The Food and Drug Administration (FDA) recently released a statement about power morcellation during hysterectomy and myomectomy (surgery to remove uterine fibroids), raising concerns about these devices spreading unanticipated cancers. There have been several reports in the literature and the press alike of this happening and when it does it significantly worsens the prognosis. The American Congress of Obstetrician and Gynecologists (ACOG) is now re-exploring this issue. Pending a full review the FDA is discouraging the use of power morcellators for hysterectomy and myomectomy.
Let’s break it down by answering answer three questions:
- What is power morcellation?
- What is the cancer risk?
- When is power morcellation indicated?
What is power morcellation?
Morcellators are medical devices used to quickly chop tissue into tiny pieces so the tissue can be removed through the very small laparoscopic incisions. Think a hand-held blender for tissue. A uterus (ranges in size from slightly smaller than a clenched fist to a couple of kilograms depending on the indication for surgery) or a fibroid any bigger than 1 cm can’t be removed through the typical 1 cm incision used for laparoscopic surgery, so a power morcellator reduces large specimens to tiny bits that can be sucked up and removed through a very small incision. Small incisions means faster recovery and a better cosmetic result.
What is the cancer risk with power morcellation?
If your surgeon suspects cancer then a power morcellator should never be used, but the problem is cancers are often not suspected and are only found later by the pathologist when she/he evaluates the surgical specimen. With a power morcellator the blended tissue is difficult to evaluate (so a cancer could be missed) and little bits of tissue get everywhere in the belly, which potentially spreads the cancer. The FDA estimates that the risk of having an undetected cancer is 1 in 350 in surgeries where power morcellators are used (which is pretty high). The Society for Gynecologic Oncologists (cancer surgeons) says that risk is 1 in 1,000. Since this is a relatively new procedure we won’t have full data about risks for a while, but suffice it to say that it is at least 1 in 1,000 and very possibly higher.
When is power morcellation indicated?
It is actually almost never indicated, it is simply a fancy way to get a uterus or a uterine fibroid out of the body and there are other methods with excellent outcomes without the cancer spreading risks of power morcellation. For a hysterectomy the best option is always a vaginal hysterectomy, which is removing the uterus entirely through the vagina with no incisions in the abdomen. It the uterus is very large it can be cut in half as it is being removed (this is also called morcellation, but a scalpel is used by hand and there is not believed to be a cancer risk associated with it). ACOG says that vaginal hysterectomy is the procedure of choice. Even quite large uteri can be removed this way.
Why might a gynecologist advise against a vaginal hysterectomy? If they don’t have the skill to do one, if they or you are convinced that you should have a supracervical hysterectomy (hold that thought, more on supracervical hysterectomies in a bit), they suspect a lot of scar tissue making it hard to remove the uterus blindly through the vagina, or if theuterus is really large (think mid-pregnancy size, which is rare but definitely happens).
The minimally invasive alternatives to a vaginal hysterectomy are a laparoscopically assisted vaginal hysterectomy and a laparoscopic supracervical hysterectomy. Most laparoscopic assisted vaginal hysterectomies don’t need power morcellation. A fairly large uterus can be pulled through the vagina and then the top of the vagina is sewn either from above using the laparoscope or below by hand through the vagina. And again, the surgeon can morcellate the uterus from below using a scalpel.
The most common reason doctors use a morcellator is for a supracervical hysterectomy (cutting the uterus off at the level of the cervix and leaving the cervix behind). Since the cervix is being left behind there is no hole to pull the uterus out through the vagina, so the morcellator grinds it up to remove from above. However, supracervical hysterctomies offer no advantage to the patient! Nothing. This has been extensively studied so much so that ACOG questions their indication. There is no better sexual functioning leaving the cervix behind, but you still need a Pap smear and many women can still get monthly bleeding if they are not yet menopausal as a small amount of uterine tissue can be left behind on the cervix. So if there is no advantage to leaving the cervix why do many doctors recommend it? A power morecllator assisted supracervical hysterectomy is technically easier for many surgeons than a vaginal hysterectomy or a laparoscopic assisted vaginal hysterectomy and some gynecologists just don’t have the skill to operate vaginally, especially on a larger uterus. Also, some gynecologists really do erroneously believe that a supracervical hysterectomy offers advantages for the patient.
There are a couple of rare situation where leaving the cervix might be recommended, for example when mesh is going to be used for vaginal prolapse (some doctors feel that sewing the mesh to the more bulky cervix as opposed to the vagina might prevent the mesh from eroding through the vaginal tissue). However, is the risk of mesh erosion greater than the potential 1/350 cancer risk with power morcellation? That would be an important discussion for the surgical consent process. Sometimes there is a lot of scar tissue low in the pelvis and it seems safer to not dig into the scar tissue to remove the cervix (rare, but happens). In this scenario the options would be a power morcellator assisted supracervical hysterectomy or converting the surgery to a traditional open hysterectomy.
What if the uterus is very large? Isn’t morcellation needed? Even a very large uterus scan be removed vaginally by morcellating by hand. A very large uterus can also be morcellated by hand and removed through a small abdominal incision (mini laparotomy). While a mini laparotomy might slow down recovery a little it doesn’t have the cancer risk. Is it worth a small scar and a slightly longer recovery to reduce the cancer risk that could be as high as 1 in 350 to zero? Everyone will weigh those risks and benefits differently that is why options and informed consent is so important.
With a fibroid removal (myomectomy) all the same options discussed above apply. An incision can be made in the vagina called a colpotomy and the fibroid can be pulled out from below or a min laparotomy (small surgery) could be performed.
What about using a morcellator in a bag to avoid spilling potentially cancerous cells? Some surgeons are now doing this, but whether it avoids all spill or not is unknown.
Uterine morcellation for a hysterectomy and myomectomy can easily be avoided, especially for smaller uteri. If your doctor tells you there is no cancer risk, they are wrong. We don’t know the exact risk, but it is somewhere (we think) between 1 in 350 and 1 in 1,000.
Do you want a hysterectomy? Ask for a vaginal hysterectomy or a laparoscopic assisted vaginal hysterectomy, not only can the power morcellator can be avoided but these are the recommended surgical approaches. If your doctor doesn’t do them, find one who does. Don’t opt for a supracervical hysterectomy unless there is a very clear surgical reason. Don’t be swayed by reports of better sexual functioning with a supracervical hysterectomy because evidence-based medicine tells us that just isn’t the case. A supracervical hysterectomy offer no health benefits and so when a power morcellator is used in this scenario the patient assumes all the risks with zero benefits.
If your uterus is really large and your doctor thinks getting it out vaginally will be a challenge ask yourself if the risks of small incision in the abdomen that might delay your recovery slightly is worth it to avoid a potential 1 in 350 risk of cancer? The right answer is to be fully informed as people view risks differently. However, if 1 in 350 is right that’s a high number. Would you get on a plane if there was a 1 in 350 change that it would crash? The same goes for uterine fibroids. Ask about a colpotomy and vaginal removal, morcellation in a bag, or hand morcellation through a mini laparotomy incision. And finally, re-assess if you even need a hysterectomy. The United States has a far higher hysterectomy rate compared with other 1st world countries. For example, the hysterectomy rate is 5.4 per 1,000 women in the United States versus 3.7 per 1,000 women in Italy and 1.2 per 1,000 women in Norway.
Power morcellation for hysterectomy is rarely indicated so currently it appears that morcellators in this scenario offer most women risk without clear benefit. A very large uterine fibroid might be a challenge to remove via colpotomy (vaginally) and so in this scenario a frank discussion about a larger incision and hand morcellation versus power morcellation in a bag would be required.
Jennifer Gunter is an obstetrician-gynecologist and author of The Preemie Primer. She blogs at her self-titled site, Dr. Jen Gunter.