Skip to main content

Advertisement

SpringerLink
Log in

Update on Fibroid Morcellation

  • Reproductive Endocrinology and Infertility (REI) (R Anchan, Section Editor)
  • Published:
Current Obstetrics and Gynecology Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

The aim of this paper is to review the risks associated with morcellation of uterine and fibroid tissue during minimally invasive surgery, and provide updated suggestions for practice.

Recent Findings

The prevalence of occult uterine sarcoma has been estimated to be in the range of 1 case per 278–8300, with significant variance reported. Strong predictors of occult malignancy include age, black race, and long-term tamoxifen use. Patient symptoms, lab abnormalities, imaging findings, and preoperative sampling may be useful in preoperative patient selection. Several tissue extraction techniques have been developed and studied in an effort to mitigate risk of morcellating fibroid tissue with potentially occult malignancy.

Summary

Minimally invasive surgery at times requires removal of large tissue specimens through small incisions. The risk of encountering an occult uterine sarcoma during tissue extraction is low, but may result in worsened oncologic outcomes if tissue is fragmented at time of removal. Several novel techniques and tools are being studied as risk reducing strategies to allow for safer gynecologic surgery.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Jin C, Hu Y, Chen XC, Zheng FY, Lin F, Zhou K, Chen FD, Gu HZ. Laparoscopic versus open myomectomy—a meta-analysis of randomized controlled trials. Eur J Obstet Gynecol Reprod Biol. 2009;145(1):14.

    Article  PubMed  Google Scholar 

  2. Aarts JW, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BW, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev. 2015 Aug 12;8:CD003677. doi:10.1002/14651858.CD003677.pub5.

    Google Scholar 

  3. • US Food and Drug Administration. Laparoscopic uterine power morcellation in hysterectomy and myomectomy: FDA Safety Communication. http:// www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm393576.htm. [Accessed 31 Dec 2016]. FDA Statement on the use of power morcellation in minimally invasive surgery.

  4. Baird DD, Dunson DB, Hill MC, Cousins D, Schectman JM. High cumulative incidence of uterine leiomyoma in black and white women: ultrasound evidence. Am J Obstet Gynecol. 2003;188(1):100.

    Article  PubMed  Google Scholar 

  5. Brooks SE, Zhan M, Cote T, Baquet CR. Surveillance, epidemiology, and end results analysis of 2677 cases of uterine sarcoma 1989-1999. Gynecol Oncol. 2004;93(1):204.

    Article  PubMed  Google Scholar 

  6. Kurman RJ, Carcangiu ML, Herrington S, Young RH. World Health Organization classification of tumours of the female reproductive organs. Lyon: IARC; 2014.

    Google Scholar 

  7. US Food and Drug Administration. Updated laparoscopic uterine power morcellation in hysterectomy and myomectomy: FDA Safety Communication. http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ ucm424443.htm. Accessed 31 Dec 2016.

  8. •• Pritts EA, Vanness DJ, Berek JS, Parker W, Feinberg R, Feinberg J, Olive DL. The prevalence of occult leiomyosarcoma at surgery for presumed uterine fibroids: a meta-analysis. Gynecol Surg. 2015;12(3):165–77. Meta-analysis of prevalence of occult malignancy at the time of hysterectomy and myomectomy

    Article  PubMed  PubMed Central  Google Scholar 

  9. • Raine-Bennett T, Tucker LY, Zaritsky E, Littell RD, Palen T, Neugebauer R, Axtell A, Schultze PM, Kronbach DW, Embry-Schubert J, Sundang A, Bischoff K, Compton-Phillips AL, Lentz SE. Occult uterine sarcoma and leiomyosarcoma: incidence of and survival associated with morcellation. Obstet Gynecol. 2016;127(1):29–39. Retrospective analysis of survival outcomes in women with occult uterine sarcoma after morcellation

    Article  PubMed  Google Scholar 

  10. Kho KA, Lin K, Hechanova M, et al. Risk of occult uterine sarcoma in women undergoing hysterectomy for benign indications. Obstet Gynecol. 2016;127:468–73.

    Article  CAS  PubMed  Google Scholar 

  11. • George S, Barysauskas C, Serrano C, et al. Retrospective cohort study evaluating the impact of intraperitoneal morcellation on outcomes of localized uterine leiomyosarcoma. Cancer. 2014;120:3154–8. Retrospective analysis of survival outcomes in women with occult uterine sarcoma after morcellation

    Article  PubMed  Google Scholar 

  12. Raspagliesi F, Maltese G, Bogani G, Fucà G, Lepori S, De Iaco P, Perrone M, Scambia G, Cormio G, Bogliolo S, Bergamini A, Bifulco G, Casali PG, Lorusso D. Morcellation worsens survival outcomes in patients with undiagnosed uterine leiomyosarcomas: A retrospective MITO group study. Gynecol Oncol. 2017;144(1):90–5. doi:10.1016/j.ygyno.2016.11.002.

    Article  PubMed  Google Scholar 

  13. Bogani G, Cliby WA, Aletti GD. Impact of morcellation on survival outcomes of patients with unexpected uterine leiomyosarcoma: a systematic review and meta-analysis. Gynecol Oncol. 2015;137:167–72.

    Article  PubMed  Google Scholar 

  14. Lee JY, Kim HS, Nam EJ, Kim SW, Kim S, Kim YT. Outcomes of uterine sarcoma found incidentally after uterus-preserving surgery for presumed benign disease. BMC Cancer. 2016 Aug 23;16(1):675. doi:10.1186/s12885-016-2727-x.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Skorstad M, Kent A, Lieng M. Uterine leiomyosarcoma - incidence, treatment, and the impact of morcellation. A nationwide cohort study. Acta Obstet Gynecol Scand. 2016;95(9):984–90. doi:10.1111/aogs.12930.

    Article  PubMed  Google Scholar 

  16. Nemec W, Inwald EC, Buchholz S, Klinkhammer Schalke M, Gerken M, Ortmann O. Effects of morcellation on long-term outcomes in patients with uterine leiomyosarcoma. Arch Gynecol Obstet. 2016;294(4):825–31. doi:10.1007/s00404-016-4086-x.

    Article  CAS  PubMed  Google Scholar 

  17. •• Wright JD, Tergas AI, Burke WM, Cui RR, Ananth CV, Chen L, Hershman DL. Uterine pathology in women undergoing minimally invasive hysterectomy using morcellation. JAMA. 2014;312(12):1253. Large insurance database of over 500 hospitals used to calculate incidence of ocular uterine sarcoma

    Article  PubMed  PubMed Central  Google Scholar 

  18. Wright JD, Tergas AI, Cui R, Burke WM, Hou JY, Ananth CV, Chen L, Richards C, Neugut AI, Hershman DL. Use of electric power morcellation and prevalence of underlying cancer in women who undergo myomectomy. JAMA Oncol. 2015 Apr;1(1):69–77.

    Article  PubMed  Google Scholar 

  19. Siedhoff MT, Doll KM, Clarke-Pearson DL, Rutstein SE. Laparoscopic hysterectomy with morcellation vs abdominal hysterectomy for presumed fibroids: an updated decision analysis following the 2014 Food and Drug Administration safety communications. Am J Obstet Gynecol. 2016; doi:10.1016/j.ajog.2016.11.1039.

    PubMed  Google Scholar 

  20. Hosh M, Antar S, Nazzal A, Warda M, Gibreel A, Refky B. Uterine sarcoma: analysis of 13,089 cases based on surveillance, epidemiology, and end results database. Int J Gynecol Cancer. 2016;26(6):1098.

    Article  PubMed  Google Scholar 

  21. Wickerham DL, Fisher B, Wolmark N, Bryant J, Costantino J, Bernstein L, Runowicz CD. Association of tamoxifen and uterine sarcoma. J Clin Oncol. 2002;20(11):2758.

    Article  PubMed  Google Scholar 

  22. Schwartz LB, Diamond MP, Schwartz PE. Leiomyosarcomas: clinical presentation. Am J Obstet Gynecol. 1993;168(1 Pt 1):180.

    Article  CAS  PubMed  Google Scholar 

  23. Tsikouras P, Liberis V, Galazios G, Savidis A, Grapsa A, Grapsas X, Teichmann AT, Maroulis G. Uterine sarcoma: a report of 57 cases over a 16-year period analysis. Eur J Gynaecol Oncol. 2008;29(2):129.

    CAS  PubMed  Google Scholar 

  24. Parker WH, Fu YS, Berek JS. Uterine sarcoma in patients operated on for presumed leiomyoma and rapidly growing leiomyoma. Obstet Gynecol. 1994;83(3):414.

    CAS  PubMed  Google Scholar 

  25. Van den Bosch T, Coosemans A, Morina M, Timmerman D, Amant F. Screening for uterine tumours. Best Pract Res Clin Obstet Gynaecol. 2012;26(2):257–66.

    Article  PubMed  Google Scholar 

  26. Schwartz LB, Zawin M, Carcangiu ML, Lange R, McCarthy S. Does pelvic magnetic resonance imaging differentiate among the histologic subtypes of uterine leiomyomata? Fertil Steril. 1998;70(3):580.

    Article  CAS  PubMed  Google Scholar 

  27. Samuel A, Fennessy FM, Tempany CM, Stewart EA. Avoiding treatment of leiomyosarcomas: the role of magnetic resonance in focused ultrasound surgery. Fertil Steril. 2008;90(3):850.e9–12.

    Article  Google Scholar 

  28. Goto A, Takeuchi S, Sugimura K, Maruo T. Usefulness of Gd-DTPA contrast-enhanced dynamic MRI and serum determination of LDH and its isozymes in the differential diagnosis of leiomyosarcoma from degenerated leiomyoma of the uterus. Int J Gynecol Cancer. 2002;12(4):354–61.

    Article  CAS  PubMed  Google Scholar 

  29. Sato K, Yuasa N, Fujita M, Fukushima Y. Clinical application of diffusion-weighted imaging for preoperative differentiation between uterine leiomyoma and leiomyosarcoma. Am J Obstet Gynecol. 2014;210(4):368.e1–8. doi:10.1016/j.ajog.2013.12.028.

    Article  Google Scholar 

  30. Li HM, Liu J, Qiang JW, Zhang H, Zhang GF, Ma F. Diffusion-weighted imaging for differentiating uterine leiomyosarcoma from degenerated leiomyoma. J Comput Assist Tomogr. 2016; doi:10.1097/RCT.0000000000000565.

    PubMed Central  Google Scholar 

  31. Hinchcliff EM, Esselen KM, Watkins JC, Oduyebo T, Rauh-Hain JA, Del Carmen MG, Quade BJ, Muto MG. The role of endometrial biopsy in the preoperative detection of uterine leiomyosarcoma. J Minim Invasive Gynecol. 2016;23(4):567–72.

    Article  PubMed  Google Scholar 

  32. Leibsohn S, d'Ablaing G, Mishell Jr DR, Schlaerth JB. Leiomyosarcoma in a series of hysterectomies performed for presumed uterine leiomyomas. Am J Obstet Gynecol. 1990;162(4):968.

    Article  CAS  PubMed  Google Scholar 

  33. Bansal N, Herzog TJ, Burke W, Cohen CJ, Wright JD. The utility of preoperative endometrial sampling for the detection of uterine sarcomas. Gynecol Oncol. 2008;110(1):43.

    Article  PubMed  Google Scholar 

  34. Oduyebo T, Hinchcliff E, Meserve EE, Seidman MA, Quade BJ, Rauh-Hain JA, George S, Nucci MR, del Carmen MG, Muto MG. Risk factors for occult uterine sarcoma among women undergoing minimally invasive gynecologic surgery. J Minim Invasive Gynecol. 2016 Jan;23(1):34–9. doi:10.1016/j.jmig.2015.07.017.

    Article  PubMed  Google Scholar 

  35. King LP, Ricciotti H, Klebanoff MJ, Hur C, Hur HC. Fibroid morcellation: a shared clinical decision tool for mode of hysterectomy. J Minim Invasive Gynecol. 2015;22(6S):S97–8. doi:10.1016/j.jmig.2015.08.262.

    Article  CAS  PubMed  Google Scholar 

  36. Mowers EL, Lim CS, Skinner B, Mahnert N, As-Sanie S. Women’s knowledge and perceptions of morcellation. J Minim Invasive Gynecol. 2015;22(6S):S36. doi:10.1016/j.jmig.2015.08.101.

    Article  CAS  PubMed  Google Scholar 

  37. Figueiredo O, Figueiredo EG, Figueiredo PG, Pelosi MA. Vaginal removal of the benign nonprolapsed uterus: experience with 300 consecutive operations. Obstet Gynecol. 1999;94(3):348–51.

    Article  CAS  PubMed  Google Scholar 

  38. Ghezzi F, Cromi A, Uccella S, Bogani G, Serati M, Bolis P. Transumbilical versus transvaginal retrieval of surgical specimens at laparoscopy: a randomized trial. Am J Obstet Gynecol. 2012;207(2):112.e1–6.

    Article  Google Scholar 

  39. Moawad G, Abi Khalil E, Opoku-Anane J, Harman A, Marfori C, Levy M, Fisher S, Robinson J. Comparison of methods of morcellation: manual versus power. J Minim Invasive Gynecol. 2015;22(6S):S79. doi:10.1016/j.jmig.2015.08.211.

    Article  CAS  PubMed  Google Scholar 

  40. Rivard C, Salhadar A, Kenton K. New challenges in detecting, grading, and staging endometrial cancer after uterine morcellation. J Minim Invasive Gynecol. 2012;19:313–6.

    Article  PubMed  Google Scholar 

  41. Cusidó M, Fargas F, Baulies S, Plana A, Rodríguez I, Tresserra F, Pascual MA, Fábregas R. Impact of surgery on the evolution of uterine sarcomas. J Minim Invasive Gynecol. 2015;22(6):1068–74. doi:10.1016/j.jmig.2015.05.024.

    Article  PubMed  Google Scholar 

  42. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm494650.htm Accessed 7 Jan 2017.

  43. Vargas MV, Cohen SL, Fuchs-Weizman N, Wang KC, Manoucheri E, Vitonis AF, Einarsson JI. Open power morcellation versus contained power morcellation within an insufflated isolation bag: comparison of perioperative outcomes. J Minim Invasive Gynecol. 2015;22(3):433.

    Article  PubMed  Google Scholar 

  44. Winner B, Porter A, Velloze S, et al. Uncontained compared with contained power morcellation in total laparoscopic hysterectomy. Obstet Gynecol. 2015;126:834–8.

    Article  PubMed  Google Scholar 

  45. Gujral H, Vilkins A, Clark NV, Vogell AB, Wright KN. Determining a learning curve for contained hand tissue extraction: perioperative outcomes and operative time. J Minim Invasive Gynecol. 2017;24(1):103–7. doi:10.1016/j.jmig.2016.09.017.

    Article  PubMed  Google Scholar 

  46. •• Cohen SL, Morris SN, Brown DN, Greenberg JA, Walsh BW, Gargiulo AR, Isaacson KB, Wright KN, Srouji SS, Anchan RM, Vogell AB, Einarsson JI. Contained tissue extraction using power morcellation: prospective evaluation of leakage parameters. Am J Obstet Gynecol. 2016;214(2):257.e1–6. Prospective analysis of tissue leakage incidence in contained tissue systems utilizing electro-mechanical morcellation

    Article  Google Scholar 

  47. Solima E, Scagnellli G, Austoni V, Natale A, Bertulessi C, Busacca M, Vignali M. Vaginal uterine morcellation within a specimen containment system: a study of bag integrity. J Minim Invasive Gynecol. 2015;22(6S):S86. doi:10.1016/j.jmig.2015.08.231.

    Article  CAS  PubMed  Google Scholar 

  48. Toubia T, Moulder JK, Schiff LD, et al. Peritoneal washings after power morcellation in laparoscopic myomectomy: a pilot study. J Minim Invasive Gynecol. 2016;23:578–81.

    Article  PubMed  Google Scholar 

  49. Ikhena DE, Paintal A, Milad MP. Feasibility of washings at the time of laparoscopic power morcellation: a pilot study. J Minim Invasive Gynecol 2016.

  50. Sandberg EM, van den Haak L, Bosse T, Jansen FW. Disseminated leiomyoma cells can be identified following conventional myomectomy. BJOG. 2016;123(13):2183–7. doi:10.1111/1471-0528.14265.

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Obstetrics and Gynecology, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA

    Pietro Bortoletto, Eduardo Hariton & Sophia Salas

  2. Division of Minimally Invasive Gynecologic Surgery, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA

    Sarah L. Cohen

Authors
  1. Pietro Bortoletto
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Eduardo Hariton
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Sophia Salas
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Sarah L. Cohen
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Sarah L. Cohen.

Ethics declarations

Conflict of Interest

Pietro Bortoletto, Eduardo Hariton, Sophia Salas, and Sarah L. Cohen declare that they have no conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

This article is part of the Topical Collection on Reproductive Endocrinology and Infertility (REI);

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Bortoletto, P., Hariton, E., Salas, S. et al. Update on Fibroid Morcellation. Curr Obstet Gynecol Rep 6, 62–66 (2017). https://doi.org/10.1007/s13669-017-0197-z

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s13669-017-0197-z

Keywords

Search

Navigation