PURPOSE:

• FDA warnings (2014) against the use of power morcellation could have a negative impact on minimally invasive hysterectomy and consequent related benefits
• Some researchers have reported decreased laparoscopic rates with reduced access to power morcellation
• Zaritsky et al. (Obstetrics & Gynecology, 2017) sought to address changes in minimally invasive hysterectomy rates in the context of clinical characteristics

METHODS:

• Trend analysis and retrospective cohort study at Kaiser Permanente Northern California (2008-2015)
• Quality improvement program to increase minimally invasive hysterectomy (defined as vaginal and laparoscopic hysterectomy)
  • Benchmark increased from 60% to 90%
  • Robotic-assisted laparoscopy limited to complex disease and core group of surgeons
• All women 18 years of age and older undergoing hysterectomy for benign conditions
• Primary outcomes
  • Hysterectomy incidence
  • Proportion of hysterectomies by surgical route and power morcellation
• Secondary study outcomes included clinical and surgical characteristics and complications

RESULTS:

• 31,971 hysterectomies performed
• Minimally invasive hysterectomies increased from 39.8% to 93.1%, almost replacing abdominal hysterectomies entirely (P<.001)
• Vaginal hysterectomies decreased slightly from 26.6% to 23.4% (P<.001)
• Nonrobotic laparoscopic hysterectomies with power morcellation increased steadily from 3.7% in 2008 to a peak of 11.4% in 2013 then decreased to 0.02% in 2015 (P<.001)
• Robot-assisted laparoscopic hysterectomies remained a small proportion of all hysterectomies (7.8% of hysterectomies in 2015)
• Laparoscopic supracervical hysterectomy was strongly associated with power morcellation use (adjusted relative risk 43.89, 95% CI 37.55–51.31)
• Uterine size (> 1,000 g) was strongly associated with
  • Abdominal vs minimally invasive hysterectomy (adjusted relative risk 11.62; 95% CI 9.89–13.66)
  • Laparoscopic hysterectomy with power morcellation vs without power morcellation (adjusted RR 5.74, 95% CI 4.12–8.00)
• Complication rates were low but highest rates seen in abdominal hysterectomies
• No differences in adjusted risk of complications for laparoscopic hysterectomies with vs without power morcellation

CONCLUSION:

• Unlike previous literature the high rate of minimally invasive hysterectomy was not altered by FDA safety communications
• Uterine size was the main driver for the decision to use abdominal vs laparoscopic approach and use of morcellation during laparoscopic surgery
• Authors suggest reasons the high minimially invasive rate was maintained were
  • Less reliance on supracervical hysterectomies
  • Use of manual vs power morcellation

Learn More – Primary Sources:

Minimally Invasive Hysterectomy and Power Morcellation Trends in a West Coast Integrated Health System

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Uterine Artery Embolization, Focused Ultrasound, or Hysterectomy for Fibroids?

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