From the Editor
Options for reducing the use of open power morcellation of uterine tumors
The most promising alternative to open power morcellation is morcellation in a bag, described here
I perform extracorporeal morcellation
Dr. Barbieri’s two editorials on open morcellation were as interesting as they were informative. I have performed many morcellations, and I now worry about disseminated leiomyomatosis as well as the possibility of spreading sarcoma cells.
Presently when I perform a supracervical hysterectomy, I use the small GelPoint single-site port (Applied Medical). With this instrument, I am able to do an extracorporeal morcellation on all but the largest of specimens.
I will continue to utilize the power morcellator in selected cases and will discuss the implications with my patients.
Phillip Madonia, MD
Mobile, Alabama
Needed: Better training in vaginal surgery
Two total vaginal hysterectomies that I performed recently were to treat patients with large uterine myomas. Final pathology weight was 757 g in the first case and 655 g in the second case. I am not fellowship trained, and I completed my ObGyn residency training in a typical program—meaning the vaginal surgery volume was just sufficient to meet training quotas.
The overwhelming evidence shows that vaginal hysterectomy is safer and more cost-effective than any other hysterectomy approach. It amazes me that, over and over again, we hear this evidence in our conferences and we memorize it for our board certification exams, yet in practice our field of gynecology continues to distance itself as far away from the vagina as possible in favor of abdominal surgery through “minimally invasive” small incisions.
And now the April 17 US Food and Drug Administration (FDA) warning regarding laparoscopic morcellation has generated quite a bit of chaos throughout the United States. Some hospitals here in New York have responded by placing a temporary ban on power morcellation, with talk that reintroduction will require special preoperative patient counseling and consent form. Another hospital, I am told, is requiring mandatory preoperative magnetic resonance imaging and endometrial biopsy (regardless of menstrual history) for any patient in which hysterectomy involving power morcellation of fibroids is planned.
I have two thoughts on this:
- It should not come as a surprise that power morcellation could in theory spread cancer. Gynecologists have long known of associated risks from a ruptured ovarian cyst, and the theoretical risk of an endometrial cancer arising in a focus of peritoneal endometriosis.
- There wouldn’t be so much panic following this warning if our colleagues in minimally invasive gynecology were trained in vaginal surgery—the most minimally invasive approach of all.
Sadly, I haven’t yet seen any statement from American Institute of Minimally Invasive Surgery (AIMIS), American Urogynecologic Society (AUGS), or Female Pelvic Medicine and Reconstructive Surgery (FPMRS) leadership that supports a renewed focus on vaginal surgery. Rather than putting in some effort to improve vaginal surgery skills, I anticipate that most surgeons will simply switch to open abdominal hysterectomy until statistical studies arise and the FDA endorses the safety of power morcellation in a protective laparoscopic bag.
Seth Finkelstein, MD
New York, New York
Don’t take away the patient’s choice
I am a 40-year-old woman who has been suffering from symptoms due to intramural fibroids for 7 years. As a strong believer in trying minimally invasive options first, I have tried oral contraception, undergone acupuncture, hysteroscopy, focused ultrasound (four times), and radiofrequency ablation. After six procedures in 7 years, multiple thrombosed hemorrhoids, an anal fissure, bladder problems, a blood transfusion, and months of intravenous iron infusions, I think it’s safe to say that I’ve tried my best.
I do not make a lot of money, and I live in an expensive area. As a single woman, no one is available to help me during a long recovery. I cannot afford to take 6 weeks off from work for open abdominal surgery. California short-term disability pays only 60% of my wages.
After meeting with several doctors, I have elected to have robotically assisted laparoscopic supracervical hysterectomy. I have been told that vaginal delivery of my uterus would be very difficult due to its size, and that surgical time and recovery would be quicker and less painful if my uterus is morcellated. In June, an associate clinical professor of reconstructive pelvic surgery at a major university will perform this surgery. I am fearful and anxious about the surgery, not to mention I am dealing with dysmenorrhea, menorrhagia, urinary frequency, and I have an abdomen the size of a women who is 4 months pregnant.
