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Morcellation Techniques for Fibroid Uterus
Published in Rooma Sinha, Arnold P. Advincula, Kurian Joseph, FIBROID UTERUS Surgical Challenges in Minimal Access Surgery, 2020
Prakash Trivedi, Soumil Trivedi, Anjali Sonawane, Aditi Parikh
Unfortunately, spillage of tissues led to leiomyomatosis, occasional spread of leiomyosarcoma [3], and port-site fibroid [4]. In April 2014, a serious concern was raised by the FDA on restricting use of morcellation because of the risk of spreading tumor or sarcoma [5]. A black-box warning was necessary for morcellation, stating that uterine tissue or myoma may contain unsuspected cancer. Insurance claims for morcellations were cancelled. Litigations grew up from patients to companies, consultants, and hospitals.
Manual or Hand Morcellation in Minimally Invasive Surgery
Published in John C. Petrozza, Uterine Fibroids, 2020
Janelle K. Moulder, Tarek Toubia, Michelle Louie
The benefits of minimally invasive surgery (MIS) have been widely documented in gynecology and include faster recovery, fewer complications, smaller scars [1–3] and reduced mortality [4] compared with laparotomy. Morcellation is required to remove large tissue specimens during MIS. In 1995, power or electromechanical morcellation was approved by the United States Food and Drug Administration (FDA), which increased the availability of MIS for women with large uteri [5]. In April and November 2014, the FDA issued safety communications regarding the potential dissemination of undiagnosed uterine sarcoma during power morcellation, which worsens patient long-term survival [6]. Following the 2014 FDA safety communication, use of power morcellation by gynecologists has significantly decreased [7], and up to 84% of gynecologists have changed their surgical approaches for hysterectomies and myomectomies [8]. Furthermore, since 2014, the rate of laparotomy has increased in 46% of cases [7], which has been associated with an increase in major surgical complications and rates of hospital readmission [9]. Almost half of the gynecologists in the United States have reported that their hospitals have banned power morcellation [7]. Gynecologists have since started to use alternative morcellation techniques such as manual or hand morcellation and in-bag or contained morcellation.
Cervical and uterine cancers
Published in Anju Sahdev, Sarah J. Vinnicombe, Husband & Reznek's Imaging in Oncology, 2020
Rosemarie Forstner, Andrea Rockall
The issue of leiomyosarcoma misdiagnosed as leiomyoma has emerged in the background of minimally invasive treatment of uterine leiomyomas. It has been shown that uterine morcellation carries a risk of disseminating unexpected malignancy (235). Unexpected leiomyoma variants or sarcoma were reported in 1.2% of presumed simple leiomyomas treated by power morcellation (236). MRI is helpful in triaging patients with atypical features of leiomyomas that are associated with a higher risk of malignancy at morcellation (235).
Ectopic leiomyoma as a late complication of laparoscopic hysterectomy with power morcellation: a case report and review of the literature
Published in Acta Chirurgica Belgica, 2020
Karel Dewulf, Valerie Weyns, Bart Lelie, Hussain Qasim, Joke Meersschaert, Bart Devos
Besides malignant cells, power morcellation can lead to the spread of benign tumor cells in the abdominal cavity. A recent systematic review showed that 39% of patients with ectopic leiomyoma have a history of power morcellation and 55% present with disseminated peritoneal leiomyomatosis [9]. Nevertheless, the reported prevalence of ectopic leiomyoma due to power morcellation is low. Until July 2018, only 134 cases of ectopic leiomyoma due to laparoscopic morcellation have been reported with a reported incidence between 0.12 and 0.95% [9–19]. This is probably an underestimation as ectopic leiomyoma are a late complication, which is reflected by a higher incidence in studies with longer follow-up [10]. Iatrogenic endometriosis has also been reported. Zhang et al. found that 0,01% of patients presented with de novo endometriosis after laparoscopic hysterectomy with use of power morcellators [18]. The spread of benign and malignant cells could probably be avoided using containment bags. Their surgical feasibility has recently been proven [20,21]; however, large studies are needed and long-term data are not yet available [5].
Simultaneously occurring disseminated peritoneal leiomyomatosis and multiple extrauterine adenomyomas following hysterectomy
Published in Baylor University Medical Center Proceedings, 2019
Jessica A. Belmarez, Hamid R. Latifi, Wei Zhang, Carolyn M. Matthews
Though uterine leiomyomas and adenomyomas are relatively common benign tumors, the appearance of these tumors in extrauterine locations is exceedingly rare. The pathogenesis behind extrauterine proliferation of leiomyomas and adenomyomas is not well understood, in part because of the rarity of the conditions. The most widely reported theory is that of parasitic spread of the tumors after seeding during hysterectomy or myomectomy.3 In particular, multiple cases of DPL have been reported following morcellated hysterectomy/myomectomy—a laparoscopic procedure in which the myometrial tissue is divided into multiple small fragments in situ using a power morcellator prior to extraction.3–5 This is due to the fact that morcellation carries the risk of leaving small fragments of fibroid or even unsuspected malignant tumor behind, thereby seeding the pelvis and laying the groundwork for tumor proliferation. In April 2014, the US Food and Drug Administration recommended that manufacturers of laparoscopic power morcellators include a warning label on the devices to inform patients and surgeons of the risk of potential abdominopelvic seeding of occult uterine cancer with morcellation procedures.6,7 Of note, however, not all patients with extrauterine leiomyomas or adenomyomas have a history of their intrauterine counterparts. In our patient, there was a history of uterine fibroids but not of adenomyoma or adenomyosis.
Vilaprisan for treating uterine fibroids
Published in Expert Opinion on Investigational Drugs, 2018
Gian Benedetto Melis, Manuela Neri, Bruno Piras, Anna Maria Paoletti, Silvia Ajossa, Monica Pilloni, Maria Francesca Marotto, Valentina Corda, Alessandra Saba, Elena Giancane, Valerio Mais
Hysterectomy is the only treatment that definitely solves the uterine fibroids and the recurrence risk [15]. This radical treatment should be considered in women in whom other therapeutic options have failed, who have satisfied their reproductive desire, and who accept surgical risk [16]. Abdominal hysterectomy has greater morbidity than vaginal or laparoscopic hysterectomy, but the overall uterine size might prevent these approaches [15–17]. Conservative interventions (myomectomy) must be offered to women who plan pregnancy. Laparoscopic myomectomy has the advantage of less postoperative morbidity and shorter hospitalization [18]. The fertility rate is more favorable after laparoscopic than abdominal myomectomy. However, this approach presents some risks in the case of several, voluminous or deep intramural fibroids, for example related to the need of morcellation or a minilaparotomy to remove the lesions [6,16,19]. The Food and Drug Administration recommends being cautious in the use of morcellation for the potential risk of dissemination of an unknown sarcoma [20].