Use Of Power Morcellation Research Articles

Myomectomy: Choosing the Surgical Approach - A Systematic Review.

Myomectomy has evolved from open laparotomy to laparoscopy, hysteroscopy, VNOTES and robotic myomectomy. The surgical approach in doing myomectomy depends on the type and location of the myoma and the surgeon's expertise. Minimally invasive surgery has been the preferred approach due to the benefit of shorter hospital stay, lesser postoperative pain, earlier recovery, minimal blood loss and the cosmetic appearance of the scar. The success of this procedure depends on the incision technique, enucleation, and blood loss prevention by using hemostatic techniques and suturing techniques. Performing myomectomy for a large uterine myoma is a laparoscopic challenge; however, with the use of Lee-Huang point (midpoint between umbilicus and xiphoid) as the primary insertion and camera port, one can easily navigate thru the abdominal cavity in case the uterus is huge obscuring the umbilical port. Laparoscopic Myomectomy can be safely and efficiently performed by experienced laparoscopic surgeons regardless of myoma size, number and location. Removal of large myoma specimen from the abdominal cavity through the laparoscope became a challenge after the use of power morcellator was abandoned. To overcome this problem, the large myoma is placed inside an Endo bag and its edges brought extracorporeally through the port site. The myoma is incised in a C-manner using a scalpel to reduce the size. Myoma can also be removed using in-bag power morcellation. Fertility preservation is the long-term aim of doing myomectomy instead of hysterectomy in the management of leiomyoma aside from alleviating symptoms of abnormal uterine bleeding, urinary frequency and abdominal pain.

Use of power morcellation during minimally-invasive gynaecological procedures in Poland

Use of power morcellation during minimally-invasive gynaecological procedures in Poland

Myomectomy - Choosing the Surgical Approach

In patients who are desirous of future pregnancy and choose to preserve the uterus, myomectomy is the best surgical option where medical management is not suitable for the patient. Myomectomy was initially performed successfully in 1840 by Amussat and the procedure has evolved from open laparotomy to laparoscopy, hysteroscopy, VNOTES and robotic myomectomy. The surgical approach in doing myomectomy depends on the type and location of the myoma and the surgeon’s expertise. Minimally invasive surgery has been the preferred approach due to the benefit of shorter hospital stay, lesser postoperative pain, earlier recovery, minimal blood loss and the cosmetic appearance of the scar. The success of this procedure depends also on the incision technique, enucleation, blood loss prevention by employing hemostatic techniques as well as suturing techniques. Performing myomectomy for a large uterine myoma is a laparoscopic challenge; however, with the use of Lee-Huang point (midpoint between umbilicus and xiphoid) as the primary insertion and camera port, one can easily navigate thru the abdominal cavity in case the uterus is huge obscuring the umbilical port. Laparoscopic Myomectomy can be safely and efficiently performed by experienced laparoscopic surgeons regardless of myoma size, number, and location. Removal of large myoma specimen from the abdominal cavity through the laparoscope became a challenge after the use of power morcellator was abandoned. To overcome this problem, the large myoma is placed inside an Endo bag and its edges brought extracorporeally through the port site. The myoma is incised in a C-manner using a scalpel to reduce the size. Myoma can also be removed using in-bag morcellation. Fertility preservation is the long-term aim of doing myomectomy instead of hysterectomy in the management of leiomyoma aside from alleviating symptoms of abnormal uterine bleeding, urinary frequency, and abdominal pain. Thus, every procedure should perform under patient centered concept.

Effect of tumor morcellation in patients with early uterine sarcoma: a multicenter study in Germany

Objective:The use of power morcellation at laparoscopy may worsen survival rates for patients with malignancy. The aim of the present study was to report the outcome of patients with early-stage uterine sarcoma after morcellation or total en-bloc resection, and evaluate potential signs of sarcoma preoperatively.Material and Methods:This multicenter retrospective study consisted of patients, who underwent surgery for FIGO-stage-1 uterine sarcoma. Twenty-four patients were divided into a non-morcellation group and a morcellation group. Clinical records and the outcomes of patients, including one-, three- and five-year survival rates were reviewed. Preoperative characteristics of patients with sarcoma were compared to those of a control group with uterine myoma (1:4 ratio), matched by age and type of operation.Results:Obesity was an independent risk factor for uterine myoma. Tumor growth, solitary growth, largest-diameter lesion >8.0 cm, and anechoic areas suggesting necrosis and increased vascularization were significantly more common in the sarcoma group. A large tumor diameter was significantly associated with mortality. Patients in the non-morcellation group had a slightly lower disease-free survival, but poorer overall survival (OS) rates compared to patients in the morcellation group, but neither difference was statistically significant. Patients in the non-morcellation group, who had undergone a re-exploration experienced late recurrence, but no upstaging was evident after the operation.Conclusion:Preoperative ultrasound characteristics could be useful to distinguish sarcoma from leiomyoma of uterus. Morcellation of a sarcoma may increase abdominal and pelvic recurrence rates, but may not be associated with OS in patients with FIGO-stage-1 disease.

Current Methods of Tissue Extraction in Minimally Invasive Surgical Treatment of Uterine Fibroids.

Background and Objectives:Since the 2014 Food and Drug Administration communication regarding the use of power morcellation, gynecologists have adopted alternative tissue extraction strategies. The objective of this study is to investigate the current techniques used by gynecologic surgeons for tissue extraction following minimally invasive hysterectomy or myomectomy for fibroids.Methods:An online survey was distributed to all AAGL members and responses were collected between March 26, 2019 and April 17, 2019.Results:Four hundred thirty-six respondents completed the survey. For hysterectomy, the most common methods of tissue extraction were manual morcellation through the colpotomy (72.4%) or minilaparotomy (66.9%). Nearly one-third (31.7%) endorsed using power morcellation. For myomectomy, manual morcellation via minilaparotomy (71.9%) was the most common approach, followed by power morcellation (35.7%). Use of containment bags was common. Minilaparotomy incisions were typically three cm and most often at the umbilicus.Geographic differences were detected, particularly with power morcellation. During hysterectomy, 18.4% of US-based surgeons reported its use, compared to 56.9% of nonUS-based surgeons. During myomectomy, 20.5% of US-based surgeons reported its use compared to 67.5% of their international counterparts. Age, years in practice, fellowship training, and practice location were all significantly associated with power morcellator use.Conclusion:A large majority of practitioners are performing manual morcellation through the colpotomy or minilaparotomy. Use of containment bags is common with all routes of tissue removal. Power morcellation use is less common in the United States than in other countries.

Impact of Intraoperative Tumor Spillage in Uterine Leiomyosarcoma: a Retrospective Single-Institution Analysis.

Uterine leiomyosarcoma is a rare female reproductive system tumor which is difficult to distinguish from uterine leiomyoma preoperatively. Manual and power morcellation are used to remove the large uterus through the vagina or small abdominal incision. Worse outcome with use of power morcellation is now clear but impact of manual morcellation on survival outcome not established till date. The objective of the present study was to find impact of tumor spillage and to evaluate influencing factors for oncological outcome and prognosis in uterine leiomyosarcoma patients. This is a single-institutional retrospective cohort study including all uterine leiomyosarcoma patients from January 2005 to December 2017. Role of intraoperative tumor spillage and other influencing factors on oncological outcome were assessed. Thirty-three patients with median follow-up period of 49.7months were evaluated. Stage 1 and absence of tumor spill had significant association with prolonged progression-free survival. Stage 1 uterine leiomyosarcoma (56.8 vs 6.8months, p = < 0.001), intraoperative tumor spillage (p = 0.03) and progression-free survival > 15months (68.5 vs 12.2months, p = < 0.001) were favourable prognostic factors to predict better survival outcome but unable to establish significance on multivariate analysis. Survival plot did not reach median limit for stage I uterine leiomyosarcoma patients with preoperative suspicion. Age, site of recurrence and mitotic index had no significant association with better survival in the present study. Stage I disease and absence of tumor spillage during surgery improved progression-free survival but did not affect overall survival. Progression-free survival more than 15months can predict better overall survival.

Morcellation in gynecology: short review and suggestions from Turkish Society of Minimally Invasive Gynecologic Oncology

Morcellation allows the removal of a large uterus and fibroids through small incisions with minimally invasive surgery. It helps to prevent the complications associated with large incisions in both hysterectomy and myomectomy operations. Currently, there is much debate regarding the use of power morcellation in laparoscopic hysterectomy and myomectomy, mainly due to the risk of peritoneal dissemination of undiagnosed uterine sarcomas. Unfortunately, there is no valid pre-operative diagnostic method that can differentiate sarcomas from myomas, and the currently available scientific literature regarding morcellation is insufficient. As the Turkish Society of Minimally Invasive Gynecological Oncology, we present our consensus opinion and suggestions for the preoperative evaluation and morcellation of fibroids, in line with the recent literature.

Preoperative MRI and LDH in women undergoing intra-abdominal surgery for fibroids: Effect on surgical route.

Our institution implemented a preoperative protocol to identify high-risk cases for which power morcellation should be avoided. In this retrospective cohort study, an institutional protocol requiring preoperative Magnetic Resonance Imaging with diffusion-weighted imaging and serum Lactate Dehydrogenase levels was implemented. Chart review was performed including all women who underwent intra-abdominal surgery for symptomatic fibroids from 4/23/2013 to 4/23/2015. A total of 1,085 women were included, 479 before and 606 after implementation of the Magnetic Resonance Imaging / Lactate Dehydrogenase protocol. The pre-protocol group had more post-menopausal women (4% vs. 2%, p = 0.022) and women using tamoxifen (2% vs. 0%, p = 0.022) than those in the post-protocol group, but baseline patient characteristics were otherwise similar between groups. Incidence of malignant pathological diagnoses did not change significantly over the time period in relation to protocol implementation. The rate of open surgery for both hysterectomy and myomectomy remained the same in the year preceding and the year following initiation of the protocol (open hysterectomy rate was 19% vs. 16% in pre- and post-protocol groups, respectively, P = 0.463, and open myomectomy rate was 10% vs. 9% rates in pre- and post-protocol groups, respectively, P = 0.776). There was a significant decrease in the use of power morcellation (66% in pre- and 50% in post-protocol cohorts, p<0.001) and an increased use of containment bags (1% in pre- and 19% in post-protocol cohort). When analyzing the subset of women who had abnormal Magnetic Resonance Imaging / and Lactate Dehydrogenase results, abnormal Magnetic Resonance Imaging results alone resulted in higher rates of open approach (65% for abnormal vs. 35% for normal). Similarly, a combination of abnormal Magnetic Resonance Imaging and Lactate Dehydrogenase tests resulted in higher rates of open approach (70% for abnormal and 17% for normal). Abnormal Lactate Dehydrogenase results alone did not influence route. Rates of MIS procedures were decreased for women with abnormal preoperative Magnetic Resonance Imaging results. False positive results appear to be one of the main drivers for the use of an open surgical route.

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

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. 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. 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. 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). 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.

2538 Current Methods of Tissue Extraction in Minimally Invasive Surgical Treatment of Uterine Fibroids

Study Objective Since the 2014 Food and Drug Administration warnings regarding the use of power morcellation, gynecologists have adopted multiple alternative tissue extraction strategies. The objective of this study is to investigate the current techniques used by minimally invasive gynecologic surgeons for tissue extraction following minimally invasive hysterectomy for fibroids. Design Web-based survey. Setting N/a Patients or Participants Current AAGL members were sent a link to access the survey, which was available from March 26, 2019 to April 17, 2019. Interventions N/a. Measurements and Main Results 420 respondents completed the survey. The most common methods of tissue extraction were manual morcellation through the colpotomy (72.4%) and mini-laparotomy (66.9%). 31.7% of all participants endorsed the use of power morcellation. Intact specimen removal through a laparotomy was reported by 10% of respondents. Other methods of tissue extraction, such as intra-abdominal manual morcellation with a laparoscopic scalpel, were reported by 1.4%. Use of containment bags was reported by 43.4% during vaginal morcellation, 83.6% during mini-laparotomy, and 56.8% during power morcellation. Mini-laparotomies were on average 3.5cm and most commonly located at the umbilicus. Geographic differences were seen with respect to power morcellation, with 18.4% of US-based surgeons reporting its use compared to 56.9% of non-US-based surgeons. Conclusion Minimally invasive gynecologic surgeons are currently employing a variety of tissue extraction strategies for hysterectomy for fibroids. A large majority of practitioners are performing manual morcellation through the colpotomy and/or mini-laparotomy; use of containment bags is more common with during mini-laparotomy than via colpotomy. Power morcellation is still in use, less commonly in the United States than in other countries, and usually within a containment system.

1364 Tips & Tricks: Step by Step How to Do Two-Port Contained Power Morcellation in A Specialized Bag

Video Objective To explain and demonstrate: 1. Laparoscopic port placement, 2. Step by step technique for the two-port contained power morcellation in a specialized bag (Morcellation Containment System by Espiner Medical), 3. Tips and tricks on each step of contained morcellation Setting Risks of electromechanical morcellation are spreading undiagnosed cancer, diffuse leiomyomatosis, and visceral injury. Food and Drug Administration (FDA) safety communication discouraged use of power morcellators for leiomyoma extraction after the case of disseminated leiomyosarcoma following a laparoscopic hysterectomy. Since FDA warning, laparoscopic contained (in bag) morcellation became popular. However, it can be challenging. Interventions A 27 years old, G0P0, woman was presented with heavy periods and pelvic pain. Her medical and surgical history was unremarkable. Ultrasound showed and anterior/broad ligament fibroid with size of 7.6 × 5.2 × 5.5 cm. After discussing the treatment option, she was consented and had laparoscopic myomectomy and two-port contained morcellation in a specialized bag. Post-operative care was uneventful. Patient was discharged home same day. Histopathology showed benign fibroid. Conclusion The Morcellation Containment System is a feasible tool to extract a pelvic mass. However, it is important to be aware of its challenges like any other contained morcellation system.

1665 Trends in Extraction Techniques in Minimally Invasive Myomectomies: A Retrospective Study

Study Objective Our study aims to evaluate how the FDA's 2014 recommendation against the use of power morcellation for tissue extraction in minimally invasive myomectomies changed surgical approach at our hospital system. Our study investigated rates of laparoscopic versus abdominal myomectomies, and for laparoscopy, trends in mode of tissue extraction and resultant perioperative outcomes. Design Retrospective cohort study. Setting Southern California Kaiser Foundation Hospitals. Patients or Participants Women undergoing a laparoscopic or robot-assisted laparoscopic myomectomy involving tissue morcellation from 2008 to 2018. Interventions One of 3 morcellation techniques: electronic power morcellation (PM), manual morcellation via minilaparotomy (ML), or contained power morcellation in a bag (CM). Measurements and Main Results A total of 3259 myomectomies were performed at our hospital system from 2008 to 2018. Rate of abdominal versus minimally invasive myomectomies, estimated blood loss, length of operation and hospital stay, major post-operative complications, and hospital re-admission were compared in the six years before and the four years after the FDA warning. A total of 151 laparoscopic cases were performed during the study period. The cohort was 38% Hispanic, 32% Black, 15% White, and 12% Asian. Mean age was 37 (SD 7.31). Mean BMI was 28 (SD 7.16). Prior to the FDA announcement, tissue extraction methods were 75% PM, 5% ML, and 9% CM. After the announcement, 0% PM, 34% ML, and 57% CM (Pearson chi = 93.28). There was no difference in complications in aggregate or individually between tissue extraction method. Conclusion Minimally invasive myomectomies make up a small portion of total myomectomies performed. For these cases, however, the FDA notice did, nonetheless, change surgical practice in regards to tissue extraction methods. There were no significant differences found among the tissue extraction techniques with regard to estimated blood loss, major post-operative complications, operating time, length of hospital stay or hospital re-admission.

Laparoscopic Approach to the Difficult Trachelectomy: Surgical Tips and Tricks

Video Objective The objective of this video is to present a stepwise approach to completing difficult trachelectomies and to review relevant anatomy. Setting Supracervical hysterectomy was once a popular procedure, accounting for 7.5% of hysterectomies in 2004, secondary to purported benefits over total hysterectomy. With mounting evidence that there are no advantages to this technique, in addition to limitations on the use of power morcellators, the supracervical approach has fallen out of favor. Five to 10% of patient will continues to have bothersome bleeding following a supracervical hysterectomy. In this video we present a patient with complaints of pelvic pain and vaginal bleeding nine years after undergoing supracervical hysterectomy for dysmenorrhea. She reports that the planned procedure was a total hysterectomy, however at the time of surgery, obliteration of the anterior culdesac was encountered and the planned procedure was not completed. She desired definitive management. Interventions Laparoscopic trachelectomy with ureteral stent placement and removal via cystoscopy. Conclusion Post-hysterectomy laparoscopic trachelectomies can be challenging in the presence of known pelvic adhesive disease. Success is achievable through familiarity with key anatomical structures and relationships along with following a stepwise approach.

Parasitic Pelvic and Infradiaphragmatic Leiomyomatosis Following Laparoscopic Myomectomy

Purpose: Uterine leiomyomas are the most common indication for gynecological surgery. The use of power morcellators has facilitated myomectomy, but appears to be associated with leiomyoma seeding, leading to parasitic leiomyomatosis. This is a case report of a patient with parasitic leiomyomatosis following laparoscopic myomectomy, which was detected incidentally during elective gallbladder surgery. Case Report: A 42-year-old female was treated for symptomatic cholelithiasis in July 2018 by elective laparoscopic cholecystectomy. Three years earlier, the patient had undergone laparoscopic myomectomy using a power morcellator for the removal of a subserosal uterine fibroid 21 cm in diameter. During laparoscopy, a firm nodule, roughly 2 cm in diameter was observed on the right infradiaphragmatic surface, and two smaller, similar pelvic nodules. The infradiaphragmatic nodule was excised and histopathological examination identified it as leiomyoma tissue, confirming the case as parasitic leiomyomatosis. Discussion: Parasitic leiomyomatosis is a rare entity first described in 1909. Reports of its incidence have increased since the advent of laparoscopic surgery for the treatment of uterine fibroids and there appears to be an association with the use of power morcellators for fragmentation of large myomas, which may promote seeding. Parasitic myoma cells display increased expression of estrogen and progesterone receptors, and increased angiogenetic capacities compared with their uterine counterparts. Further studies are required to ascertain whether power morcellators play a key role in myoma dissemination, and to evaluate possible therapeutic solutions.

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

To evaluate the incidence of leiomyosarcoma (LMS) at surgery for presumed uterine myomas according to different age groups. A retrospective cohort study. A tertiary referral hospital. All women undergoing surgery for presumed uterine myomas between January 1, 2006, and December 31, 2016. Laparoscopic myomectomy, laparotomic myomectomy, total hysterectomy, or hysteroscopic myomectomy. 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%). 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.

Uterine sarcoma: a clinical case and a literature review.

Uterine sarcomas are rare gynaecologic tumours representing 3-7% of all uterine malignancies. The aetiology of sarcomas is still unclear: it is thought, that chromosomal translocations have influence on wide histological variety of sarcomas. Presenting symptoms are vague and nonspecific. Usually sarcoma causes abnormal vaginal bleeding, can cause abdominal or pelvic pain, or manifests as a rapidly growing uterine tumour. The diagnosis of sarcoma is often made retrospectively after surgical removal of a presumed benign uterine neoplasm, because imaging modalities such as ultrasound, computed tomography, or magnetic resonance imaging cannot yet accurately and reliably distinguish between benign leiomyoma and malignant pathology. If there are certain clinical features that raise a suspicion of malignancy in the uterus, it is recommended to avoid the use of power morcellation through laparoscopic surgery in order to prevent disease dissemination. We present a clinical case of a 64-year-old patient, who was referred to hospital due to abdominal pain and tenesmus that lasted for two days. From a past medical history it was known that previously the patient had been diagnosed with uterine myoma. Transvaginal ultrasonography showed a 10.4 cm × 9.8 cm uterine tumour of nonhomogeneous structure with signs of necrosis and good vascularization. The patient refused urgent hysterectomy, that was advised to her. The patient was operated on one month later and total hysterectomy with bilateral salpingooforectomy was performed. Postoperative histological evaluation showed undifferentiated sarcoma uterus pT1b L/V0. Imaging modalities were made to evaluate possible dissemination of the disease. In the absence of signs of disease progression, the patient received radiotherapy and brachytherapy and was followed-up by doctors. Uterine sarcomas are highly malignant tumours that originate from smooth muscles and connective tissue elements of the uterus and make up 1% of all malignant gynaecological tumours and about 3-7% of all malignant uterine tumours. Imaging modalities cannot yet reliably distinguish benign myomas from malignant sarcomas. It is important not to damage the wholeness of uterus during operation in order to prevent dissemination of the disease in the abdominal cavity. The low-grade endometrial stromal sarcoma has the best survival prognosis, while carcinosarcoma and undifferentiated uterine sarcoma have the lowest survival rates.

Racial Disparities in Response to a US Food and Drug Administration Safety Communication Regarding the Use of Power Morcellation for the Treatment of Uterine Leiomyoma

Study ObjectiveTo investigate whether the rate of increase in the performance of abdominal myomectomy over a laparoscopic approach after the US Food and Drug Administration (FDA) safety communication regarding morcellator use for myomectomy differs among races. DesignRetrospective cohort study. SettingThe American College of Surgeons National Surgical Quality Improvement data. PatientsPatients aged 18 to 55 years who underwent either laparoscopic or abdominal myomectomy, excluding malignant cases, emergency cases, operations performed by nongynecologic specialists, and cases in which myomectomy was performed during cesarean section. InterventionsNone. Measurements and Main ResultsThe odds ratios of abdominal myomectomy over laparoscopic myomectomy before and after the release of the FDA communication were calculated in 3 race categories: white, African American, and other races. In a logistic regression analysis adjusted for possible confounders, including all races, the odds ratio of abdominal myomectomy before and after the FDA communication was 1.30 (95% confidence interval [CI], 1.20–1.41; p <.001). In a logistic regression analysis with a product term of FDA communication exposure and race as a possible effect modifier, the African American population showed a significantly greater change in the odds of abdominal myomectomy over laparoscopic myomectomy in comparison with the white population (1.22; 95% CI, 1.02–1.47; p = .03). In contrast, other races showed no significant change (.83; 95% CI, .64–1.08; p = .17). ConclusionAfter the FDA communication, the odds ratio of abdominal myomectomy was disproportionately increased in the African American population.

Incidence of sarcoma in patients undergoing hysterectomy for benign indications: a population-based study

Minimally invasive hysterectomy may require the use of morcellation to remove the uterus. In the presence of unexpected sarcoma, morcellation risks disseminating malignant cells and worsening survival outcomes. As a consequence, in 2014 the US Food and Drug Administration issued a black box warning against the use of power morcellator for the treatment of uterine fibroids. However, the proportion of unexpected sarcoma at the time of hysterectomy for presumed benign indication remains unclear. The objective of the study was to estimate the incidence of sarcoma among women undergoing hysterectomy for benign indication in Olmsted County, MN, between 1999 and2013. We conducted a population-based study including all hysterectomies performed for benign indication in Olmsted County women between Jan. 1, 1999, and Dec. 31, 2013. Cases were identified using the medical records-linkage system of the Rochester Epidemiology Project, and data were abstracted by a gynecologist who reviewed the complete medical records of eachwoman who underwent hysterectomy. An expert pathologist reviewed the pathologic slides of each sarcoma to ensure the accuracy of thediagnosis. Incidences of sarcoma (overall and by type of sarcoma) were estimated both overall and stratified by menopausal status, indication for surgery, and uterine weight as a rate per 100 persons. A total of 4232 hysterectomies were performed during the study period. Among them, we identified 16 sarcomas, of which 11 (69%) were suspected preoperatively and 5 (31%) were unexpected. Of the total number of hysterectomies, 3759 (88.8%) were performed for benign indication. Among those, the incidence of unexpected sarcoma was 0.13% (5 per 3759 [95% confidence interval, 0.04-0.31%]). Uterine fibroids comprised 27.3% of all hysterectomies for benign indication (n= 1025) and was the indication most commonly associated with diagnosis of unexpected sarcoma. The incidence of unexpected sarcoma among surgeries for uterine fibroids was 0.35% (3 of 851) for premenopausal women and 0.57% (1 of 174) for peri/postmenopausal, and all 4 unexpected sarcomas were leiomyosarcoma. The incidence of unexpected sarcoma progressively increased with higher uterine weight with an incidence of 0.03% (1 of 2993) among women with a uterine weight <250 g vs 15.4% (2 of 13) with a uterine weight ≥2000 g. Unexpected uterine sarcoma was low in all women undergoing hysterectomy for benign indication (0.13% or 1 in 752 surgeries) while it was increased in women with uterine fibroids (0.39% or 1 in 256 surgeries). Peri/postmenopausal women, women with large uteri, and age ≥45 years were risk factors for sarcoma.

Unexpected Parasitic Fibroid Necessitates Mandatory Contained Morcellation

Objective: Uterine leiomyomas are the most common benign pelvic tumours in women, occurring in at least 25% of reproductive aged women and up to 80% on pathologic examination of surgically removed uteri. Parasitic leiomyomas, first described in 1909, are a rare type of extra-uterine fibroid which are thought to arise from a subserosal fibroid which obtains a blood supply from other structures with resultant deterioration of its uterine pedicle. The rise of laparoscopic surgery and power morcellation has seen an increasing incidence of the iatrogenic parasitic fibroid. The FDA has put a warning on the use of power morcellation due to the risk of disseminating a uterine sarcoma, which has resulted in a drastic decline in the use of power morcellation and the entry of “morcellation bags” into the market.

Public Awareness of Uterine Power Morcellation Through US Food and Drug Administration Communications: Analysis of Google Trends Search Term Patterns.

BackgroundUterine power morcellation, where the uterus is shred into smaller pieces, is a widely used technique for removal of uterine specimens in patients undergoing minimally invasive abdominal hysterectomy or myomectomy. Complications related to power morcellation of uterine specimens led to US Food and Drug Administration (FDA) communications in 2014 ultimately recommending against the use of power morcellation for women undergoing minimally invasive hysterectomy. Subsequently, practitioners drastically decreased the use of morcellation.ObjectiveWe aimed to determine the effect of increased patient awareness on the decrease in use of the morcellator. Google Trends is a public tool that provides data on temporal patterns of search terms, and we correlated this data with the timing of the FDA communication.MethodsWeekly relative search volume (RSV) was obtained from Google Trends using the term “morcellation.” Higher RSV corresponds to increases in weekly search volume. Search volumes were divided into 3 groups: the 2 years prior to the FDA communication, a 1-year period following, and thereafter, with the distribution of the weekly RSV over the 3 periods tested using 1-way analysis of variance. Additionally, we analyzed the total number of websites containing the term “morcellation” over this time.ResultsThe mean RSV prior to the FDA communication was 12.0 (SD 15.8), with the RSV being 60.3 (SD 24.7) in the 1-year after and 19.3 (SD 5.2) thereafter (P<.001). The mean number of webpages containing the term “morcellation” in 2011 was 10,800, rising to 18,800 during 2014 and 36,200 in 2017.ConclusionsGoogle search activity about morcellation of uterine specimens increased significantly after the FDA communications. This trend indicates an increased public awareness regarding morcellation and its complications. More extensive preoperative counseling and alteration of surgical technique and clinician practice may be necessary.