UTERINE MORCELLATION IN MINIMALLY INVASIVE SURGERY, SHOULD BE APPLIED ? OR SHOULD NOT BE APPLIED ?

Abstract

In recent years, minimally invasive surgery has been preferred to open abdominal procedures in gynecology. The one of the biggest problem in minimally invasive surgery is extraction of large uteri or myomas. For this purpose, morcellators are used for removal of tissues which are divided into small pieces with electromechanical or manuel power. Since the safety warning from the US Food and Drug Administration about the use of power morcellators, minimally invasive procedures involving the removal of large uterus and myomas are under review. Scientific proofs about that morcellation of undiagnosed uterine sarcomas is associated with worse survival outcomes of pa-tients are increasing. However currently a few data about morcellation of occult uterine malignan-cies are available. We will discuss the effects of morcellation of undiagnosed uterine malignancies, focusing on possible radiologic imaging techniques for preoperative diagnosis of uterine sarcoma and for avoiding intra-abdominal dissemination of potentially malignant tissues in this review. However, according to current data, intra-abdominal morcellation should be banned from clinical practice.

Keywords

• Uterine sarcoma,power morcellation,minimal invasive surgery

MİNİMAL İNVAZİV CERRAHİDE UTERİN MORSELASYON, UYGULANMALI MI ? UYGULANMAMALI MI ?

Abstract

Son yıllarda jinekolojide minimal invaziv cerrahi, açık abdominal cerrahilere tercih edilmektedir. Minimal invaziv cerrahideki en büyük problemlerden biri büyük uterusların ve leiomyomların batın dışına çıkarılmasıdır. Bu amaçla morselatör olarak adlandırılan ve dokuların elektromekanik güç ile ya da manuel olarak küçük parçalara bölünerek batın dışına çıkarılmasını sağlayan cerrahi aletler kullanılmaktadır. The US Food and Drug Administration (FDA)’nın power morselatör kul-lanımı ile ilgili güvenlik uyarısı sonrasında, minimal invaziv cerrahide büyük uterus ve myomların çıkarılması ile ilgili derlemeler artmıştır. Tanı konulmamış uterin sarkomların morselasyonu neden-li, hastaların kötü sağkalım sonuçlarını gösteren bilimsel kanıtlar artmaktadır. Fakat şu anda okült uterus maligniteleri ile ilgili az sayıda veri bulunmaktadır. Biz bu derlemede, morselasyonun tanı konulmamış uterus malignitelerinin üzerindeki etkisini, uterin sarkomların preoperatif tanısı için kullanılabilecek radyolojik görüntüleme tekniklerini ve potansiyel malign dokuların intraabdomi-nal yayılımının nasıl önüne geçilebileceğini tartıştık fakat şu anki veriler ışığında klinik pratikte intraabdominal morselasyondan kaçınılmalıdır

Keywords

• Uterin sarkom,power morselasyon,minimal invaziv cerrahi

References

1. 1. Schollmeyer T, Soyinka AS, Schollmeyer M, et al. Georg Kelling (1866-1945): the root of modern day minimal invasive surgery. A forgotten legend? Arch Gynecol Obstet 2007; 276:505–509.
2. 2. Mouret G. From the first laparoscopic cholecystectomy to the frontiers of laparoscopic surgery: the future prospectives. Dig Surg 1991; 8:124–125
3. 3. Schlaerth AC, Abu-Rustum NR. Role of minimally invasive surgery in gynecologic cancers. Oncologist 2006;11:895-901.
4. 4. Kho KA, Nezhat CH. Evaluating the risks of electric uterine morcellation. JAMA 2014;311:905-906.
5. 5. Larraín D, Rabischong B, Khoo CK, et al. “Iatrogenic” parasitic myomas: Unusual late complication of laparoscopic morcellation procedures. J Minim Invasive Gynecol 2010;17:719-724.
6. 6. Hampton, T., 2014. Use of morcellation to remove fibroids scrutinized at FDA hearings. JAMA 312, 588.
7. 7. Larra´ın D, Rabischong B, Khoo CK et al. “Iatrogenic” parasitic myomas: Unusual late complication of laparoscopic morcellation procedures. J Minim Invasive Gynecol 2010;17:719–724.
8. 8. Milad MP, Milad EA. Laparoscopic morcellatorrelated complications. J Minim Invasive Gynecol 2014;21:486– 491.

9. 9. Gerster AG. II.On the surgical dissemination of cancer. Ann Surg 1885;2:98–109.
10. 10. Dobronte Z, Wittman T, Karc´asony G. Rapid development of malignant metastases in the abdominal wall aft er laparocopy. Endoscopy 1978;10:127–130.
11. 11. Bogani G, Cliby WA, Aletti GD. Impact of morcellation on survival outcomes of patients with unexpected uterine leiomyosarcoma: A systematic review andmeta-analysis. Gynecol Oncol 2015;137: 167–172.
12. 12. Hampton T. Critics of fibroid removal procedure question risks it may pose for women with undetected uterine cancer.JAMA 2014;311: 891–893.
13. 13. Kho KA, Lin K, Hechanova M, Richardson DL. Risk of Occult Uterine Sarcoma in Women Undergoing Hysterectomy for Benign Indications. Obstet Gynecol. 2016 Mar;127(3):468-73.
14. 14 Senapati S, Tu FF, Magrina JF.Power morcellators: a review of current practice and assessment of risk.Am J Obstet Gynecol. 2015 Jan;212(1):18-23.
15. 15. Hagemann, I.S., Hagemann, A.R., LiVolsi, V.A., Montone, K.T., Chu, C.S., 2011. Risk of occult malignancy in morcellated hysterectomy: a case series. Int. J. Gynecol. Pathol. 30 (5), 476–483.
16. 16. Wright, J.D., Tergas, A.I., Burke, W.M., et al., 2014. Uterine pathology in women undergoing minimally invasive hysterectomy using morcellation. JAMA 312, 1253–1255. 17. Nagai, T., Takai, Y., Akahori, T., et al., 2014. Novel uterine sarcoma preoperative diagnosis score predicts the need for surgery in patients presenting with a uterine mass. Springerplus 3, 678.
17. 18. Skorstad M, Kent A, Lieng M. Uterine leiomyosarcoma - incidence, treatment, and the impact of morcellation. A nationwide cohort study. Acta Obstet Gynecol Scand. 2016 Sep;95(9):984-90.
18. 19. Parker WH, Fu YS, Berek JS. Uterine sarcoma in patients operated on for presumed leiomyoma and rapidly growing leiomyoma. Obstet Gynecol 1994; 83:414–418. 20. Mahnert N, Morgan D, Campbell D et al. Unexpected gynecologic malignancy diagnosed aft er hysterectomy performed for benign indications. Obstet Gynecol 2015;125:397–405.
19. 21. Giorgio B, Valentina C, Antonino D et al. Morcellation of undiagnosed uterine sarcoma: A critical review. Critical Reviews in Oncology/Hematology 98 (2016) 302–308
20. 22. Van den Bosch, T., Dueholm, M., Leone, F.P., et al., 2015. Terms and definitions for describing myometrial pathology using ultrasonography. Ultrasound Obstet. Gynecol.
21. 23. Nitta, E., Kanenishi, K., Itabashi, N., Tanaka, H., Hata, T., 2014. Real-time tissue elastography of uterine sarcoma. Arch. Gynecol. Obstet. 289, 463–465.
22. 24. Namimoto T, Yamashita Y, Awai K et al. Combined use of T2-weighted and diff usionweighted 3-T MR imaging for diff erentiating uterine sarcomasfrombenignleiomyomas. Eur Radiol 2009; 19:2756–2764.
23. 25. J.R. Lorain, M.S. Piver, Uterine sarcomas: clinical features and management, in: X. Coppleson, J. Monaghan, P. Morrow, M. Tattersall (Eds.), Gynecologic Oncology, Churchill Livingstone, London 1992, pp. 827–840.
24. 26. Artioli, G., Wabersich, J., Ludwig, K., Gardiman, M.P., Borgato, L., Garbin, F., 2015. Rare uterine cancer: carcinosarcomas: review from histology to treatment. Crit. Rev. Oncol. Hematol. 94, 98–104.
25. 27. Gadducci, A., 2011. Prognostic factors in uterine sarcoma. Best Pract. Res. Clin. Obstet. Gynaecol. 25, 783–795.
26. 28. Raspagliesi F, Maltese G, Bogani G, et all. Morcellation worsens survival outcomes in patients with undiagnosed uterine leiomyosarcomas: A retrospective MITO group study. Gynecol Oncol. 2016 Nov 4. pii: S0090- 8258(16)31519-0.
27. 29. Guo, X.M., Xu, X., Desai, V.B., 2015. Alterations in surgical technique following FDA statement on power morcellation. Am. J. Obstet. Gynecol.
28. 30. Harris JA, Swenson CW, Uppal S, et al. Practice patterns and postoperative complications before and aft er US Food and Drug Administration safety communication on power morcellation. Am J Obstet Gynecol. 2016 Jan;214(1):98.e1-98.e13.
29. 31. Einstein MH, Barakat RR, Chi DS et al. Management of uterine malignancy found incidentally aft er supracervical hysterectomy or uterinemorcellation for presumed benign disease. Int J Gynecol Cancer 2008;18:1065–1070.
30. 32. Kho KA, Brown DN. Surgical Treatment of Uterine Fibroids Within a Containment System and Without Power Morcellation.Clin Obstet Gynecol. 2016 Mar;59(1):85-92.
31. 33. Parker WH1, Pritts EA, Olive DL. What is the Future of Open Intraperitoneal Power-Morcellation of Fibroids?Clin Obstet Gynecol. 2016 Mar;59(1):73-84.
32. 34. Nieboer TE, JohnsonN, LethabyAet al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev 2009; CD003677.
33. 35. Serur E, Lakhi N. Laparoscopic hysterectomy with manual morcellation of the uterus: An original technique that permits the safe and quick removal of a large uterus. Am J Obstet Gynecol 2011;204: 566.e1–566.e2.
34. 36. Montella F, Riboni F, Cosma S et al. A safe method of vaginal longitudinal morcellation of bulky uterus with endometrial cancer in a bag at laparoscopy. Surg Endosc 2014;28:1949–1953.
35. 37. Cohen SL, Einarsson JI, Wang KC et al. Contained power morcellation within an insuffl ated isolation bag. Obstet Gynecol 2014;124:491–497.
36. 38. Moawad GN, Samuel D, Abi Khalil ED. Abdominal Approaches to Tissue Containment and Extraction in Minimally Invasive Gynecologic Surgery.J Minim Invasive Gynecol. 2016 Nov - Dec;23(7):1032.
37. 39. Cohen SL, Morris SN, Brown DN et al. Contained tissue extraction using power morcellation: prospective evaluation of leakage parameters.Am J Obstet Gynecol. 2016 Feb;214(2):257.e1-6
38. 40. Steiner RA, Wight E, Tadir Y et al. Electrical cutting device for laparoscopic removal of tissue from the abdominal cavity. Obstet Gynecol 1993;81: 471–474.
39. 41. 510(k) premarket notification. Device name: KSE Steiner electromechanic morcellator. Available at http://www. accessdata.fda.gov/scripts/cdrh/ cfdocs/cfPMN/pmn. cfm?ID5K946147. Accessed January 29, 2015.
40. 42. Seidman MA, Oduyebo T, Muto MG et al. Peritoneal dissemination complicating morcellation of uterine mesenchymal neoplasms. PLoS One 2012; 7:e50058.
41. 43. GO position statement: Morcellation. Avail- able at https://www.sgo.org/newsroom/position- statements-2/ morcellation/. Accessed January 29, 2015.
42. 44. Updated: Laparoscopic uterine power morcel- lation in hysterectomy and myomectomy: FDA safety communication. Available at http://www. fda.gov/MedicalDevices/ Safety/AlertsandNotices/ ucm424443.htm. Accessed January 30, 2015.
43. 45. ACOG statement: FDA issues safety communi- cation on laparoscopic uterine power morcellation in hysterectomy and myomectomy. Available at http:// www.acog. org/About-ACOG/Announcements/FDA- Issues-Safety Communication-on-Laparoscopic-Uterine- Power-Morcellation. Accessed January 30, 2015
44. 46. AAGL statement to the FDA on power morcellation. Available at http://www.aagl.org/ aaglnews/aagl-statementto-the-fda-on-power- morcellation/. Accessed January 30, 2015.
45. 47. Levitz J. FBI is investigating hysterectomy device found to spread uterine cancer. Available at http://www.wsj.com/ articles/fb i-is-investigating- surgical-device-1432746641. Accessed June 7, 2015.