The Role of Power Morcellation and Controversies

Abstract

A large proportion of women with uterine prolapse will undergo hysterectomy at the time of surgical pelvic organ prolapse (POP) repair. Abdominal sacrocolpopexy with concomitant hysterectomy (total vs. supracervical), the gold standard for POP repair, can be performed laparoscopically with or without robotic assistance to afford less pain, faster recovery, improved quality of life, and reduced morbidity and mortality. While the majority of women with POP are candidates, these minimally invasive surgical techniques frequently require morcellation, in which the surgical specimen is reduced in size with a bladed electromechanical instrument (“power morcellation”). After a few highly publicized cases documented the potential intra-abdominal spread of cancer in patients with presumed fibroids who harbored an undiagnosed uterine sarcoma, the FDA issued a black-box warning against the use of morcellation, which has made the technique unavailable to many women. While the existing data regarding the risk of uterine sarcomas in patients with presumed fibroids is poor, meta-analyses suggest that the risk of leiomyosarcoma in women with symptomatic fibroids who have undergone an appropriate preoperative assessment is very low, approximately 0.02%. For those with occult malignancy who undergo unintended morcellation, there is a significant risk of worsening their cancer outcomes. However, the real impact of morcellation on outcomes remains unclear. While it is necessary to continue developing new technologies, population-level modeling suggests that restrictions on the use of this current technology will be costly to society, both monetarily and through increased patient morbidity and mortality.