Every year, hundreds of thousands of women undergo what can be routine surgery to remove benign fibroid tumors from their uterus. But the “routine” can be dangerous, perhaps life-threatening, because of the potential to spread cancer.
The concern, as explained last week in the New York Times, is over the procedure called morcellation, which cuts or grinds the tissue to be removed into tiny pieces suitable for extraction through a small incision. Smaller incisions, of course, are less invasive than surgery in which the whole abdominal cavity is opened, so it’s generally preferred because there’s less risk of infection, blood loss and other complications, less pain and a shorter time of recovery.
Morcellation can be performed by knife or a device with a spinning blade. The latter, especially, is worrisome, according to two articles published in the Journal of the American Medical Association (JAMA), because it can spray bits of uterine tissue or fibroids around the surgical cavity. Although fibroids are benign, the tissue can grow on other organs, causing pain, infection or bowel obstruction. And the spinning blades can cut abdominal organs and blood vessels.
But the scariest potential harm is that in a few cases, a sarcoma, a rare tumor that’s difficult to diagnose, can be hidden in the uterus or mistaken for a fibroid, and morcellation appears to spread cancer cells throughout the patient’s abdomen. Advanced cancer follows.
Not only are uterine sarcomas rare, they’re usually not diagnosed until after the initial surgery, when the tissue is analyzed by a pathologist.
According to the American Congress of Obstetricians and Gynecologists (ACOG), says The Times, nearly 500,000 women in the U.S. had hysterectomies to remove their uterus in 2010; about 11 in 100 involved morcellation.
One of the authors of a JAMA study, Dr. Kimberly Kho, professor of obstetrics and gynecology at the University of Texas Southwestern Medical Center, had patients who had undergone morcellation of fibroids or the uterus consult with her because of abdominal complications.
They required additional surgery to remove lumps of uterine tissue or fibroids growing on the liver, appendix or bladder.
One well-reported case of such complications concerned Dr. Amy Reed, an anesthesiologist whose story was told in the Wall Street Journal. After her surgery to remove fibroids, she was found to have advanced cancer, apparently from a hidden sarcoma that might have been spread by morcellation.
Although Kho wants to ensure the medical community understands the risks of morcellation, she doesn’t believe it should be banned, because minimally invasive surgery has so many benefits for many patients.
“I do think, however, that we could be more prudent and conservative with whom we use these instruments on,” she told The Times, “and more systematic about preoperative evaluation to prevent morcellating detectable cancers.”
She suggests enclosing the tissue to be removed in a bag, then morcellating it inside the bag to prevent tissue dispersal. Called closed morcellation, that approach works in other types of surgery. But most gynecologists don’t know how to perform it, and it takes months to learn.
If you are planning to have fibroids or your uterus removed, discuss with your surgeon the technique he or she intends to use. Discuss the risks and benefits of open surgery in which the tissue is removed intact versus laparoscopy, the less invasive approach that requires smaller tissue for removal. Seek referrals for surgeons familiar with closed morcellation.
To learn more about hysterectomies, see the FAQ page from the ACOG.