By Dr. Charles H. Bowers
The latest controversy in OB/GYN is whether power morcellation should be allowed to continue as part of minimally invasive gynecological surgery. Recent events, most notably a story published in the Wall Street Journal, discussed the unfortunate case of a physician mother of six who was found to have a rare occult uterine cancer (leiomyosarcoma) after undergoing a minimally invasive procedure through several small incisions instead of one large incision, using a power morcellator.
Morcellation in various forms has been a surgical technique for several decades. The FDA approved the first power morcellator in the U.S. in 1995. It is estimated that power morcellation procedures account for 10 percent to 25 percent of all hysterectomies in the U.S. (50,000 to 150,000) per year. Power morcellation is a technique that uses a rotary covered blade to slice/dissect segments of the fibroid or portions of the uterus into smaller pieces in order to get them through the smaller incisions needed with minimally invasive surgical procedures. The size of the tissue mass needing to be removed will determine the overall number of segments/pieces removed, and the texture and the ease of dissection will determine if small pieces of the mass will be lost or left behind. Every attempt at removing all pieces is made. However, sometimes it is impossible to account for every little piece, and, in theory, microscopic cells will be left behind. It is these small, sometimes-microscopic, pieces that raise concern if there is an unsuspecting malignancy.
The problem with certain types of cancers (sarcoma/leiomyosarcoma) associated with the uterus and fibroids is that they can only be diagnosed after the removal of the uterus or fibroids. The incidence of these tumors accounts for only 3 percent to 9 percent of all uterine malignancies. They are rare and very aggressive, but many (60 percent) present at an early stage. These cancers can occur at any age, but the mean age at diagnosis is 60 years old. African-American women have a twofold increased incidence of leiomyosarcoma than other ethnicities. Women who have had other cancers, especially those with breast cancer and those taking Tamoxifen, are also at increased risk for sarcomas.
Proper knowledge, selection and diligence by one's provider, as with any surgical procedure, are critically important for the proper selection of the best and safest route for the patient.
Important considerations in deciding if surgery is indicated:
- Your age
- Desire for future childbearing
- Symptoms - bleeding, pain type and duration
- Size of uterus
- Rate of growth
- Other medical problems - obesity, other cancers, medications
- Family history and ethnicity
- Important to question your provider about risks, benefits and alternatives that cover all reasonable options
- Must get second and (if needed) third opinion
- Presence of fibroids alone is not a reason for surgical intervention
For the following reasons, minimally invasive surgery has been a benefit to those women who have no other option but surgery:
- Less trauma during surgery
- Less blood loss
- Shorter hospital stay
- Quicker recovery
- Smaller incisions
- Less infection risk
- Fewer complications
Remember, there is no surgical procedure that is without risk of complication.