Fibroid Removal after Myomectomy: An Overview on the Problems of Power Morcellation

Abstract

The authors reviewed uterine fibroid (UF) morcellation and its potential consequences, notably a hypothetical spread and dissemination of occult uterine leiomyosarcoma (LMS) tissue, evaluating the effect of laparoscopic versus open myomectomies with and without morcellation on patients’ outcomes, as well as related medical-legal issues. MEDLINE and PubMed search was performed for the years 1990–2021, using a combination of keywords on this topic. Relevant articles were identified and included in this narrative review. There is an individual risk, for all patients, for LMS diagnosis after myomectomy. However, the risk for occult LMS diagnosis during a laparoscopic myomectomy is generally reduced when the guidelines of scientific societies are followed, with an overall benefit from the laparoscopic approach with morcellation in appropriate cases. Gynecological societies do not ban morcellation and laparoscopic hysterectomy/myomectomy per se, but recommend their use on the basis of the patients’ clinical characteristics. It is suggested for gynecologists to provide detailed information to patients when obtaining an informed consent for open or laparoscopic hysterectomy/myomectomy. A detailed preoperative assessment of patients and the risk benefit ratio of laparoscopic morcellation of uterine mass could overcome the “a priori” banning of the morcellation technique.

Rate of Leiomyosarcomas during Surgery for Uterine Fibroids: 8-Year Experience of a Single Center

“…It may be that any type of tumor penetration at the time of surgery will enhance the hematogenous spread of tumor cells, meaning that tumor spread may occur prior to and independent of morcellation [10]. This is in agreement with the findings of a recent review, which states that disease-free survival is not affected by morcellation and that prognosis is influenced only by tumor size and grade [38]. So, particularly for early stage LMS, morcellation compared to en block uterine removal results in a higher risk of tumor dissemination and recurrence and poorer overall survival [10].…”

An intrauterine cavity morcellator: A novel approach to high volume uterus morcellation. Ex-vivo study

“…The electric morcellator involves a mass being reduced, delivered to the pathologist as a slice of ground tissue. Unfortunately, the pathologist is often unable to distinguish the anatomy to be analyzed and to indicate exactly the parts to be analyzed, given that there are no reference points [30]. Conversely, manual morcellation with a scalpel allows the organ or mass to be removed and reconstructed with a good approximation using sutures.…”