Open power morcellation of uterine tumors during hysterectomy banned at two Boston hospitals

The use of power morcellation to remove the uterus or uterine tumors during hysterectomy may be riskier than many have thought, especially when morcellation is performed in an “open” fashion (without use of a protective bag) in the peritoneal cavity. That’s the conclusion reached by two top Boston hospitals recently, when Brigham and Women’s and Massachusetts General both banned use of open power morcellation in gynecologic surgery.

Both hospitals assert that, when used outside of a containment system such as a morcellation bag, intraperitoneal open morcellation can spread tumor tissue throughout the peritoneal cavity. Robert L. Barbieri, MD, who is chair of obstetrics and gynecology at Brigham and Women’s Hospital, recently wrote about this concern for OBG Management in his capacity as editor in chief of the journal.

“When used to treat tumors presumed to be fibroids, open power morcellation is associated with an increased risk of dispersing benign myoma tissue and occult malignant leiomyosarcoma tissue throughout the abdominal cavity,” he wrote.¹ “Dispersion of benign myoma tissue may result in the growth of fibroids on the peritoneal surface, omentum, and bowel, causing abdominal and pelvic pain and necessitating reoperation. Dispersion of leiomyosarcoma tissue throughout the abdominal cavity may result in a Stage I cancer being upstaged to a Stage IV malignancy, requiring additional surgery and chemotherapy. In cases in which open power morcellation causes the upstaging of a leiomyosarcoma, the death rate is increased.”¹

Related article: Options for reducing the use of open power morcellation of uterine tumors Robert L. Barbieri, MD (Editorial, March 2014)

The two Boston hospitals are not the only institutions reconsidering the use of open power morcellation. Temple University Hospital in Philadelphia banned the procedure in late February 2014.

And in December 2013, the Society of Gynecologic Oncology issued a position statement on the issue, which said, “power morcellation or other techniques that cut up the uterus in the abdomen have the potential to disseminate an otherwise contained malignancy throughout the abdominal cavity. For this reason, the Society of Gynecologic Oncology (SGO) asserts that it is generally contraindicated in the presence of documented or highly suspected malignancy, and may be inadvisable in premalignant conditions or risk-reducing surgery.”²

For its part, the AAGL, previously known as the American Association of Gynecologic Laparoscopists, “is reviewing the scientific evidence and best practices reported by our members,” stated an article in its Association News. “We recognize that, in rare cases, the use of power morcellators can lead to the dissemination of an occult malignancy of endometrial or myometrial origin, and also of dissemination of benign morcellated tissues. We encourage our members to fully research and understand the risks of power morcellation and to learn more about when alternative methods of tissue extraction may be appropriate.”³

The most recent committee opinion on choosing a hysterectomy route from the American College of Obstetricians and Gynecologists (ACOG) to touch on the issue states that, “the decision to perform a hysterectomy via [minimally invasive surgery] (with or without morcellation) is based on a patient evaluation, including the patient’s history and general health, tests, and procedures, such as pre-surgery biopsies. The evaluation and diagnostic process also provides an opportunity to identify any cautions or contraindications, such as finding a gynecological cancer.”⁴

FILLING THE TECHNOLOGY GAP
Now that open power morcellation appears to be receding as an option for minimally invasive gynecologic surgeons, what is the best approach?

In its position statement, the SGO recommends that, “Patients being considered for minimally invasive surgery performed by laparoscopic or robotic techniques who might require intracorporeal morcellation should be appropriately evaluated for the possibility of coexisting uterine or cervical malignancy. Other options to intracorporeal morcellation include removing the uterus through a mini-laparotomy or morcellating the uterus inside a laparoscopic bag.”²

K. Anthony Shibley, MD, a Minneapolis-area ObGyn, has developed a novel strategy to prevent tissue dissemination during open power morcellation. His strategy involves utilization of a large bowel isolation bag. For more on this approach, click here.

AAGL is in the process of formulating a policy on the use of open power morcellation. ACOG has not signaled its intent to weigh in on the issue.

Brigham and Women’s Hospital intends to carefully review requests for permission to utilize open power morcellation on a case-by-case basis, provided the surgeon presents all case details and a rationale for exemption from the new rule.