The overall rate of malignant and premalignant gynecological conditions was 5.14 per 1,000 for laparoscopic supracervical hysterectomy and 1.87 per 1,000 for laparoscopic myomectomy. ConclusionApproximately 1 in 350 women undergoing laparoscopic supracervical hysterectomy had an undiagnosed uterine cancer, with higher risks among older women. Approximately one-half of women had endometrial biopsies documented before hysterectomy. Safer alternatives, such as contained morcellation, should be evaluated to reduce the risk of complications after morcellation procedures.