“Your surgeon is spewing cancer all over the inside of your abdomen!” In October 2013, Dr. Amy Reed underwent a routine surgery to rid her of her symptomatic benign fibroids. Or so she thought. In order to cut her recovery time, the surgeons used a “minimally invasive” approach. They used tiny incisions and a camera to do the surgery. When it came time to remove the big fibroids, they used an instrument called a power morcellator to eat up the fibroid into tiny pieces, which could then be removed through the tiny incisions, piece by piece. In those days, the surgeons just morcellated the fibroid, allowing the tissue to fall where it would, all over the abdominal cavity. For Dr. Reed, her routine surgery ended with some not-so-routine findings. When the pathologists looked at the fibroid tissue they discovered it was not really a fibroid, but rather a type of cancer called leiomyosarcoma. Leiomyosarcoma parades around like a benign, harmless fibroid, but it is actually a rare and aggressive cancer. For the unfortunate Dr. Reed, power morcellation of this cancerous tumor meant that bits of tumor were spewed all over her abdomen. As a result, she and her husband started a campaign to end power morcellation.
It turns out that leiomyosarcoma is more common than gynecologists thought. The rate of unexpected leiomyosarcoma is 0.09%. Perhaps even more concerning, other undiscovered cancers can be lurking in what looks like a normal uterus, such as endometrial cancer (cancer of the inner lining of the uterus). Furthermore, even benign tissue can lead to problems down the road, such as endometriosis or leiomyomatosis, if it ends up where it shouldn’t be. By 2014, most hospitals stopped using power morcellation, realizing that the risks were too high.
However, gynecologic surgeons still wanted to provide their patients with a minimally invasive option for removal of their fibroids. So, they got creative. One group of surgeons at the Washington University in St. Louis developed a technique for using a power morcellator inside a bag in 2014. The bag would catch all the bits of tissue, preventing them from falling all over the inside of the abdomen, while still allowing the surgeons to use tiny incisions.
In the October 2015 issue of the Green Journal, the surgeons at Washington University in St. Louis, lead by Dr. Brooke Winner, published the results of their new power morcellation technique. They collected medical records from 101 traditional, uncontained power morcellation surgeries that occurred between 2007 and 2014, before the hospital stopped using uncontained power morcellation. In February 2014, the surgeons started using the contained bag method. They collected medical records on 51 contained power morcellation surgeries from 2014 to 2015.
The primary outcome the researchers compared was operative time. As one might expect, performing the power morcellation inside a bag took longer, about 20 minutes on average longer operating time, which was a statistically significant difference. Although there were not enough patients in the study to get a really good understanding of their secondary outcomes (it was underpowered to show a difference), the authors also compared estimated blood loss, length of hospital stay, pathology findings, uterine weight, and complications. They did not find any differences in any of these outcomes. For complications, there were 7 complications in the uncontained group including a bladder injury and a blood transfusion (~7% complication rate). There were no complications in the contained morcellation group. There were also no cases of bag rupture or tears in the bag or cases of uterine tissue getting disseminated into the abdominal cavity.
It is important to note that the authors are not looking at differences in long-term outcomes such as development of metastatic cancer or iatrogenic endometriosis. They do report that there was one case of unexpected cancer in the uncontained power morcellation group. For this unfortunate patient, she had a CAT scan before the surgery that showed a normal fibroid and a biopsy of the tissue inside her uterus that was normal. Nevertheless, when the pathologists looked at the tissue from the surgery under the microscope, it revealed leiomyosarcoma. The authors do not report on this patient’s long-term outcome.
Taken all together, these results are good news for patients seeking a minimally invasive route to removal of a problematic uterus. This larger collection of clinical data examining this new surgical technique shows that it may be a solution to the problem of spewing tissue all over the abdomen while still keeping incisions small.