Rethinking the Issue of Power Morcellation of Uterine Fibroids: Is Morcellation the Real Problem or Is this Another Symptom of Disparity in Healthcare Provision?

Odejinmi, Funlayo; Aref‐Adib, Mehrnoosh; Liou, Natasha; Sideris, Michail; Mallick, Rebecca

doi:10.21873/invivo.11616

Cited by 12 publications

(6 citation statements)

References 65 publications

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“…We also confirmed there was no malignancy in the histopathological results for all patients. Our results support a recent review supporting the safety of morcellation in appropriately selected women (22).…”

Section: Discussionsupporting

confidence: 91%

Surgical Intervention for Uterine Fibroids. Our 4-Year Experience and Literature Review: Is It Time to Centralise Care Provision Via Specialist Fibroid Centres?

Strong

Sideris

Magama

et al. 2020

In Vivo

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Background: Leiomyomas are common in women of reproductive age, for whom treatment-stratification can be challenging. We assessed factors influencing pre-operative selection of surgical intervention and compare outcomes. Patients and Methods: A literature review was performed and surgical interventions for fibroids at a London hospital (2015-2018) were retrospectively examined. Outcomes assessed were estimated blood loss, length of stay (LOS) and complications. Data were analysed using univariate non-parametric inferential statistics. Results: A total of 258 cases were identified. Estimated blood loss was statistically significantly lower for laparoscopic versus open myomectomy [200 (interquartile range; IQR)=100-200 vs. 400 (IQR=200-700 ml), p<0.001]. Length of stay was also statistically significantly lower in the laparoscopic cohort compared with open hysterectomy [1 (IQR=1-1) days vs. 2 (IQR=2-3 days)]. Similar results were noted when comparing laparoscopic versus open hysterectomy [167 (IQR=100-200) vs. 500 (IQR=100-750) ml, p<0.001]. No differences in complications were reported across groups. Patients counselled by a surgeon trained in minimally invasive surgery (MIS) opted more frequently for laparoscopy (p<0.01, rho=−0.669). Estimated blood loss during MIS was 225 ml versus 545 ml for non-MIS, and 285 ml for the overall cohort (p<0.01).The length of stay was statistically significantly lower for those treated with MIS (1.37 days) versus other surgeons (2.65 days), or overall cohort (1.63 days) (p<0.01 for all associations). Conclusion: Laparoscopic surgery offers superior short-term outcomes when performed by experienced operators. Multidisciplinary counselling and treatment stratification should be goldstandard practice. Centralisation of care provision in fibroid Centres of Excellence is required.Uterine fibroids are the most common solid benign tumours in women of reproductive age affecting over 70% of women by menopausal age (1). Associated symptoms such as menorrhagia, dysmenorrhea, pressure effects and subfertility can have an impact quality of life. One third of women with fibroids request treatment for symptom management (2), however, many of them are dissatisfied with the information received during counselling and are often unaware of the short-and long-term outcomes at the units where they receive treatment. Besides the financial and emotional burden to the individual who suffers from the effects of fibroids (3), there is also a societal burden. In the UK, surgical management of fibroids carries a significant financial burden to the United Kingdom National Health Service (NHS). Recent costs for the NHS tariff were estimated at £2,400 for uterine artery embolization, £2,609 for myomectomy and £3,275 for hysterectomy. Of the 31,624 hysterectomies performed in England in 2017 and 2018, 60% (18,974) were for fibroids, and the total in-patient cost was estimated at £103,568,600. It is also estimated that 1,600 myomectomies are performed in the UK each year (4). In the United States of America, the ...

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Section: Discussionsupporting

confidence: 91%

Surgical Intervention for Uterine Fibroids. Our 4-Year Experience and Literature Review: Is It Time to Centralise Care Provision Via Specialist Fibroid Centres?

Strong

Sideris

Magama

et al. 2020

In Vivo

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“…In uterine leiomyosarcoma (LMS), morcellation increases the overall recurrence rate (62% vs. 39%; OR = 3.16; 95% CI: 1.38–7.26) and the intra-abdominal relapse (39% vs. 9%; OR = 4.11; 95% CI: 1.92–8.81), as well as the mortality rate (48% vs. 29%; OR = 2.42; 95% CI: 1.19–4.92) [ 134 ], whilst no survival differences were observed for patients with morcellated low-grade endometrial stromal sarcoma [ 135 ] or occult endometrial carcinoma [ 136 ]. The risk of occult LMS is elevated in black women, patients aged > 40 years, patients with a history of retinoblastoma, women presenting with a rapidly growing, large (≥ 8 cm), solitary, highly vascularized (peripheral and central), heterogeneous myometrial tumor with central necrosis or degenerative cystic changes [ 127 , 137 ]. In case of uncertainty, magnetic resonance imaging with contrast enhancement, determination of lactate dehydrogenase and its isoenzyme type 3 in serum, as well as endometrial sampling prior to surgery, may help to better distinguish between LMS and fibroid [ 138 , 139 ].…”

Section: Methodsmentioning

confidence: 99%

Complications in laparoscopic and robotic-assisted surgery: definitions, classifications, incidence and risk factors - an up-to-date review.

Watrowski

Kostov

Alkatout

2021

Videosurgery and Other Miniinvasive Techniques

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Almost all gynecological and general-surgical operations are – or can be – performed laparoscopically. In comparison to an abdominal approach, the minimally invasive access offers several advantages; however, laparoscopy (both conventional and robotic-assisted) can be associated with a number of approach-specific complications. Although the majority of them are related to the laparoscopic entry, adverse events may also occur due to the presence of pneumoperitoneum or the use of laparoscopic instruments. Unfortunately, a high proportion of complications (especially affecting the bowel and ureter) remain unrecognized during surgery. This narrative review provides comprehensive up-to-date information about definitions, classifications, risk factors and incidence of surgical complications in conventional and robotic-assisted laparoscopy, with a special focus on gynecology. The topic is discussed from various perspectives, e.g. in the context of stage of surgery, injured organs, involved instruments, and in relation to malpractice claims.

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“…When the meta-analysis was restricted to only prospective studies, the result was 1 leiomyosarcoma per 8300 surgeries, which is less frequent than previously estimated 23. There has been a return to open procedures24 and abrupt development of new specimen extraction techniques such as contained morcellation 25. However, recent studies report the detection of leiomyoma cells in peritoneal washings after open myomectomy,26 laparoscopic myomectomy prior to morcellation,27 and even after the use of in-bag morcellation 28.…”

Section: Discussionmentioning

confidence: 99%

Uterine smooth muscle tumors with uncertain malignant potential: analysis following fertility-saving procedures

Richtárová

Boudova

Dundr

et al. 2023

International Journal of Gynecological Cancer

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ObjectiveThe aim of this study was to analyze the clinical and reproductive outcomes of patients treated with myomectomy who were histologically diagnosed with uterine smooth muscle tumor of uncertain malignant potential (STUMP).MethodsPatients who were diagnosed with STUMP and underwent a myomectomy at our institution between October 2003 and October 2019 were identified. Variables of interest obtained from the institution’s database included patient age, relevant medical history, pre-operative appearance of the tumor on ultrasound, parameters of the surgical procedure, histopathological analysis of the tumor, post-operative clinical course, and course of follow-up, including reinterventions and fertility outcomes.ResultsThere were a total of 46 patients that fulfilled the criteria of STUMP. The median patient age was 36 years (range, 18–48 years) and the mean follow-up was 47.6 months (range, 7–149 months). Thirty-four patients underwent primary laparoscopic procedures. Power morcellation was used for specimen extraction in 19 cases (55.9% of laparoscopic procedures). Endobag retrieval was used in nine patients and six procedures were converted to an open approach due to the suspicious peri-operative appearance of the tumor. Five patients underwent elective laparotomy due to the size and/or number of tumors; three patients had vaginal myomectomy; two patients had the tumor removed during planned cesarean section; and two underwent hysteroscopic resection.There were 13 reinterventions (five myomectomies and eight hysterectomies) with benign histology in 11 cases and STUMP histology in two cases (4.3% of all patients). We did not observe any recurrence as leiomyosarcoma or other uterine malignancy. We did not observe any deaths related to the diagnosis. Twenty-two pregnancies were recorded among 17 women, which resulted in 18 uncomplicated deliveries (17 by cesarean section and one vaginal), two missed abortions, and two pregnancy terminations.ConclusionsOur study found that uterus-saving procedures and fertility-preservation strategies in women with STUMP are feasible, safe, and seem to be associated with a low risk of malignant recurrence, even while maintaining the mini-invasive laparoscopic approach.

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Rethinking the Issue of Power Morcellation of Uterine Fibroids: Is Morcellation the Real Problem or Is this Another Symptom of Disparity in Healthcare Provision?

Cited by 12 publications

References 65 publications

Surgical Intervention for Uterine Fibroids. Our 4-Year Experience and Literature Review: Is It Time to Centralise Care Provision Via Specialist Fibroid Centres?

Surgical Intervention for Uterine Fibroids. Our 4-Year Experience and Literature Review: Is It Time to Centralise Care Provision Via Specialist Fibroid Centres?

Complications in laparoscopic and robotic-assisted surgery: definitions, classifications, incidence and risk factors - an up-to-date review.

Uterine smooth muscle tumors with uncertain malignant potential: analysis following fertility-saving procedures

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