Benefits, harms, and costs
- 1Uterine 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).
- 2Morcellation of any type is contraindicated in women with established cancer, pre-cancerous lesions, or suspected cancer (III).
- 3When 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).
- 4Alternatives 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).
- 5The benefits of in-bag contained morcellation, including survival rates and ability to prevent dissemination of malignant cells/tissue, have not been established (II-2).
- 6An 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).
- 7Clinicians should be aware of the general complications associated with morcellation beyond the spread of malignant tissue (II-3).
- 1Each 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).
- 2If 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).
- 3Preoperative 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).
- 4Uterine morcellation should be avoided in hereditary cancer syndromes that increase the risk of uterine malignancy (III-C).
- 5Techniques for morcellation of a uterine specimen vary, and physicians should consider employing techniques that minimize specimen disruption and intra-abdominal spread (III-C).
- 6Uterine morcellation is contraindicated in women with established or suspected uterine neoplasia (II-2A).
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)
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- AAGL position statement: route of hysterectomy to treat benign uterine disease.J Minim Invasive Gynecol. 2011; 18: 1-3
- U. Electrical cutting device for laparoscopic removal of tissue from the abdominal cavity.Obstet Gynecol. 1993; 81: 471-474
- Quantitative assessment of the prevalence of unsuspected uterine sarcoma in women undergoing treatment of uterine fibroids: summary and key findings.FDA, Silver Spring, MD2014
- Laparoscopic Electric Morcellators—Risk of Spread of Unsuspected Uterine Sarcoma—Notice to Hospitals.Health Canada, Ottawa2014 (Available at:)http://healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2014/39409a-eng.php?_ga=1.235271169.1810080818.1412167324(Accessed on August 20, 2018)
- Abnormal uterine bleeding in pre-menopausal women.J Obstet Gynaecol Can. 2013; 35: 473-475
- High cumulative incidence of uterine leiomyoma in black and white women: ultrasound evidence.Am J Obstet Gynecol. 2003; 188: 100-107
- Surgical approach to hysterectomy for benign gynaecological disease.Cochrane Database Syst Rev. 2009; CD003677
- Surgical approach to hysterectomy: introducing the concept of technicity.J Obstet Gynaecol Can. 2009; 31: 1050-1053
- Abdominal versus laparoscopic hysterectomies for benign diseases: evaluation of morbidity and mortality among 465,798 cases.Gynecol Surg. 2013; 10: 117-122
- A multicenter randomized, controlled study comparing laparoscopic versus minilaparotomic myomectomy: reproductive outcomes.Fertil Steril. 2007; 88: 933-941
- Comparative performance of the 2009 International Federation of Gynecology and Obstetrics’ staging system for uterine corpus cancer.Obstet Gynecol. 2010; 116: 1141-1149
- 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
- Occult uterine cancer in patients undergoing laparoscopic hysterectomy with morcellation: implications for surveillance for disease recurrence and outcomes.Gynecol Oncol. 2013; 130: e1-e169
- Endometrial cancer: a review and current management strategies: part I.Gynecol Oncol. 2014; 134: 385-392
- Cancer and Lhermitte-Duclos disease are common in Cowden syndrome patients.Hered Cancer Clin Pract. 2010; 8: 6
- Diagnosis and treatment of sarcoma of the uterus.Acta Oncol. 2012; 51 (A review.): 694-705
- Uterine sarcomas 2013.Gynecol Oncol. 2013; 130: 3-5
- 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
- Morcellation in Canada: perspectives on current practices and future implications.J Minim Invasive Gynecol. 2015; 22: 1142-1144
- The prevalence of occult leiomyosarcoma at surgery for presumed uterine fibroids: a meta-analysis.Gynecol Surg. 2015; 12: 165-177
- 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
- Management of uterine fibroids.Agency for Healthcare Research and Quality, Rockville, MD2017 (Comparative effectiveness review no. 195)
- Occult uterine sarcoma and leiomyosarcoma: incidence of and survival associated with morcellation.Obstet Gynecol. 2016; 127: 29-39
- Population-based estimates of the prevalence of uterine sarcoma among patients with leiomyomata undergoing surgical treatment.JAMA Surg. 2015; 150: 368-370
- Incidence of occult leiomyosarcoma in presumed morcellation cases: a database study.Eur J Obstet Gynecol Reprod Biol. 2016; 197: 31-35
- 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
- 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
- Clinical application of diffusion-weighted imaging for preoperative differentiation between uterine leiomyoma and leiomyosarcoma.Am J Obstet Gynecol. 2014; 210 (368): e1-e8
- 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
- Analysis of the prognostic significance of microscopic margins in 2,084 localized primary adult soft tissue sarcomas.Ann Surg. 2002; 235: 424-434
- Uterine Sarcoma.(Available at:)Accessed on August 20, 2018)
- The utility of preoperative endometrial sampling for the detection of uterine sarcomas.Gynecol Oncol. 2008; 110(1): 43-48
- Novel vaginal “paper roll” uterine morcellation technique for removal of large (>500 g) uterus.J Minim Invasive Gynecol. 2010; 17: 374-378
- A prospective comparison of morcellator and culdotomy for extracting of uterine myomas laparoscopically in nullipara.J Minim Invasive Gynecol. 2006; 13: 463-466
- A safe method of vaginal longitudinal morcellation of bulky uterus with endometrial cancer in a bag at laparoscopy.Surg Endosc. 2014; 28: 1949-1953
- Minilaparotomy: a minimally invasive alternative for major gynecologic abdominal surgery.Perm J. 2005; 9: 41-45
- Laparoendoscopic single-site surgery in gynecology: review of literature and available technology.J Minim Invasive Gynecol. 2011; 18: 12-23
Savage GM, Christian JJ, Dillow DC. Disposable laparoscopic morcellator. US Patent 6,039,748A. 2000.
- Diagnosis of malignant mesenchymal uterine tumors by hysteroscopic excisional biopsy.J Minim Invasive Gynecol. 2005; 12: 29-33
- The management of uterine leiomyomas.J Obstet Gynaecol Can. 2015; 37: 157-178
- 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
- Nonmalignant sequelae of unconfined morcellation at laparoscopic hysterectomy or myomectomy.J Minim Invasive Gynecol. 2016; 23: 331-337
- Technical update on tissue morcellation during gynaecologic surgery: its uses, complications, and risks of unsuspected malignancy.J Obstet Gynaecol Can. 2015; 37: 68-81
- Incidence of tissue morcellation during surgery for uterine sarcoma at a Canadian academic centre.J Obstet Gynaecol Can. 2015; 37: 421-425
- A multicentre retrospective review of clinical characteristics of uterine sarcoma.J Obstet Gynaecol Can. 2017; 39: 652-658
- Contained morcellation: review of current methods and future directions.Front Surg. 2017; 4: 15
- Contained tissue extraction using power morcellation: prospective evaluation of leakage parameters.Am J Obstet Gynecol. 2016; 214 (257): e1-e6
- Power morcellation using a contained bag system.JSLS. 2017; 21 (e2016.00095)
- AAGL practice report: morcellation during uterine tissue extraction.J Minim Invasive Gynecol. 2014; 21: 517-530
- Surgical treatment of uterine fibroids within a containment system and without power morcellation.Clin Obstet Gynecol. 2016; 59: 85-92
- The Pryor technique of uterine morcellation.Int J Gynaecol Obstet. 1997; 58: 299-303
- Vaginal uterine morcellation within a specimen containment system: a study of bag integrity.J Minim Invasive Gynecol. 2015; 22: 1244-1246
- 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
- Prognostic value of initial surgical procedure for patients with uterine sarcoma: analysis of 123 patients.Eur J Gynaecol Oncol. 2003; 24: 237-240
- Prognostic factors and outcomes in 28 cases of uterine leiomyosarcoma.Oncology. 2011; 81: 91-97
- SGO Position Statement: Morcellation.(Available at:)Accessed on August 20, 2018)
- Peritoneal dissemination complicating morcellation of uterine mesenchymal neoplasms.PLoS One. 2012; 7: e50058
- 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
- The impact of tumor morcellation during surgery on the prognosis of patients with apparently early uterine leiomyosarcoma.Gynecol Oncol. 2011; 122: 255-259
- Retrospective cohort study evaluating the impact of intraperitoneal morcellation on outcomes of localized uterine leiomyosarcoma.Cancer. 2014; 120: 3154-3158
- Uterine leiomyosarcoma: does the primary surgical procedure matter?.Int J Gynecol Cancer. 2009; 19: 257-260
- The value of re-exploration in patients with inadvertently morcellated uterine sarcoma.Gynecol Oncol. 2014; 132: 360-365
- Progression of pelvic implants to complex atypical endometrial hyperplasia after uterine morcellation.Obstet Gynecol. 2011; 117: 447-449
- 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
- Parasitic myomas after laparoscopic surgery: an emerging complication in the use of morcellator? Description of four cases.Fertil Steril. 2011; 96: e90-e96
- Iatrogenic endometriosis caused by uterine morcellation during a supracervical hysterectomy.Obstet Gynecol. 2003; 102: 1125-1127
- Removal of pelvic leiomyomata and endometriosis five years after supracervical hysterectomy.Obstet Gynecol. 2006; 108: 772-774
- “Iatrogenic” parasitic myomas: unusual late complication of laparoscopic morcellation procedures.J Minim Invasive Gynecol. 2010; 17: 719-724
- Laparoscopic morcellator-related complications.J Minim Invasive Gynecol. 2014; 21: 486-491
This document reflects emerging clinical and scientific advances on the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these opinions. They should be well documented if modified at the local level. None of these contents may be reproduced in any form without prior written permission of the publisher.
All people have the right and responsibility to make informed decisions about their care in partnership with their health care providers. In order to facilitate informed choice, patients should be provided with information and support that is evidence-based, culturally appropriate and tailored to their needs.
This guideline was written using language that places women at the centre of care. That said, the SOGC is committed to respecting the rights of all people - including transgender, gender non-binary, and intersex people - for whom the guideline may apply. We encourage healthcare providers to engage in respectful conversation with patients regarding their gender identity as a critical part of providing safe and appropriate care. The values, beliefs and individual needs of each patient and their family should be sought and the final decision about the care and treatment options chosen by the patient should be respected.