Is There a Future for Morcellation in Gynecologic Surgery?

An expert interview with Jubilee Brown, MD, member of the board of trustees for AAGL - Advancing Minimally Invasive Gynecology Worldwide

Stephanie Cajigal; Jubilee B. Brown, MD

Disclosures

April 25, 2014

Editor's Note:
Morcellation has been a commonly used technique in minimally invasive gynecologic surgeries since the US Food and Drug Administration (FDA) approved the first power morcellation device in 1995. Last week, however, the FDA announced that it discourages the use of morcellation for hysterectomy and myomectomy in most women with uterine fibroids.

Where do gynecologists go from here? In this interview with Medscape, Jubilee Brown, MD, a member of the board of trustees for AAGL - Advancing Minimally Invasive Gynecology Worldwide, discussed what additional research is needed and which guidelines gynecologists can rely on in the meantime.

Medscape: Can you give a brief history of morcellation and how it works?

Dr. Brown: The idea behind morcellation is the ability to remove -- in this case -- an enlarged uterus through a small incision. The benefit is that it involves minimally invasive surgery, which has substantial benefits over open surgery -- ie, laparotomy, which is the traditional method. Morcellation was first described in 1993[1] and has since expanded the realm of minimally invasive surgery in patients looking at hysterectomy.

There are several different types of morcellation. The one that has come under question is power morcellation, but there are other methods of tissue extraction, including bagged or unbagged morcellation; mini-laparotomy; removal through the vagina; or traditional, open surgery.

Which procedure to perform on which patient has a lot to do with patient-specific factors. Comparing and contrasting risks and benefits is an area in which additional research needs to be performed.

About 600,000 hysterectomies are performed annually in the United States.[2] Estimates for power morcellation range from 50,000 to 150,000, according to the FDA,[3] but most patients who undergo minimally invasive surgery for hysterectomy do not have power morcellation performed. Most patients have tissue extraction done through the vagina. The issue is that for patients with a very large uterus that's larger than any orifice, how do you safely and successfully remove it? That's where morcellation comes in.

Medscape: How does the AAGL leadership feel about the recent FDA announcement that laparoscopic power morcellators should no longer be used for hysterectomy or myomectomy in most women with uterine fibroids?

Dr. Brown: First of all, I should say that AAGL recognizes the role of the FDA in regulating these devices. We recognize that the FDA is committed to patients. However, we think that all of the approaches for tissue extraction that I have described have merit. We don't believe that there should be an outright ban on any of these approaches.

We've established a task force to do a scientific review of all of the details, including risks and benefits of all these procedures. At this point, we would encourage individualized patient care that takes into account best outcomes.

Medscape: The AAGL announced the creation of this task force in a letter to members in January in which it also asked members to submit examples of tissue extraction techniques. Can you explain what exactly the task force will be doing?

Dr. Brown: The task force will review and analyze all of the published data regarding tissue extraction techniques, including power morcellation and alternatives. They will consider the most important things that come to mind when thinking about morcellation: appropriate patient selection, patient safety, risk-benefit ratios of all of the alternatives, and use of a bag. But again, those things have to be undertaken with caution, given the concerns that exist right now. That's why we will look to the statement that the task force will publish to provide us with the best information.

Fortunately, AAGL comprises 7000 gynecologists. Many of those gynecologists do perform minimally invasive surgery; it's not only the board that performs procedures. It's useful to gain information from our membership on how gynecologists are practicing and what techniques they're using. Certainly this is short of a survey, but it's useful to request information about current practice and gain the opinions of our member gynecologists.

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