Morcellation: Even With Benign Disease, Problems May Follow

Veronica Hackethal, MD

December 08, 2014

Power morcellation can spread benign uterine disease, increasing morbidity and necessitating more extensive surgery, according to three case reports from Johns Hopkins Hospital in Baltimore, Maryland. The reports were published in the January issue of Obstetrics & Gynecology.

"While there is currently much debate regarding the safety of morcellation techniques in the setting of an undiagnosed malignancy, this series demonstrates the potential risks even in the setting of benign uterine pathology," write Amanda Ramos, MD, Amanda Fader, MD, and Kara Long Roche, MD, all from the Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Hospital.

Although rare, past case reports have described the spread of endometriosis after power morcellation, according to the authors. However, "the extent of disease and radical resection required in the patients presented in the current case report is unique," they point out.

Morcellation breaks tissue into smaller pieces for easier removal during laparoscopic surgery. The technique has recently come under scrutiny because of its potential to spread undiagnosed uterine malignancies through the peritoneal cavity.

In November, the US Food and Drug Administration (FDA) toughened its previous warning from last April, stating that power morcellation should not be used in the majority of women undergoing hysterectomy or myomectomy for fibroids. A black box warning about the risks of spreading unsuspected cancer will also be added to the labeling of power morcellators.

The cases reported in this article concerned three women who had previously had laparoscopic hysterectomies with power morcellation for benign disease. The women presented between 6 and 12 months after their initial surgeries. Workup for each woman was "highly suspicious for malignancy." All three women underwent exploratory laparotomy and required extensive organ resection or radical dissection to remove their disease. Pathology results showed disseminated benign disease for all three women.

Case 1 concerned a 38-year-old mother of four who had left-sided abdominal pain, constipation, and an elevated CA-125 level. She was found to have multiple soft tissue tumors whose removal required resection of parts of the spleen, colon, diaphragm, omentum, ureters, and left ovaries.

Case 2 was a 51-year-old mother of two with abdominal pain, painful urination, and pelvic pressure. She was found to have a 15-cm abdominal mass adherent to surrounding organs. Removal required resection of parts of the ureters, bladder, rectosigmoid colon, omentum, and her remaining left ovary and fallopian tube.

Case 3 involved a 51-year-old mother of two who had nausea, vomiting, and abdominal pain. On computed tomography scan, she had a bowel obstruction and a pelvic mass. Removal required lysis of adhesions and removal of the right ovaries and tubes.

The authors reiterate recommendations issued last May by the American College of Obstetricians and Gynecologists, the European Society of Gynecologic Endoscopy, and AAGL, formerly known as the American Association of Gynecologic Laparoscopists. They urge surgeons to do a thorough preoperative workup to rule out malignancy and to appropriately counsel patients about the risks involved with morcellation.

The authors have disclosed no relevant financial relationships.

Obstet Gynecol. 2014;125:99-102.

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