Advertisement
JOGC

No. 371-Morcellation During Gynaecologic Surgery: Its Uses, Complications, and Risks of Unsuspected Malignancy

      ABSTRACT

      Objective

      This guideline provides guidance to gynaecologists regarding the use of tissue morcellation in gynaecologic surgery.

      Outcomes

      Morcellation may be used in gynaecologic surgery to allow removal of large uterine specimens, thus providing women with a minimally invasive surgical option. Adverse oncologic outcomes of tissue morcellation should be mitigated through improved patient selection, preoperative investigations, and novel techniques that minimize tissue dispersion.

      Evidence

      Published literature was retrieved through searches of PubMed and Medline in the spring of 2014 using appropriate controlled vocabulary (leiomyosarcoma, uterine neoplasm, uterine myomectomy, hysterectomy) and key words (leiomyoma, endometrial cancer, uterine sarcoma, leiomyosarcoma, and morcellation). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date limits, but results were limited to English or French language materials. Searches were updated on a regular basis and incorporated in the guideline to July 2017. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

      Values

      The quality of evidence in this document was rated using the criteria described in the report of the Canadian Task Force on Preventive Health Care.

      Benefits, harms, and costs

      Gynaecologists offer women minimally invasive surgery, and this may involve tissue morcellation and the use of a power morcellator for specimen retrieval. Women should be counselled that in the case of unexpected uterine (sarcoma, endometrial), cervical, and/or tubo-ovarian cancer, the use of a morcellator is associated with increased risk of tumour dissemination. Tissue morcellation should be performed only after complete investigation, appropriate patient selection, and informed consent and by surgeons with appropriate training in the safe practices of tissue morcellation.

      Summary Statements

      • 1
        Uterine sarcoma is rare, and as such it is difficult to characterize the absolute risk of occult sarcoma at the time of fibroid surgery. Risk estimates range from 1 in 350 to 1 in 2000. Patient counselling regarding risks should be tailored based on age and other risk factors (II-2).
      • 2
        Morcellation of any type is contraindicated in women with established cancer, pre-cancerous lesions, or suspected cancer (III).
      • 3
        When considering morcellation, patients should be counselled about the risks (malignant and non-malignant), benefits, and alternatives as part of the informed consent, especially in women over 50 (III).
      • 4
        Alternatives to uncontained electromechanical morcellation can be used during fibroid surgery for tissue extraction depending on surgical route, specimen size, surgeon skill/training, and patient preference. If the specimen cannot be removed intact, then no method of tissue extraction can eliminate the risk of iatrogenic tissue dissemination (II-2).
      • 5
        The benefits of in-bag contained morcellation, including survival rates and ability to prevent dissemination of malignant cells/tissue, have not been established (II-2).
      • 6
        An unexpected uterine sarcoma treated by primary surgery involving tumour disruption, including morcellation of the tumour, has the potential for intra-abdominal tumour spread and a worse prognosis (II-2).
      • 7
        Clinicians should be aware of the general complications associated with morcellation beyond the spread of malignant tissue (II-3).

      Recommendations

      • 1
        Each patient presenting with uterine leiomyoma should be assessed for the possible presence of malignancy, based on her risk factors and preoperative imaging, although the predictive value of preoperative assessment is limited (III-C).
      • 2
        If there is a high index of suspicion of a uterine sarcoma prior to surgery, attempts should be made to remove the uterus intact. Myomectomy in perimenopausal and postmenopausal women should be discouraged (III-C).
      • 3
        Preoperative endometrial biopsy and cervical assessment is recommended in order to avoid morcellation of potentially detectable malignant and pre-malignant conditions of the endometrium and cervix (II-2A).
      • 4
        Uterine morcellation should be avoided in hereditary cancer syndromes that increase the risk of uterine malignancy (III-C).
      • 5
        Techniques for morcellation of a uterine specimen vary, and physicians should consider employing techniques that minimize specimen disruption and intra-abdominal spread (III-C).
      • 6
        Uterine morcellation is contraindicated in women with established or suspected uterine neoplasia (II-2A).

      Key Words

      Abbreviations:

      EMM (electromechanical morcellation), ESS (endometrial stromal sarcoma), FDA (Food and Drug Administration), LDH (lactate dehydrogenase), LMS (Vaginose bactérienne), MIS (minimally invasive surgery), MRI (magnetic resonance imagery)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Obstetrics and Gynaecology Canada
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      REFERENCES

        • AAGL Advancing Minimally Invasive Gynecology Worldwide
        AAGL position statement: route of hysterectomy to treat benign uterine disease.
        J Minim Invasive Gynecol. 2011; 18: 1-3
        • Steiner RA
        • Wight E
        • Tadir Y
        • et al.
        U. Electrical cutting device for laparoscopic removal of tissue from the abdominal cavity.
        Obstet Gynecol. 1993; 81: 471-474
        • US Food and Drug Administration (FDA)
        Quantitative assessment of the prevalence of unsuspected uterine sarcoma in women undergoing treatment of uterine fibroids: summary and key findings.
        FDA, Silver Spring, MD2014
        • Health Canada
        Laparoscopic Electric Morcellators—Risk of Spread of Unsuspected Uterine Sarcoma—Notice to Hospitals.
        Health Canada, Ottawa2014 (Available at:) (Accessed on August 20, 2018)
        • Singh S
        • Best C
        • Dunn S
        • et al.
        Abnormal uterine bleeding in pre-menopausal women.
        J Obstet Gynaecol Can. 2013; 35: 473-475
        • Baird DD
        • Dunson DB
        • Hill MC
        • et al.
        High cumulative incidence of uterine leiomyoma in black and white women: ultrasound evidence.
        Am J Obstet Gynecol. 2003; 188: 100-107
        • Nieboer TE
        • Johnson N
        • Lethaby A
        • et al.
        Surgical approach to hysterectomy for benign gynaecological disease.
        Cochrane Database Syst Rev. 2009; CD003677
        • Laberge PY
        • Singh SS
        Surgical approach to hysterectomy: introducing the concept of technicity.
        J Obstet Gynaecol Can. 2009; 31: 1050-1053
        • Wiser A
        • Holcroft CA
        • Tulandi T
        • et al.
        Abdominal versus laparoscopic hysterectomies for benign diseases: evaluation of morbidity and mortality among 465,798 cases.
        Gynecol Surg. 2013; 10: 117-122
        • Palomba S
        • Zupi E
        • Falbo A
        • et al.
        A multicenter randomized, controlled study comparing laparoscopic versus minilaparotomic myomectomy: reproductive outcomes.
        Fertil Steril. 2007; 88: 933-941
        • Lewin SN
        • Herzog TJ
        • Barrena Medel NI
        • et al.
        Comparative performance of the 2009 International Federation of Gynecology and Obstetrics’ staging system for uterine corpus cancer.
        Obstet Gynecol. 2010; 116: 1141-1149
        • Creasman WT
        • Odicino F
        • Maisonneuve P
        • et al.
        Carcinoma of the corpus uteri. FIGO 26th annual report on the results of treatment in gynecological cancer.
        Int J Gynaecol Obstet. 2006; 95: S105-S143
        • Rowland M
        • Lesnock J
        • Edards R
        • et al.
        Occult uterine cancer in patients undergoing laparoscopic hysterectomy with morcellation: implications for surveillance for disease recurrence and outcomes.
        Gynecol Oncol. 2013; 130: e1-e169
        • Clinical Practice Endometrial Cancer Working Group SGO
        • Burke WM
        • Orr J
        • et al.
        Endometrial cancer: a review and current management strategies: part I.
        Gynecol Oncol. 2014; 134: 385-392
        • Riegert-Johnson DL
        • Gleeson FC
        • Roberts M
        • et al.
        Cancer and Lhermitte-Duclos disease are common in Cowden syndrome patients.
        Hered Cancer Clin Pract. 2010; 8: 6
        • Tropé CG
        • Abeler VM
        • Kristensen GB
        Diagnosis and treatment of sarcoma of the uterus.
        Acta Oncol. 2012; 51 (A review.): 694-705
        • Sutton G.
        Uterine sarcomas 2013.
        Gynecol Oncol. 2013; 130: 3-5
        • Kokawa K
        • Nishiyama K
        • Ikeuchi M
        • et al.
        Clinical outcomes of uterine sarcomas: results from 14 years worth of experience in the Kinki district in Japan (1990-2003).
        Int J Gynecol Cancer. 2006; 16: 1358-1363
        • Singh SS
        • Bougie O
        • Arendas K
        • et al.
        Morcellation in Canada: perspectives on current practices and future implications.
        J Minim Invasive Gynecol. 2015; 22: 1142-1144
        • Pritts EA
        • Vanness DJ
        • Berek JS
        • et al.
        The prevalence of occult leiomyosarcoma at surgery for presumed uterine fibroids: a meta-analysis.
        Gynecol Surg. 2015; 12: 165-177
        • Siedhoff MT
        • Doll KM
        • Clarke-Pearson DL
        • et al.
        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. 2017; 216 (259): e1-e6
        • Hartmann KE
        • Fonnesbeck C
        • Surawicz T
        • et al.
        Management of uterine fibroids.
        Agency for Healthcare Research and Quality, Rockville, MD2017 (Comparative effectiveness review no. 195)
        • Raine-Bennett T
        • Tucker LY
        • Zaritsky E
        • et al.
        Occult uterine sarcoma and leiomyosarcoma: incidence of and survival associated with morcellation.
        Obstet Gynecol. 2016; 127: 29-39
        • Mao J
        • Pfeifer S
        • Zheng XE
        • et al.
        Population-based estimates of the prevalence of uterine sarcoma among patients with leiomyomata undergoing surgical treatment.
        JAMA Surg. 2015; 150: 368-370
        • Rodriguez AM
        • Asoglu MR
        • Sak ME
        • et al.
        Incidence of occult leiomyosarcoma in presumed morcellation cases: a database study.
        Eur J Obstet Gynecol Reprod Biol. 2016; 197: 31-35
        • Toro JR
        • Nickerson ML
        • Wei MH
        • et al.
        Mutations in the fumarate hydratase gene cause hereditary leiomyomatosis and renal cell cancer in families in North America.
        Am J Hum Genet. 2003; 73: 95-106
        • Goto A
        • Takeuchi S
        • Sugimura K
        • et al.
        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: 354-361
        • Sato K
        • Yuasa N
        • Fujita M
        • et al.
        Clinical application of diffusion-weighted imaging for preoperative differentiation between uterine leiomyoma and leiomyosarcoma.
        Am J Obstet Gynecol. 2014; 210 (368): e1-e8
        • Tamura R
        • Kashima K
        • Asatani M
        • et al.
        Preoperative ultrasound-guided needle biopsy of 63 uterine tumors having high signal intensity upon T2-weighted magnetic resonance imaging.
        Int J Gynecol Cancer. 2014; 24: 1042-1047
        • Stojadinovic A
        • Leung DH
        • Hoos A
        • et al.
        Analysis of the prognostic significance of microscopic margins in 2,084 localized primary adult soft tissue sarcomas.
        Ann Surg. 2002; 235: 424-434
        • American Cancer Society
        Uterine Sarcoma.
        (Available at:) (Accessed on August 20, 2018)
        • Bansal N
        • Herzog TJ
        • Burke W
        • et al.
        The utility of preoperative endometrial sampling for the detection of uterine sarcomas.
        Gynecol Oncol. 2008; 110(1): 43-48
        • Wong WS
        • Lee TC
        • Lim CE
        Novel vaginal “paper roll” uterine morcellation technique for removal of large (>500 g) uterus.
        J Minim Invasive Gynecol. 2010; 17: 374-378
        • Wang CJ
        • Yuen LT
        • Lee CL
        • et al.
        A prospective comparison of morcellator and culdotomy for extracting of uterine myomas laparoscopically in nullipara.
        J Minim Invasive Gynecol. 2006; 13: 463-466
        • Montella F
        • Riboni F
        • Cosma S
        • et al.
        A safe method of vaginal longitudinal morcellation of bulky uterus with endometrial cancer in a bag at laparoscopy.
        Surg Endosc. 2014; 28: 1949-1953
        • Glasser MH
        Minilaparotomy: a minimally invasive alternative for major gynecologic abdominal surgery.
        Perm J. 2005; 9: 41-45
        • Uppal S
        • Frumovitz M
        • Escobar P
        • et al.
        Laparoendoscopic single-site surgery in gynecology: review of literature and available technology.
        J Minim Invasive Gynecol. 2011; 18: 12-23
      1. Savage GM, Christian JJ, Dillow DC. Disposable laparoscopic morcellator. US Patent 6,039,748A. 2000.

        • Shveiky D
        • Revel A
        • Rojansky N
        • et al.
        Diagnosis of malignant mesenchymal uterine tumors by hysteroscopic excisional biopsy.
        J Minim Invasive Gynecol. 2005; 12: 29-33
        • Vilos GA
        • Allaire C
        • Laberge PY
        • et al.
        The management of uterine leiomyomas.
        J Obstet Gynaecol Can. 2015; 37: 157-178
        • Shazly SA
        • Laughlin-Tommaso SK
        • Breitkopf DM
        • et al.
        Hysteroscopic morcellation versus resection for the treatment of uterine cavitary lesions: a systematic review and meta-analysis.
        J Minim Invasive Gynecol. 2016; 23: 867-877
        • Tulandi T
        • Leung A
        • Jan N
        Nonmalignant sequelae of unconfined morcellation at laparoscopic hysterectomy or myomectomy.
        J Minim Invasive Gynecol. 2016; 23: 331-337
        • Singh SS
        • Scott S
        • Bougie O
        • et al.
        Technical update on tissue morcellation during gynaecologic surgery: its uses, complications, and risks of unsuspected malignancy.
        J Obstet Gynaecol Can. 2015; 37: 68-81
        • Chen I
        • Hopkins L
        • Firth B
        • et al.
        Incidence of tissue morcellation during surgery for uterine sarcoma at a Canadian academic centre.
        J Obstet Gynaecol Can. 2015; 37: 421-425
        • Wais M
        • Tepperman E
        • Bernardini M
        • et al.
        A multicentre retrospective review of clinical characteristics of uterine sarcoma.
        J Obstet Gynaecol Can. 2017; 39: 652-658
        • Taylan E
        • Sahin C
        • Zeybek B
        • et al.
        Contained morcellation: review of current methods and future directions.
        Front Surg. 2017; 4: 15
        • Cohen SL
        • Morris SN
        • Brown DN
        • et al.
        Contained tissue extraction using power morcellation: prospective evaluation of leakage parameters.
        Am J Obstet Gynecol. 2016; 214 (257): e1-e6
        • Steller C
        • Cholkeri-Singh A
        • Sasaki K
        • et al.
        Power morcellation using a contained bag system.
        JSLS. 2017; 21 (e2016.00095)
        • AAGL Advancing Minimally Invasive Gynecology Worldwide
        AAGL practice report: morcellation during uterine tissue extraction.
        J Minim Invasive Gynecol. 2014; 21: 517-530
        • Kho KA
        • Brown DN
        Surgical treatment of uterine fibroids within a containment system and without power morcellation.
        Clin Obstet Gynecol. 2016; 59: 85-92
        • Pelosi 3rd, MA
        • Pelosi MA
        The Pryor technique of uterine morcellation.
        Int J Gynaecol Obstet. 1997; 58: 299-303
        • Solima E
        • Scagnelli G
        • Austoni V
        • et al.
        Vaginal uterine morcellation within a specimen containment system: a study of bag integrity.
        J Minim Invasive Gynecol. 2015; 22: 1244-1246
        • Lee EJ
        • Kim DH
        Vaginal morcellation through the posterior cul-de-sac using an electromechanical morcellator after laparoscopic myomectomy or subtotal hysterectomy: a retrospective, case-control study.
        Surg Endosc. 2016; 30: 4865-4870
        • Morice P
        • Rodriguez A
        • Rey A
        • et al.
        Prognostic value of initial surgical procedure for patients with uterine sarcoma: analysis of 123 patients.
        Eur J Gynaecol Oncol. 2003; 24: 237-240
        • Loizzi V
        • Cormio G
        • Nestola D
        • et al.
        Prognostic factors and outcomes in 28 cases of uterine leiomyosarcoma.
        Oncology. 2011; 81: 91-97
        • Society of Gynecologic Oncology
        SGO Position Statement: Morcellation.
        (Available at:) (Accessed on August 20, 2018)
        • Seidman MA
        • Oduyebo T
        • Muto MG
        • et al.
        Peritoneal dissemination complicating morcellation of uterine mesenchymal neoplasms.
        PLoS One. 2012; 7: e50058
        • Park JY
        • Kim DY
        • Kim JH
        • et al.
        The impact of tumor morcellation during surgery on the outcomes of patients with apparently early low-grade endometrial stromal sarcoma of the uterus.
        Ann Surg Oncol. 2011; 18: 3453-3461
        • Park JY
        • Park SK
        • Kim DY
        • et al.
        The impact of tumor morcellation during surgery on the prognosis of patients with apparently early uterine leiomyosarcoma.
        Gynecol Oncol. 2011; 122: 255-259
        • 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: 3154-3158
        • Perri T
        • Korach J
        • Sadetzki S
        • et al.
        Uterine leiomyosarcoma: does the primary surgical procedure matter?.
        Int J Gynecol Cancer. 2009; 19: 257-260
        • Oduyebo T
        • Rauh-Hain AJ
        • Meserve EE
        • et al.
        The value of re-exploration in patients with inadvertently morcellated uterine sarcoma.
        Gynecol Oncol. 2014; 132: 360-365
        • Kill LM
        • Kapetanakis V
        • McCullough AE
        • et al.
        Progression of pelvic implants to complex atypical endometrial hyperplasia after uterine morcellation.
        Obstet Gynecol. 2011; 117: 447-449
        • Donnez O
        • Squifflet J
        • Leconte I
        • et al.
        Posthysterectomy pelvic adenomyotic masses observed in 8 cases out of a series of 1405 laparoscopic subtotal hysterectomies.
        J Minim Invasive Gynecol. 2007; 14: 156-160
        • Cucinella G
        • Granese R
        • Calagna G
        • et al.
        Parasitic myomas after laparoscopic surgery: an emerging complication in the use of morcellator? Description of four cases.
        Fertil Steril. 2011; 96: e90-e96
        • Sepilian V
        • Della Badia C
        Iatrogenic endometriosis caused by uterine morcellation during a supracervical hysterectomy.
        Obstet Gynecol. 2003; 102: 1125-1127
        • Hilger WS
        • Magrina JF
        Removal of pelvic leiomyomata and endometriosis five years after supracervical hysterectomy.
        Obstet Gynecol. 2006; 108: 772-774
        • Larrain D
        • Rabischong B
        • Khoo CK
        • et al.
        “Iatrogenic” parasitic myomas: unusual late complication of laparoscopic morcellation procedures.
        J Minim Invasive Gynecol. 2010; 17: 719-724
        • Milad MP
        • Milad EA
        Laparoscopic morcellator-related complications.
        J Minim Invasive Gynecol. 2014; 21: 486-491