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Kim R, Pepin K, Dmello M, Clark N, Ajao M, Einarsson J, Rassier SC. Current Methods of Tissue Extraction in Minimally Invasive Surgical Treatment of Uterine Fibroids. JSLS 2022; 26:JSLS.2022.00036. [PMID: 36071994 PMCID: PMC9385112 DOI: 10.4293/jsls.2022.00036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background and Objectives: Since the 2014 Food and Drug Administration communication regarding the use of power morcellation, gynecologists have adopted alternative tissue extraction strategies. The objective of this study is to investigate the current techniques used by gynecologic surgeons for tissue extraction following minimally invasive hysterectomy or myomectomy for fibroids. Methods: An online survey was distributed to all AAGL members and responses were collected between March 26, 2019 and April 17, 2019. Results: Four hundred thirty-six respondents completed the survey. For hysterectomy, the most common methods of tissue extraction were manual morcellation through the colpotomy (72.4%) or minilaparotomy (66.9%). Nearly one-third (31.7%) endorsed using power morcellation. For myomectomy, manual morcellation via minilaparotomy (71.9%) was the most common approach, followed by power morcellation (35.7%). Use of containment bags was common. Minilaparotomy incisions were typically three cm and most often at the umbilicus. Geographic differences were detected, particularly with power morcellation. During hysterectomy, 18.4% of US-based surgeons reported its use, compared to 56.9% of nonUS-based surgeons. During myomectomy, 20.5% of US-based surgeons reported its use compared to 67.5% of their international counterparts. Age, years in practice, fellowship training, and practice location were all significantly associated with power morcellator use. Conclusion: A large majority of practitioners are performing manual morcellation through the colpotomy or minilaparotomy. Use of containment bags is common with all routes of tissue removal. Power morcellation use is less common in the United States than in other countries.
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Affiliation(s)
- Renita Kim
- Department of Obstetrics, Gynecology, and Reproductive Science, Mt, Sinai Hospital, New York, New York
| | - Kristen Pepin
- Department of Obstetrics and Gynecology, New York-Presbyterian Weill, Cornell Medical Center, New York, New York
| | - Monalisa Dmello
- Department of Obstetrics and Gynecology, Brigham and Women's, Hospital, Boston, Massachusetts
| | - Nisse Clark
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts
| | - Mobolaji Ajao
- Department of Obstetrics and Gynecology, Brigham and Women's, Hospital, Boston, Massachusetts
| | - Jon Einarsson
- Department of Obstetrics and Gynecology, Brigham and Women's, Hospital, Boston, Massachusetts
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Chikazawa K, Imai K, Ko H, Ichi N, Misawa M, Kuwata T. Risk factors associated with perineal and vaginal lacerations and vaginal removal in total laparoscopic hysterectomy. Gynecol Minim Invasive Ther 2022; 11:150-154. [PMID: 36158298 PMCID: PMC9491053 DOI: 10.4103/gmit.gmit_118_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 02/10/2022] [Accepted: 05/03/2022] [Indexed: 11/27/2022] Open
Abstract
Objectives: This study aimed to identify risk factors associated with perineal and vaginal lacerations related to vaginal removal during total laparoscopic hysterectomy (TLH). Materials and Methods: We retrospectively assessed 134 patients who underwent TLH, of whom 44 (32.8%) had vaginal lacerations. Results: Univariate analysis revealed that for patients with myomas and adenomyosis, gonadotropin-releasing hormone agonist use and myomas with a transverse diameter of ≥5 cm were significant risk factors, while multiparity (vaginal delivery) was a protective factor for perineal and vaginal lacerations. Moreover, multivariate analysis indicated that multiparity was the only statistically significant protective factor. For cervical intraepithelial neoplasia, endometrial cancer, and endometrial hyperplasia, only a uterine transverse diameter of ≥5 cm was a significant risk factor for perineal or vaginal lacerations. Conclusion: For patients with large myomas, multiple vaginal delivery was a protective factor, and in patients with normal-sized uteri, a uterine transverse diameter of ≥5 cm was a risk factor for perineal or vaginal lacerations.
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American College of Obstetricians and Gynecologists’ Committee on Gynecologic Practice. Uterine Morcellation for Presumed Leiomyomas: ACOG Committee Opinion, Number 822. Obstet Gynecol 2021; 137:e63-74. [PMID: 33595252 DOI: 10.1097/AOG.0000000000004291] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
ABSTRACT Morcellation is a surgical technique used to reduce the size of the uterus or myomas by creating smaller pieces to allow the tissue to be removed through small incisions or with laparoscopic instruments. Open (uncontained) morcellation of the uterus and myomas has been scrutinized because of the possible spread of an unsuspected leiomyosarcoma while using a power morcellator during a hysterectomy or myomectomy for presumed symptomatic uterine leiomyomas. Before considering morcellation of the uterus, a woman should be evaluated to determine if she is at increased risk of malignancy of the uterine corpus. Morcellation of a malignancy is contraindicated and women should be evaluated preoperatively to identify malignancy. However, leiomyosarcoma cannot be reliably diagnosed preoperatively; thus, there is a risk that a woman with a presumed leiomyoma may have a malignancy that may be spread through morcellation, leading to a potentially worsened prognosis. Although an abdominal hysterectomy or myomectomy may reduce the chance of spreading cancer cells in women with undiagnosed leiomyosarcoma, it is associated with increased morbidity when compared with minimally invasive approaches. The obstetrician-gynecologist and patient should engage in shared decision making, including informed consent, explaining the risks and benefits of each approach to surgery for presumed leiomyomas, the risks and benefits of morcellation, and alternatives to morcellation.
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Xu X, Desai VB, Wright JD, Lin H, Schwartz PE, Gross CP. Hospital variation in responses to safety warnings about power morcellation in hysterectomy. Am J Obstet Gynecol 2021; 224:589.e1-589.e13. [PMID: 33359176 DOI: 10.1016/j.ajog.2020.12.1207] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 11/17/2020] [Accepted: 12/17/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Safety warnings about power morcellation in 2014 considerably changed hysterectomy practice, especially for laparoscopic supracervical hysterectomy that typically requires morcellation to remove the corpus uteri while preserving the cervix. Hospitals might vary in how they respond to safety warnings and altered hysterectomy procedures to avoid use of power morcellation. However, there has been little data on how hospitals differ in their practice changes. OBJECTIVE This study aimed to examine whether hospitals varied in their use of laparoscopic supracervical hysterectomy after safety warnings about power morcellation and compare the risk of surgical complications at hospitals that had different response trajectories in use of laparoscopic supracervical hysterectomy. STUDY DESIGN This was a retrospective analysis of data from the New York Statewide Planning and Research Cooperative System and the State Inpatient Databases and State Ambulatory Surgery and Services Databases from 14 other states. We identified women aged ≥18 years undergoing hysterectomy for benign indications in the hospital inpatient and outpatient settings from October 1, 2013 to September 30, 2015. We calculated a risk-adjusted utilization rate of laparoscopic supracervical hysterectomy for each hospital in each calendar quarter after accounting for patient clinical risk factors. Applying a growth mixture modeling approach, we identified distinct groups of hospitals that exhibited different trajectories of using laparoscopic supracervical hysterectomy over time. Within each trajectory group, we compared patients' risk of surgical complications in the prewarning (2013Q4-2014Q1), transition (2014Q2-2014Q4), and postwarning (2015Q1-2015Q3) period using multivariable regressions. RESULTS Among 212,146 women undergoing benign hysterectomy at 511 hospitals, the use of laparoscopic supracervical hysterectomy decreased from 15.1% in 2013Q4 to 6.2% in 2015Q3. The use of laparoscopic supracervical hysterectomy at these 511 hospitals exhibited 4 distinct trajectory patterns: persistent low use (mean risk-adjusted utilization rate of laparoscopic supracervical hysterectomy changed from 2.8% in 2013Q4 to 0.6% in 2015Q3), decreased medium use (17.0% to 6.9%), decreased high use (51.4% to 24.2%), and rapid abandonment (30.5% to 0.8%). In the meantime, use of open abdominal hysterectomy increased by 2.1, 4.1, 7.8, and 11.8 percentage points between the prewarning and postwarning periods in these 4 trajectory groups, respectively. Compared with the prewarning period, the risk of major complications in the postwarning period decreased among patients at "persistent low use" hospitals (adjusted odds ratio, 0.88; 95% confidence interval, 0.81-0.94). In contrast, the risk of major complications increased among patients at "rapid abandonment" hospitals (adjusted odds ratio, 1.48; 95% confidence interval, 1.11-1.98), and the risk of minor complications increased among patients at "decreased high use" hospitals (adjusted odds ratio, 1.31; 95% confidence interval, 1.01-1.72). CONCLUSION Hospitals varied in their use of laparoscopic supracervical hysterectomy after safety warnings about power morcellation. Complication risk increased at hospitals that shifted considerably toward open abdominal hysterectomy.
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Affiliation(s)
- Xiao Xu
- Departments of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT; Cancer Outcomes Public Policy and Effectiveness Research Center, Yale School of Medicine, New Haven, CT.
| | - Vrunda B Desai
- Departments of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT; Medical Affairs, CooperSurgical, Inc, Trumbull, CT
| | - Jason D Wright
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Haiqun Lin
- Division of Nursing Science, School of Nursing, Rutgers University, Newark, NJ
| | - Peter E Schwartz
- Departments of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT
| | - Cary P Gross
- Internal Medicine, Yale School of Medicine, New Haven, CT; Cancer Outcomes Public Policy and Effectiveness Research Center, Yale School of Medicine, New Haven, CT
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Winkelman WD, Modest AM, Richardson ML. The Surgical Approach to Abdominal Sacrocolpopexy and Concurrent Hysterectomy: Trends for the Past Decade. Female Pelvic Med Reconstr Surg 2021; 27:e196-201. [DOI: 10.1097/spv.0000000000000891] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Ko JS, Suh CH, Huang H, Zhuo H, Harmanli O, Zhang Y. Association of Race/Ethnicity with Surgical Route and Perioperative Outcomes of Hysterectomy for Leiomyomas. J Minim Invasive Gynecol 2021; 28:1403-1410.e2. [PMID: 33242598 DOI: 10.1016/j.jmig.2020.11.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 11/10/2020] [Accepted: 11/11/2020] [Indexed: 11/20/2022]
Abstract
STUDY OBJECTIVE To evaluate the associations among race/ethnicity, route of surgery, and perioperative outcomes for women undergoing hysterectomy for uterine leiomyomas. DESIGN Retrospective cohort study. SETTING Multistate. PATIENTS Women who underwent hysterectomies for leiomyomas from the American College of Surgeons National Surgical Quality Improvement Program database, 2014 to 2017. INTERVENTIONS None. Exposures of interest were race/ethnicity and route of surgery. MEASUREMENTS AND MAIN RESULTS Racial/ethnic variation in route of surgery and perioperative outcomes. Propensity score matching was employed to control for possible confounders. We identified 20 133 women who underwent nonemergent abdominal hysterectomy (AH), laparoscopic hysterectomy (LH), or vaginal hysterectomy (VH) for leiomyomas. We defined minimally invasive hysterectomy (MIH) as LH or VH. Black women were more likely to have open surgery (AH vs MIH adjusted odds ratio [aOR], 2.22; 95% confidence interval [CI], 2.07-2.38; AH vs VH aOR, 1.79; 95% CI, 1.54-2.08; AH vs LH aOR, 2.27; 95% CI, 2.13-2.44) than white women. Likewise, Hispanic women were more likely to have open surgery (AH vs MIH aOR, 1.76; 95% CI, 1.58-1.96; AH vs LH aOR, 1.82; 95% CI, 1.61-2.00) than white women. Black women were more likely to experience any complication after hysterectomy (AH aOR, 1.54; 95% CI, 1.31-1.80; VH aOR, 1.65; 95% CI, 1.02-2.68; LH aOR, 1.37; 95% CI, 1.13-1.66) than white women. Hispanic women were less likely than white women to experience major complications after VH (aOR, 0.28; 95% CI, 0.08-0.98). Compared with white women, the mean length of stay was longer for black women who underwent AH or LH. The mean total operation time was higher for all minority groups (except for Asian/other undergoing AH) regardless of surgical approach. CONCLUSION Women of minority race/ethnicity were more likely to undergo abdominal rather than MIH for leiomyomas. Even when controlling for route of surgery, they were more likely to experience perioperative complications.
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Pepin K, Cope A, Einarsson JI, Cellini J, Cohen SL. Safety of Minimally Invasive Tissue Extraction in Myoma Management: A Systematic Review. J Minim Invasive Gynecol 2020; 28:619-643. [PMID: 32977002 DOI: 10.1016/j.jmig.2020.09.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 08/28/2020] [Accepted: 09/08/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE This review seeks to establish the incidence of adverse outcomes associated with minimally invasive tissue extraction at the time of surgical procedures for myomas. DATA SOURCES Articles published in the following databases without date restrictions: PubMed, EMBASE, Web of Science, Cochrane Database of Systematic Reviews and Trials. Search was conducted on March 25, 2020. METHODS OF STUDY SELECTION Included studies evaluated minimally invasive surgical procedures for uterine myomas involving morcellation. This review did not consider studies of nonuterine tissue morcellation, studies involving uterine procedures other than hysterectomy or myomectomy, studies involving morcellation of known malignancies, nor studies concerning hysteroscopic myomectomy. A total of 695 studies were reviewed, with 185 studies included for analysis. TABULATION, INTEGRATION, AND RESULTS The following variables were extracted: patient demographics, study type, morcellation technique, and adverse outcome category. Adverse outcomes included prolonged operative time, morcellation time, blood loss, direct injury from a morcellator, dissemination of tissue (benign or malignant), and disruption of the pathologic specimen. CONCLUSION Complications related to morcellation are rare; however, there is a great need for higher quality studies to evaluate associated adverse outcomes.
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Affiliation(s)
- Kristen Pepin
- Department of Obstetrics & Gynecology, Weill Cornell Medical Center, New York, New York (Dr. Pepin).
| | - Adela Cope
- Department of Obstetrics & Gynecology, The Mayo Clinic, Rochester, Minnesota (Drs. Cope and Cohen)
| | - Jon I Einarsson
- Department of Obstetrics & Gynecology, Brigham and Women's Hospital (Dr. Einarsson)
| | - Jacqueline Cellini
- Department of Research & Instruction, Harvard TH Chan School of Public Health (Ms. Cellini), Boston, Massachusetts
| | - Sarah L Cohen
- Department of Obstetrics & Gynecology, The Mayo Clinic, Rochester, Minnesota (Drs. Cope and Cohen)
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Zhu CR, Mallick R, Singh SS, Auer R, Solnik J, Choudhry AJ, Chen I. Risk Factors for Bowel Injury in Hysterectomy for Benign Indications. Obstet Gynecol 2020; 136:803-10. [PMID: 32925612 DOI: 10.1097/AOG.0000000000004007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To estimate the incidence and risk factors for bowel injury in women undergoing hysterectomy for benign indications. METHODS A retrospective cohort study was conducted among women undergoing hysterectomy for benign indications from 2012 to 2016 at institutes participating in the American College of Surgeons National Surgical Quality Improvement Program, including both inpatient and outpatient settings. Bowel injury was identified using Current Procedural Terminology codes as patients who underwent bowel repair at the time of hysterectomy or postoperatively within 30 days. Multivariate logistic regression models were used to control for patient clinical factors and perioperative factors. RESULTS Bowel injury occurred in 610 of 155,557 (0.39%) included women. After bivariate analysis, factors associated with bowel injury included age, race, body mass index, American Society of Anesthesiologists classification, increased operative time, surgical approach, type of hysterectomy, lysis of adhesions, and operative indication. After adjusting for potential confounders, bowel injury was found associated with older age, surgical indication of endometriosis, and abdominal surgical approach. Compared with the surgical indication of endometriosis (n=63/10,625), the surgical indications of menstrual disorder (odds ratio [OR] 0.33, 95% CI 0.23-0.47; adjusted odds ratio [aOR] 0.33, 95% CI 0.23-0.48; n=67/34,168), uterine leiomyomas (OR 0.80, 95% CI 0.61-1.05; aOR 0.44, 95% CI 0.33-0.59; n=243/51,232), and genital prolapse (OR 0.30, 95% CI 0.20-0.45; aOR 0.41, 95% CI 0.25-0.67; n=36/20,384) were each associated with lower odds of bowel injury. Compared with the vaginal approach to hysterectomy (n=27/27,434), the abdominal approach was found to have significantly increased odds of bowel injury (OR 10.80, 95% CI 7.31-15.95; aOR 10.49 95% CI 6.42-17.12; n=401/38,106); the laparoscopic approach had smaller but significantly increased odds (OR 2.06, 95% CI 1.37-3.08; aOR 2.03 95% CI 1.24-3.34; n=182/90,017) as well. CONCLUSION Increased risk of bowel injury is associated with endometriosis and the abdominal surgical approach to hysterectomy. These findings have implications for the surgical care of women with benign uterine disease.
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Chang OH, Ferrando CA. Occult Uterine Malignancy at the Time of Sacrocolpopexy in the Context of the Safety Communication on Power Morcellation by the FDA. J Minim Invasive Gynecol 2020; 28:788-793. [PMID: 32681994 DOI: 10.1016/j.jmig.2020.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 07/07/2020] [Accepted: 07/10/2020] [Indexed: 11/17/2022]
Abstract
STUDY OBJECTIVE The objective of this study was to determine the incidence of occult uterine malignancy at the time of sacrocolpopexy with concurrent hysterectomy, in the context of practice pattern changes as a result of the 2014 Food and Drug Administration (FDA) power morcellation safety communication. DESIGN Retrospective chart review. SETTING Tertiary care referral center in the United States. PATIENTS A total of 839 patients who underwent sacrocolpopexy from January 2004 to December 2018. INTERVENTIONS All patients received a concurrent hysterectomy without a diagnosis of suspected or confirmed gynecologic malignancy before surgery. Trends of surgeries were compared before and after the 2014 FDA power morcellation safety communication. MEASUREMENTS AND MAIN RESULTS Demographic and perioperative data were collected from the system-wide electronic medical record. Operative and pathology reports were reviewed to determine the method of specimen retrieval and specimen pathology results. A total of 238 patients (28.4%) had a hysterectomy at the time of sacrocolpopexy. There were no cases of occult uterine malignancy (0%, 95% CI 0%-1.6%). There was 1 case of borderline tumor of the ovary. The most common mode of hysterectomy over the 15-year period was laparoscopic hysterectomy (n = 84, 35.3%), followed by vaginal hysterectomy (n = 63, 26.5%). After the FDA communication, the most common form of hysterectomy changed significantly to vaginal hysterectomy (n = 35, 55.6%; p <.001). When comparing the first 2 years after the announcement (2014-2016) to the subsequent 2 years (2017-2018), there was again a significant increase in the use of laparoscopic hysterectomy in the latter time period (7.3% vs 40.9%; p <.001). CONCLUSION In this cohort of patients undergoing sacrocolpopexy with concurrent hysterectomy, the incidence of occult uterine malignancy was low. After the FDA safety communication, practice patterns with regard to the mode of hysterectomy changed, but the magnitude of these changes were transient.
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Affiliation(s)
- Olivia H Chang
- Center for Urogynecology and Pelvic Reconstructive Surgery, Women's Health Institute, Cleveland Clinic, Cleveland, Ohio (all authors)..
| | - Cecile A Ferrando
- Center for Urogynecology and Pelvic Reconstructive Surgery, Women's Health Institute, Cleveland Clinic, Cleveland, Ohio (all authors)
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Tyan P, Amdur R, Berrigan M, Robinson H, Sparks A, Gu A, Wei C, Klebanoff J, Moawad G. Differences in Postoperative Morbidity among Obese Patients Undergoing Abdominal Versus Laparoscopic Hysterectomy for Benign Indications. J Minim Invasive Gynecol 2020; 27:464-72. [DOI: 10.1016/j.jmig.2019.04.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 03/25/2019] [Accepted: 04/01/2019] [Indexed: 11/21/2022]
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Abstract
OBJECTIVE To characterize long-term national trends in surgical approach for hysterectomy after the U.S. Food and Drug Administration (FDA) warning against power morcellation for laparoscopic specimen removal. METHODS This was a descriptive study using data from the American College of Surgeons National Surgical Quality Improvement Program from 2012 to 2016. We identified hysterectomies using Current Procedural Terminology codes. We used an interrupted time-series analysis to evaluate abdominal and supracervical hysterectomy trends surrounding The Wall Street Journal article first reporting morcellation safety concerns and the FDA safety communication. We compared categorical and continuous variables using χ, t, and Wilcoxon rank sum tests. RESULTS We identified 179,950 hysterectomies; laparoscopy was the most common mode of hysterectomy in every quarter. Before The Wall Street Journal article, there was no significant change in proportion of abdominal hysterectomies (0.3% decrease/quarter, P=.14). After The Wall Street Journal article, use of abdominal hysterectomy increased 1.1% per quarter for two quarters through the FDA warning (P<.001), plateaued for three quarters until March 2015 (P=.65), then decreased by 0.8% per quarter through 2016 (P<.001). Supracervical hysterectomy volume continuously decreased after the FDA warning (1.0% decrease per quarter, P<.001) and after three quarters (0.7% decrease per quarter, P=.01), then plateaued from April 2015 through 2016 (0.05% decrease per quarter, P=.40). Mode of supracervical hysterectomy was unchanged from 2012 to 2013 (P=.43), followed by two quarters of significant increase in proportion of supracervical abdominal hysterectomies (11.7%/quarter, P<.001). This change in mode of supracervical hysterectomy then plateaued through 2016 (P=.06). CONCLUSION Despite early studies suggesting that minimally invasive hysterectomy decreased in response to safety concerns regarding power morcellation, we found that this effect reversed 1 year after the FDA safety communication. However, there was a sustained decline in supracervical hysterectomy, and the remaining supracervical hysterectomies were more likely to be performed using laparotomy.
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Shalaby S, Khater M, Laknaur A, Arbab A, Al-Hendy A. Molecular Bio-Imaging Probe for Non-Invasive Differentiation Between Human Leiomyoma Versus Leiomyosarcoma. Reprod Sci 2020; 27:644-654. [PMID: 31925772 DOI: 10.1007/s43032-019-00067-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 07/23/2019] [Indexed: 12/27/2022]
Abstract
Leiomyosarcoma is the most frequent subtype of the deadly uterine sarcoma and shares many common clinical grounds with leiomyoma, which is in turn the most common solid benign uterine neoplasm. With the recent progress in minimally invasive techniques for managing leiomyomas, accurate preoperative diagnosis of uterine masses has become the most important selection criterion for the safest therapeutic option. Therefore, different imaging modalities would be playing a key role in management of uterine masses. Testing for a sarcoma-specific promoter that expresses its downstream reporter gene only in leiomyosarcoma and not in leiomyoma or healthy uterine tissue. Adenoviral vectors were utilized both in vitro and in vivo to test the specificity of the promoters. Quantitative studies of downstream gene expression of these promoters was carried out both in vitro and in vivo. Our data indicated that human leiomyosarcoma cells highly expressed the reporter gene downstream to survivin promoter (Ad-SUR-LUC) when compared with benign leiomyoma or normal cells (p value of 0.05). Our study suggested that survivin is the unique promoter capable of distinguishing between the deadly sarcoma and the benign counterparts.
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Affiliation(s)
| | - Mostafa Khater
- Department of Pharmacology and toxicology, Medical College of Georgia, Augusta University, Augusta, GA, 30912, USA
| | - Archana Laknaur
- Department of Obstetrics and Gynecology, Medical College of Georgia, Augusta University, Augusta, GA, 30912, USA
| | - Ali Arbab
- Cancer Centre, Medical College of Georgia, Augusta University, Augusta, GA, 30912, USA
| | - Ayman Al-Hendy
- Department of Obstetrics and Gynecology, Medical College of Georgia, Augusta University, Augusta, GA, 30912, USA.
- Department of Obstetrics and Gynecology, UIC, Chicago, IL, 60612, USA.
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Matsushita T, Sekizawa A, Jacobs LK. Racial Disparities in Response to a US Food and Drug Administration Safety Communication Regarding the Use of Power Morcellation for the Treatment of Uterine Leiomyoma. J Minim Invasive Gynecol 2020; 27:178-185.e1. [DOI: 10.1016/j.jmig.2019.03.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 03/25/2019] [Accepted: 03/26/2019] [Indexed: 12/26/2022]
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Abstract
Fibroid tissue extraction during hysterectomy and myomectomy has become increasingly controversial. A wave of research has tried to clarify difficult questions around the prevalence of occult malignancies, the effect of morcellation on cancer outcomes, proper informed consent, and surgical options for tissue extraction. This review examines the history of these controversies and discusses tissue extraction techniques and continued areas of debate in the field.
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Abstract
Aim: We examine the impact of the new risk information about a surgical device on surgery and patient outcomes for hysterectomy in the inpatient setting. Methods: We utilize a difference-in-differences approach to assess the impact of new risk information on patient outcomes in the inpatient setting between 2009 and 2014. The inpatient data come from a nationally representative sample of hospitalizations in the USA. We use the likelihood of laparoscopic surgery, measures of resource use and surgical complications as outcome variables. Results: We estimate a three-percentage point decrease in the likelihood of receiving laparoscopic hysterectomy, a one-percentage point increase in the likelihood of experiencing a surgical complication and no impact on resource use, relative to pre-existing means. Conclusion: Our findings show that there was movement away from laparoscopic surgery in the months following the dissemination of new risk information. These changes had limited effect on patient outcomes.
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Affiliation(s)
- Ehren Schuttringer
- Food & Drug Administration Office of the Commissioner, 10903 New Hampshire Ave, Silver Spring, Maryland, MD 20993, USA
| | - Trinidad Beleche
- Food & Drug Administration Office of the Commissioner, 10903 New Hampshire Ave, Silver Spring, Maryland, MD 20993, USA
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Lum D. Rising From the Ashes: Minimally Invasive Surgery in the Wake of Power Morcellation. Obstet Gynecol 2019; 134:225-6. [PMID: 31348208 DOI: 10.1097/AOG.0000000000003386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Cohen SL, Clark NV, Ajao MO, Brown DN, Gargiulo AR, Gu X, Einarsson JI. Prospective Evaluation of Manual Morcellation Techniques: Minilaparotomy versus Vaginal Approach. J Minim Invasive Gynecol 2019; 26:702-8. [DOI: 10.1016/j.jmig.2018.07.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 07/17/2018] [Accepted: 07/22/2018] [Indexed: 12/25/2022]
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19
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Chene G, Lamblin G, Lebail Carval K, Chabert P, Mellier G. [How I do… easily a vaginal hysterectomy? (Lyons school of vaginal surgery)]. ACTA ACUST UNITED AC 2018; 47:381-386. [PMID: 30482523 DOI: 10.1016/j.gofs.2018.10.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Indexed: 10/27/2022]
Affiliation(s)
- G Chene
- Département de gynécologie, hôpital Femme-Mère-Enfant, HFME, hospices civils de Lyon, 69000 Lyon, France; Université Claude-Bernard Lyon 1, EMR 3738, 69000 Lyon, France.
| | - G Lamblin
- Département de gynécologie, hôpital Femme-Mère-Enfant, HFME, hospices civils de Lyon, 69000 Lyon, France
| | - K Lebail Carval
- Département de gynécologie, hôpital Femme-Mère-Enfant, HFME, hospices civils de Lyon, 69000 Lyon, France
| | - P Chabert
- Département de gynécologie, hôpital Femme-Mère-Enfant, HFME, hospices civils de Lyon, 69000 Lyon, France
| | - G Mellier
- Département de gynécologie, hôpital Femme-Mère-Enfant, HFME, hospices civils de Lyon, 69000 Lyon, France
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Wu MY, Ding DC, Chu TY, Hong MK. Robotic-Assisted “Containment Before Resection and Manual Morcellation” Using a Tissue Pouch for a Solid Ovarian Tumor of Unknown Characteristics. J Gynecol Surg 2018. [DOI: 10.1089/gyn.2017.0134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Meng-Yu Wu
- Department of Obstetrics and Gynecology, Hualien Tzu Chi Hospital, Hualien, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Dah-Ching Ding
- Department of Obstetrics and Gynecology, Hualien Tzu Chi Hospital, Hualien, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Minimally Invasive Gynecology Surgery Center, Hualien Tzu Chi Hospital, Hualien, Taiwan
| | - Tang-Yuan Chu
- Department of Obstetrics and Gynecology, Hualien Tzu Chi Hospital, Hualien, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Minimally Invasive Gynecology Surgery Center, Hualien Tzu Chi Hospital, Hualien, Taiwan
| | - Mun-Kun Hong
- Department of Obstetrics and Gynecology, Hualien Tzu Chi Hospital, Hualien, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Minimally Invasive Gynecology Surgery Center, Hualien Tzu Chi Hospital, Hualien, Taiwan
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Abstract
PURPOSE OF REVIEW This review was written in an effort to describe the evolution of power morcellation equipment from their creation to their current state. In addition, this review addresses the continuously evolving equipment involved with power morcellation and looks to describe where the field is headed in the future. In addition, recent professional and federal recommendations have changed the way power morcellation is being approached and has led to the development of contained morcellation systems, which, although in their infancy, are also being proven to be well tolerated options. RECENT FINDINGS This article will review the most current research on electronic power morcellation and the multiple attempts to prove superiority from the many different types of equipment, and also the many different approaches to morcellation. In addition, with the adaptation to contained morcellation, this review will cover research focused on optimizing a containment system and the techniques involved. SUMMARY In summary, this review is aimed at describing many of the currently available power morcellation products and contained morcellation systems in an effort to allow physicians to understand the different options available, and to discuss well tolerated, effective, and clinically proven techniques that can lead to improved surgical outcomes in the future.
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Multinu F, Casarin J, Hanson KT, Angioni S, Mariani A, Habermann EB, Laughlin-Tommaso SK. Practice Patterns and Complications of Benign Hysterectomy Following the FDA Statement Warning Against the Use of Power Morcellation. JAMA Surg 2018; 153:e180141. [PMID: 29641835 DOI: 10.1001/jamasurg.2018.0141] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Importance In November 2014, the US Food and Drug Administration (FDA) issued a black box warning against the use of power morcellation for excision of uterine fibroids to decrease the risk of disseminating malignant cells and worsening survival outcomes of patients with unexpected malignant neoplasms. After the FDA statement was issued, studies showed decreased rates of minimally invasive surgery and increased rates of open abdominal hysterectomy. However, there are limited and controversial data on the association of these changed rates with 30-day hysterectomy complications. Objective To assess changes in the rates of 30-day major and minor complications of hysterectomy for benign gynecologic indications following the FDA-issued statement. Design, Setting, and Participants This retrospective cohort study used the American College of Surgeons National Surgical Quality Improvement Program database and included 603 hospitals participating between January 1, 2013, and December 31, 2015. Thirty-day posthysterectomy complications were compared before and after the FDA-issued warning. Women who underwent hysterectomy for benign gynecologic indications (n = 75 487), including hysterectomies with indication of uterine fibroids (n = 25 571), were included. Complication rates and procedure distributions between the periods were compared with χ2 tests and multivariable logistic regression controlling for patient and operative factors. Main Outcomes and Measures Major and minor 30-day complication rates before (from 2013 through the first quarter of 2014) and after (from the fourth quarter of 2014 through 2015) the FDA-issued warning. Results Of 75 487 women (mean [SD] age, 47.8 [10.7] years) who underwent hysterectomy for benign gynecologic indications, 32 186 (42.6%) were treated before and 43 301 (57.4%) after the FDA-issued warning. Non-Hispanic white women comprised most (59.4%) of the total population, followed by African American women (15.1%). Overall, major and minor complications remained stable before and after the FDA-issued warning. By contrast, among a subset of 25 571 women (33.9%) who underwent hysterectomy for uterine fibroids, major complications significantly increased after the FDA-issued warning from 1.9% to 2.4% (adjusted odds ratio [OR], 1.23; 95% CI, 1.04-1.47; P = .02), and minor complications significantly increased from 2.7% to 3.3% (adjusted OR, 1.21; 95% CI, 1.04-1.40; P = .01). In this subgroup, the rate of open abdominal surgery increased from 37.2% to 43.0%, and the rate of minimally invasive surgery (total laparoscopic hysterectomy, laparoscopic supracervical hysterectomy, and laparoscopic-assisted vaginal hysterectomy) decreased from 56.1% to 49.7% (P < .001). Conclusions and Relevance Major and minor 30-day complication rates among women undergoing hysterectomy for uterine fibroids increased following the FDA-issued statement. This increased risk corresponding with a decreased use of minimally invasive surgery should be balanced against the potential harms of morcellation during a shared decision-making process between clinician and patient. Regulatory bodies and medical societies should consider these findings when issuing relevant communications.
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Affiliation(s)
- Francesco Multinu
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota.,Division of Gynecology and Obstetrics, Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
| | - Jvan Casarin
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota
| | | | - Stefano Angioni
- Division of Gynecology and Obstetrics, Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
| | - Andrea Mariani
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota.,Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Elizabeth B Habermann
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Shannon K Laughlin-Tommaso
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota.,Department of Surgery, Mayo Clinic, Rochester, Minnesota
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Yu SP, Lee BB, Han MN, Chan C, Rao J, Levin M, Fung PC, Parker W. Irrigation after Laparoscopic Power Morcellation and the Dispersal of Leiomyoma Cells: A Pilot Study. J Minim Invasive Gynecol 2018; 25:632-637. [DOI: 10.1016/j.jmig.2018.01.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 01/22/2018] [Accepted: 01/26/2018] [Indexed: 12/14/2022]
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Abstract
Background and Objectives After the U. S. Food and Drug Administration's recommendation against the use of power morcellation for tissue extraction in minimally invasive hysterectomy, the number of procedures completed laparoscopically declined in favor of open surgery laparotomy. We conducted a retrospective cohort study comparing perioperative and long-term outcomes, including complications associated with laparoscopic hysterectomy before and after the FDA recommendation. Methods We included procedures performed in Danish government hospitals (GHs) and a hospital specializing in minimally invasive gynecological surgery (MIGS). Different types of hysterectomy over the period from January 2011 through May 2016 were examined. Results Hysterectomies were analyzed from GHs (n = 21,495) and from a hospital specializing in MIGS (n = 749). In the GHs, we found a decrease in open hysterectomy from 40% in 2011 to 20% in 2016. In the MIGS hospital, 4 of 749 (0.05%) open hysterectomies were performed during the 6 years; however, there was a change in operative technique. After the FDA recommendation, there was a shift from laparoscopic subtotal hysterectomy (LSH) to total laparoscopic hysterectomy (TLH) from 32% in 2011 to 82% by May 2016. Containment bags were used in LSH and large-uterus TLH after the 2014 advisory. Significantly more complications occurred in the GHs than in the MIGS hospital: 3224/21,495 (15%) vs 53/749 (7.0%), respectively. Conclusion The rate of minimally invasive hysterectomies continues to increase. However, after 2014, many of the morcellation techniques have been replaced by a minilaparotomy to extract the uterus at the end of surgery, compared to the use of the contained morcellation in 100% of cases in the MIGS hospital. There was a major difference in complication rates between the hospitals that is partly explainable by the challenge in training residents and the low operative volume of surgeons in GHs.
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Affiliation(s)
- Olav Istre
- Department of Obstetrics and Gynecology South Danish University, Odense, Denmark, and Aleris Hamlet Private Hospital, Copenhagen, Denmark
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DiNapoli MN, Truong MD, Halfon JK, Burke WM. Unsuspected Uterine Sarcoma in an Urban Hospital: Does Surgical Approach Matter? J Minim Invasive Gynecol 2018; 25:491-497. [DOI: 10.1016/j.jmig.2017.10.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 10/08/2017] [Accepted: 10/09/2017] [Indexed: 11/16/2022]
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Affiliation(s)
- Francesco Raspagliesi
- Fondazione IRCCS Istituto Nazionale dei Tumori, Department of Gynecologic Oncology, Milan, Italy
| | - Giorgio Bogani
- Fondazione IRCCS Istituto Nazionale dei Tumori, Department of Gynecologic Oncology, Milan, Italy
| | - Domenica Lorusso
- Fondazione IRCCS Istituto Nazionale dei Tumori, Department of Gynecologic Oncology, Milan, Italy
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Clark NM, Schembri M, Jacoby VL. Change in Surgical Practice for Women With Leiomyomas After the U.S. Food and Drug Administration Morcellator Safety Communication. Obstet Gynecol 2017; 130:1057-63. [DOI: 10.1097/aog.0000000000002309] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Glaser LM, Friedman J, Tsai S, Chaudhari A, Milad M. Laparoscopic myomectomy and morcellation: A review of techniques, outcomes, and practice guidelines. Best Pract Res Clin Obstet Gynaecol. 2018;46:99-112. [PMID: 29078975 DOI: 10.1016/j.bpobgyn.2017.09.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 09/11/2017] [Indexed: 12/14/2022]
Abstract
Laparoscopic myomectomy is a minimally invasive surgical approach to treat symptomatic uterine fibroids in women wishing for a uterine-sparing procedure. With careful patient selection, these procedures are associated with favorable reproductive outcomes and low perioperative morbidity. Current available methods for specimen retrieval include power and hand morcellation. The 2014 FDA safety warnings regarding power morcellation arose from concerns about the spread of occult malignancy and prompted widespread use of containment systems that may limit spread of myometrial cells. Investigation into the clinical effects of laparoscopic myomectomy and uncontained morcellation on the prognosis and spread of occult leiomyosarcoma has yielded mixed results. Other complications of uncontained power morcellation exist, including the development of parasitic leiomyomas. The FDA safety warnings have greatly influenced trends in benign gynecologic surgery, and survey data reflect trends in providers' opinions of these trends. In conclusion, recommendations for the current practice of laparoscopic myomectomy and morcellation are reviewed.
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Clark NV, Cohen SL. Tissue Extraction Techniques During Laparoscopic Uterine Surgery. J Minim Invasive Gynecol 2017; 25:251-256. [PMID: 28866098 DOI: 10.1016/j.jmig.2017.07.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 07/24/2017] [Accepted: 07/25/2017] [Indexed: 10/18/2022]
Abstract
Morcellation allows minimally invasive approaches to surgery even in the presence of large uteri or myomas. Recent restrictions in the use of power morcellation, as well as concerns regarding the potential for morcellation to disseminate malignant tissue, have initiated investigation and innovation to find safer methods. This review examines current techniques for tissue extraction during uterine surgery, with a focus on contained power morcellation and contained manual morcellation via mini-laparotomy or colpotomy. Videos are included to demonstrate these methods.
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Affiliation(s)
- Nisse V Clark
- Division of Minimally Invasive Gynecologic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Sarah L Cohen
- Division of Minimally Invasive Gynecologic Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
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