European Society of Gynecological Oncology Statement on Fibroid and Uterine Morcellation

Abstract

Recently, there has been an intense discussion about the issue of fibroid and uterine morcellation in relation to the risk of unrecognized uterine sarcoma spread. Morcellation can negatively influence the prognosis of patients, and transecting the specimen into pieces prevents the pathologist from performing proper disease staging. Many societies have published their statements regarding this issue. The European Society for Gynecological Oncology has established a working group of clinicians involved in diagnostics and treatment of oncogynecological patients to provide a statement from the oncological point of view. Leiomyosarcomas and undifferentiated endometrial sarcomas have generally dismal prognosis, whereas low-grade endometrial stromal sarcomas and adenosarcomas have variable prognosis based on their stage. A focus on the detection of patients at risk of having a sarcoma should be mandatory before every surgery where morcellation is planned by evaluation of risk factors (African American descent, previous pelvic irradiation, use of tamoxifen, rapid lesion growth particularly in postmenopausal patients) and exclusion of patients with any suspicious ultrasonographic signs. Preoperative endometrial biopsy should be mandatory, although the sensitivity to detect sarcomas is low. An indication for myomectomy should be used only in patients with pregnancy plans; otherwise en bloc hysterectomy is preferred in both symptomatic and postmenopausal patients. Eliminating the technique of morcellation could lead to an increased morbidity in low-risk patients; therefore, after thorough preoperative evaluation and discussion with patients, morcellation still has its place in the armamentarium of gynecologic surgery.

Hysterectomy in Poland between 2011 and 2016. Changing trends in the surgical approach to hysterectomy

“…Advances in the operative techniques resulted in the development of a special intraperitoneal bag to prevent uncontrolled tissue dissemination during morcellation. Additionally, recommendations of the European Society of Gynecological Oncology on fibroid and uterine morcellation resulted in subsequent increase (by 262.2%) in the number of SLH in 2016 [21,22]. Reports from the literature showed that careful preoperative counseling further reduces the risk of unexpected malignancies in the uterus and confirmed safety of morcellation in selected group of patients [23].…”

Contained Morcellation: Review of Current Methods and Future Directions

“…Therefore, morcellation of the specimen in an enclosed fashion should be the preferred method as many developed techniques and several specimen retrieval bags for this method have been widely available. Nonetheless, in patients with suspicion for occult uterine malignancy after an appropriate preoperative evaluation, morcellation should be avoided (45). In those cases, alternatives such as minilaparotomy or vaginal retrieval of the uterine specimen are more reliable options.…”

Occult uterine malignancy during laparoscopic supracervical hysterectomy

“…The FDA's April 2014 statement [6,7], published following the incidental morcellation of the uterine leiomyosarcoma, efficiently supplanted minimally invasive procedures associated with use of power morcellation, including LSH, in the United States (US) [8,9]. In other countries, the power morcellation and LSH are commonly performed [10].…”