Risk, Risk Reduction and Management of Occult Malignancy Diagnosed after Uterine Morcellation: A Commentary

Abstract

Minimally invasive surgical techniques compared with laparotomy offer the advantages of less intraoperative blood loss, shorter hospitalization, fewer wound complications and faster return to baseline activity for both hysterectomy and myomectomy. While morcellation allows for the laparoscopic removal of large specimens, it may result in intraperitoneal dissemination of benign disease or upstaging of occult malignancy leading to compromised survival. There has been heightened scrutiny over appropriate patient selection and preoperative assessment in light of recent warnings against power morcellation issued by the US FDA. This commentary therefore summarizes the magnitude of such risks associated with uterine morcellation, current national regulatory statements and potential merits of risk-reducing approaches such as contained morcellation. The importance of patient counseling is underscored.

Drain or not drain? A surgical dilemma using suction drain for drain site metastasis in a patient with uterine sarcoma

“…Disease spread can occur through the exfoliation of malignant cells from a primary tumour during surgery due to tumour manipulation. 8 Tumour seeding could also occur along an artificial percutaneous tract by contaminated In conclusion, drain placement in the surgical area is not a completely harmless procedure, and in many situations, it is unessential and port site recurrence should be kept in mind when deciding to place a drain.…”

Cluster of “Grapes” in the Pelvis: A Sporadic Case of Disseminated Peritoneal Leiomyomatosis with Endometriosis

“…The etiology of DPL remains unclear. However, it is known to be associated with previous myomectomy; the incidence of DPL after power morcellation is thought to be approximately 0.1% to 1% [5]. Although the clinical presentations of sporadic and iatrogenic DPL are similar, their underlying pathophysiology must differ.…”

Laparoscopic myomectomy: a review of alternatives, techniques and controversies

“…In addition to increasing age, other risk factors for leiomyosarcoma include African origin, use of tamoxifen for >5 years, pelvic radiation or hereditary predisposition to uterine cancer (e.g. Lynch syndrome) . Patients with such risk factors should undergo a thorough preoperative work‐up to gauge their leiomyosarcoma risk, which may include serum lactate dehydrogenase, endometrial biopsy, ultrasound, and/or MRI.…”

“…Both parasitic myomata and DPL can lead to inflammation, infection, and intestinal obstruction. The incidence of parasitic myomata or DPL is thought to range from 0.1 to 1% …”

“…Specimen morcellation can hamper the pathological diagnosis of leiomyosarcoma: margin status, tumour size and extent of invasion become impossible to interpret. In 20% of cases, the ultimate diagnosis of leiomyosarcoma may be obscured …”