Up until 20 years ago, there was no efficient way to laparoscopically remove a uterus enlarged by fibroids. Most fibroids are far larger than the tiny abdominal incisions that are used to perform a laparoscopic hysterectomy (removal of the uterus) or myomectomy (removal of fibroids with preservation of the uterus). The breakthrough in technology that enabled the surgeon to safely remove any size fibroid or uterus through a tiny incision is a device known as a morcellator.
A morcellator cuts a large uterus or fibroid into smaller strips of tissue, which can then be easily removed through a half-inch incision. Using this technique, an accomplished surgeon can remove even a large fibroid in a matter of minutes.
Recently there have been concerns raised about morcellation spreading the cells of an undetected uterine cancer in the event that what appear to be fibroids (noncancerous tumors) are actually a leiomyosarcoma (LI-o-MY-o-sar-CO-ma).
A Leiomyo What?
Most uterine cancers are not leiomyosarcomas but are endometrial cancers, which is almost always known prior to surgery. Since endometrial cancer is usually detected at an early stage, the cure rate is more than 90%. If an undetected endometrial cancer is inadvertently morcellated, the outcome is no worse.
Leiomyosarcoma, on the other hand, is a very serious, very rare form of uterine cancer.
While leiomyosarcoma can occur at any age, it most commonly occurs in women over the age of 50. Many, not all, cases are characterized by rapid growth. While a leiomyosarcoma can often be discovered by a biopsy prior to surgery, not all are detected or predicted prior to removal. If an unknown leiomyosarcoma is present, the process of morcellation can potentially spread cancer cells throughout the abdominal cavity. If cancer cells are spread during the process of morcellation (either by power morcellation or hand morcellation) the outcome may be worse.
Morcellation Isn’t Dangerous, Leiomyosarcoma Is Dangerous
Keep in mind that even if a traditional hysterectomy is performed (with no morcellation), this is a serious cancer and only 40% of women survive at the five-year mark since cancer cells in most cases have already spread prior to surgery.
The frequency of a leiomyosarcoma is highly controversial and ranges between as high as one in 360 cases of fibroids and as low as one in 12,000. Experts know that the one in 360 number is not correct, since the statistic comes from a very small study that was flawed and included patients with other medical circumstances and many other kinds of cancer.
The notion that one out of 360 women with fibroids has a life-threatening cancer defies logic. Fibroids are very common and are present in up to 80% of women. The majority of women with fibroids do not require, and do not have any treatment. Women that do need treatment often undergo uterine-sparing solutions such as myomectomy or fibroid embolization. If one in 360 women with fibroids had a leiomyosarcoma, every gynecologist would see dozens of cases during their career! In fact, most gynecologists see only one or two. If the one in 360 number were accurate, then every woman with fibroids should have a hysterectomy! A more recent analysis of frequency of “fibroids” that are actually a leiomyosarcoma (pending publication in the New England Journal of Medicine and presented at an FDA hearing) shows that the actual rate of leiomyosarcoma is closer to one in 7,400 cases, which makes a lot more sense.
Over the last 20 years I have taken care of approximately 40,000 women with fibroids. My partners and I have performed morcellation roughly 1,000 times. I have seen exactly one case of leiomyosarcoma, which I suspected and diagnosed prior to surgery.
This is an important women’s health issue since without the option of morcellation, the majority of women who are now candidates for a laparoscopic or robotic assisted myomectomy or hysterectomy would require a large incision resulting in a longer recovery, more pain and a significantly higher complication rate. Because fibroids are common, and leiomyosarcoma is rare, the risk of a complication from an incision is higher than the risk of spreading an undetected cancer.
Minimize Your Risk
Every surgeon wants to reduce the risk as much as possible to protect his or her patient. So, the answer is not to eliminate morcellation, but instead to minimize the risk associated with morcellation. Fortunately, recent innovations in surgical technique have come up with a new system to reduce or eliminate the risk for patients undergoing surgery who have an undetected gynecologic cancer. First of all, a uterine biopsy (a sample from the lining of the uterus) should always be performed before the operation. If there is a known or suspected cancer, morcellation should not be used.
A specimen bag during morcellation can be used to contain the uterine tissue and almost entirely eliminates the risk of spread in the abdomen and pelvis. That’s right, by inserting a bag into the abdominal cavity and morcellating the tissue inside the bag, there will be no spill of cells outside the bag and in the event of an undiagnosed cancer, there will be no spread. Many experts are already doing this and as the technique becomes widely known, I suspect it will become the standard of care.
As a surgeon, I can guarantee you that my primary goal is for my patients to have the best outcome possible. As an informed consumer, you need to know the facts so you can have a conversation with your doctor. If you require fibroid removal or hysterectomy and are a candidate for a minimally invasive procedure, let your doctor know if you are comfortable with a morcellation procedure and ask if a bag technique will be utilized. Understand that an open incision will not eliminate your risk, but is always an option. When I wrote The Essential Guide to Hysterectomy, it was with the premise that if women are given good, accurate information, they will make good, informed decisions. Now you can.