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Fragmented tissue extraction (morcellation) of uterine and leiomyoma tissue in gynecologic surgery has been performed for decades, but recent years have seen a vast expansion of techniques to address risks associated with tissue dispersion. Use of power, or electromechanical, morcellation has largely been replaced by manual morcellation with a scalpel. Morcellation can take place through a laparoscopic incision, a minilaparotomy incision, or through a colpotomy. Containment systems are now available for both power and manual morcellation, allowing tissue fragmentation to take place within an enclosed specimen bag. These products require additional training and skill and may add operating time, but have the potential to mitigate risks associated with tissue dissemination.

Previous decision analyses demonstrate the safety of minimally invasive hysterectomy for presumed benign fibroids, accounting for the risk of occult leiomyosarcoma and the differential mortality risk associated with laparotomy. Studies published since the 2014 Food and Drug Administration safety communications offer updated leiomyosarcoma incidence estimates. Incorporating these studies suggests that mortality rates are low following hysterectomy for presumed benign fibroids overall, and a minimally invasive approach remains a safe option. Risk associated with morcellation, however, increases in women age >50 years due to increased leiomyosarcoma rates, an important finding for patient-centered discussions of treatment options for fibroids., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose of Review: Safety concerns regarding morcellation of presumed benign fibroid disease have led to an increase in recent research activity on this topic, as well as advances in surgical technique., Recent Findings: The prevalence of occult leiomyosarcoma is debated; however, estimates from a robust meta-analysis suggest it may be in the range of 1 case per 1960-8300 fibroid surgeries. Advancing age is an important clinical risk factor for occult malignancy. The impact of tumor morcellation may vary by mode of tissue removal, though tissue fragmentation is consistently associated with poorer outcomes. Decision and cost analyses continue to support laparoscopic hysterectomy as a low-morbidity and cost-effective approach. The increased scrutiny on fibroid procedures in the past few years may lead to changes in surgical approach; however, alternative tissue extraction options are evolving, including incorporation of contained morcellation., Summary: Although the incidence of occult leiomyosarcoma is low, outcomes are poor and may be worsened by morcellation. By addressing risk factors for malignancy and incorporating evolving surgical techniques into practice, gynecologists can continue to offer patients a minimally invasive approach for fibroid management.

Study Objective: To evaluate if peritoneal washings of the abdominopelvic cavity during laparoscopic myomectomy can detect leiomyoma cells after power morcellation., Design: Prospective cohort pilot study., Setting: University of North Carolina Hospitals, an academic, tertiary referral center (Canadian Task Force classification II-2)., Patients: Patients undergoing laparoscopic or robotic myomectomy for suspected benign leiomyoma by members of the Minimally Invasive Gynecologic Surgery division between September 2014 and January 2015., Intervention: Washings of the peritoneal cavity were collected at 3 times during surgery: the beginning of the procedure once the peritoneal cavity was accessed laparoscopically, after the myoma was excised and myometrial incision closed, and after uncontained power morcellation., Measurements and Main Results: Twenty patients were included in the analysis. The median morcellation time was 16 minutes (range, 2-36). The median specimen weight was 283.5 g (range, 13-935). Cytologic evaluation (ThinPrep with Papanicolaou staining) did not detect any smooth muscle cells. Cell block histology, however, detected spindle cells in 6 postmorcellation samples. Three of these 6 cases also had spindle cells detected on the postmyomectomy closure samples. When performed on the postmorcellation samples, desmin and smooth muscle actin immunostaining were positive, confirming the presence of smooth muscle cells., Conclusion: Cell block histology, but not cytology, can detect leiomyoma cells in peritoneal washings after power morcellation. With myomectomy, there is some tissue disruption that seems to cause cell spread even in the absence of morcellation. Further protocol testing might allow peritoneal washings to be used in assessing containment techniques and testing comparative safety of different morcellation methods., (Copyright © 2016 AAGL. Published by Elsevier Inc. All rights reserved.)

Study Objective: Hysterectomy for presumed leiomyomata is 1 of the most common surgical procedures performed in nonpregnant women in the United States. Laparoscopic hysterectomy (LH) with morcellation is an appealing alternative to abdominal hysterectomy (AH) but may result in dissemination of malignant cells and worse outcomes in the setting of an occult leiomyosarcoma (LMS). We sought to evaluate the cost-effectiveness of LH versus AH., Design: Decision-analytic model of 100 000 women in the United States assessing the incremental cost-effectiveness ratio (ICER) in dollars per quality-adjusted life-year (QALY) gained (Canadian Task Force classification III)., Setting: U.S. hospitals., Patients: Adult premenopausal women undergoing LH or AH for presumed benign leiomyomata., Interventions: We developed a decision-analytic model from a provider perspective across 5 years, comparing the cost-effectiveness of LH to AH in terms of dollar (2014 US dollars) per QALY gained. The model included average total direct medical costs and utilities associated with the procedures, complications, and clinical outcomes. Baseline estimates and ranges for cost and probability data were drawn from the existing literature., Measurements and Main Results: Estimated overall deaths were lower in LH versus AH (98 vs 103). Death due to LMS was more common in LH versus AH (86 vs 71). Base-case assumptions estimated that average per person costs were lower in LH versus AH, with a savings of $2193 ($24 181 vs $26 374). Over 5 years, women in the LH group experienced 4.99 QALY versus women in the AH group with 4.91 QALY (incremental gain of .085 QALYs). LH dominated AH in base-case estimates: LH was both less expensive and yielded greater QALY gains. The ICER was sensitive to operative costs for LH and AH. Varying operative costs of AH yielded an ICER of $87 651/QALY gained (minimum) to AH being dominated (maximum). Probabilistic sensitivity analyses, in which all input parameters and costs were varied simultaneously, demonstrated a relatively robust model. The AH approach was dominated 68.9% of the time; 17.4% of simulations fell above the willingness-to-pay threshold of $50 000/QALY gained., Conclusion: When considering total direct hospital costs, complications, and morbidity, LH was less costly and yielded more QALYs gained versus AH. Driven by the rarity of occult LMS and the reduced incidence of intra- and postoperative complications, LH with morcellation may be a more cost-effective and less invasive alternative to AH and should remain an option for women needing hysterectomy for leiomyomata., (Copyright © 2016 AAGL. Published by Elsevier Inc. All rights reserved.)

Minimally invasive surgery (MIS) is increasingly being used to treat uterine fibroids because of the significant patient and societal benefits of these techniques over traditional laparotomy. Morcellation affords the removal of large fibroids in MIS but carries the risk of disseminating occult malignant tissue. The benefits of MIS for treating fibroids must be carefully weighed against its risks of morcellation., (© 2015 Wiley Periodicals, Inc.)

Objective: The goal of this research was to explore physicians' perceptions of uterine morcellation and minimally invasive hysterectomy in the setting of new hospital regulations, comparing gynecologists and internal medicine providers, geographic locations, and levels of training. Design: This was a multicenter cross-sectional study. Materials and Methods: A 17-question, anonymous, electronic survey was administered to resident, fellow, and attending gynecologists, and internal medicine physicians at three institutions. Results: Two hundred and twenty-two gynecologists responded for a response rate of 46%. Most gynecologists believe morcellation is safe and acceptable, and the benefits of minimally invasive surgery outweigh the potential risk of cancer dissemination as a result of morcellation. The majority reported that the incidence of occult leiomyosarcoma is rarer than 1 in 350. Physicians from Boston, MA, responded less favorably toward morcellation than providers in Pittsburgh, PA, and Chapel Hill, NC ( p < 0.001). Trainees were not significantly different from attending gynecologists. One hundred and forty-seven internal medicine physicians responded for a response rate of 40%. Compared to internal medicine providers, significantly more gynecologists believe minimally invasive approaches, as opposed to laparotomy, yield the best overall outcome ( p < 0.001), and the benefits of morcellation outweigh its potential risks ( p < 0.001). Compared to gynecologists, more internal medicine physicians felt morcellation should be banned ( p < 0.001). Conclusions: Most gynecologists highly value morcellation as a means of tissue extraction to facilitate minimally invasive approaches in order to provide the most optimal patient outcomes. Gynecologists' opinions regarding morcellation differ by geographical location but not by level of training. Gynecologists responded more favorably toward minimally invasive hysterectomy and morcellation, compared to internal medicine physicians. (J GYNECOL SURG 33:12) [ABSTRACT FROM AUTHOR]

Objective The purpose of this study was to model outcomes in laparoscopic hysterectomy with morcellation compared with abdominal hysterectomy for the presumed fibroid uterus and to examine short- and long-term complications and death. Study Design A decision tree was constructed to compare outcomes for a hypothetical cohort of 100,000 premenopausal women who underwent hysterectomy for presumed fibroid tumors over a 5-year time horizon. Parameter and quality-of-life utility estimates were determined from published literature for postoperative complications, leiomyosarcoma incidence, death related to leiomyosarcoma, and procedure-related death. Results The decision-tree analysis predicted fewer overall deaths with laparoscopic hysterectomy compared with abdominal hysterectomy (98 vs 103 per 100,000). Although there were more deaths from leiomyosarcoma after laparoscopic hysterectomy (86 vs 71 per 100,000), there were more hysterectomy-related deaths with abdominal hysterectomy (32 vs 12 per 100,000). The laparoscopic group had lower rates of transfusion (2400 vs 4700 per 100,000), wound infection (1500 vs 6300 per 100,000), venous thromboembolism (690 vs 840 per 100,000) and incisional hernia (710 vs 8800 per 100,000), but a higher rate of vaginal cuff dehiscence (640 vs 290 per 100,000). Laparoscopic hysterectomy resulted in more quality-adjusted life years (499,171 vs 490,711 over 5 years). Conclusion The risk of leiomyosarcoma morcellation is balanced by procedure-related complications that are associated with laparotomy, including death. This analysis provides patients and surgeons with estimates of risk and benefit on which patient-centered decisions can be made. [ABSTRACT FROM AUTHOR]