Electromechanical morcellation has been instrumental in advancing the field of minimally invasive gynecologic surgery. Recently, the technique has come under scrutiny due to the concern of inadvertent morcellation and dissemination of malignant cells in the setting of uterine cancer (for example leiomyosarcoma). Currently, there is limited data as to whether there is a difference in safety between vaginal and peritoneal morcellation. This study by Wasson et al. (Journal of Minimally Invasive Gynecology, 2017) sought to determine the incidence of occult uterine malignancy at the time of vaginal hysterectomy and secondarily, peri-operative data as well as long-term patient outcomes.
Retrospective Cohort Study
2,296 women across three institutions underwent total vaginal hysterectomy. 73.39% of women did not have vaginal morcellation and 611 women did undergo vaginal morcellation via cold-knife wedge resection. All patients requiring morcellation had benign indications for hysterectomy and all surgeries were performed by gynecologists with subspecialty training in minimally invasive surgery. In the non-morcellation group, occult malignancy was found in 5 patients (0.3%) of patients; Stage IA, grade I endometrial adenocarcinoma in 4 patients (0.24%), and low-grade stromal sarcoma was found in 1 patient (0.06%). In the morcellation group, 5 patients (0.82%) had an occult uterine malignancy; stage IA, grade I endometrial adenocarcinoma in 3 patients (0.49%) and low grade stromal sarcoma in 2 patients (0.33%). There were no cases of uterine sarcoma. In all 5 patients, the initial indication for hysterectomy was abnormal uterine bleeding and all patients underwent uterine sampling and pelvic imaging. All the patients have remained disease-free and no deaths have occurred with a mean disease-free survival of 48.33 months (range, 33-67 months) for those with endometrial adenocarcinoma and 42.0 months (range, 19-65 months) for patients with stromal carcinoma. The authors recognize limitations of the study, including retrospective design, limited sample size and subspecialty surgeons. The authors conclude that for patients undergoing uncontained vaginal hysterectomy with morcellation, prognosis in the setting of occult endometrial carcinoma or low-grade stromal sarcoma was not adversely affected.
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