In‐bag morcellation for presumed myoma retrieval at laparoscopy

Abstract

We read with interest the article by George et al,1 in which they provided further evidence suggesting that intraperitoneal morcellation has a negative impact on the survival of patients with undiagnosed uterine sarcomas.1 Recently, the US Food and Drug Administration, in a safety communication, advised against the use of power morcellators during laparoscopic and robotic-assisted procedures because they can disperse occult cancerous tissues beyond the uterus.2 The subsequent suspension of power morcellator sales from Johnson & Johnson has increased concerns regarding the use of minimally invasive techniques for myomectomy and hysterectomy in cases of large uteri, thus potentially limiting the diffusion of minimally invasive procedures.3 Two interesting points of the investigation by George et al1 deserve to be addressed. The first is in regard to the cost-effectiveness and risk-to-benefit ratio between intraperitoneal morcellation of undiagnosed leiomyosarcoma and the execution of unnecessary open abdominal procedures in patients with leiomyomas. In fact, although survival outcomes are not comparable with surgery-related outcomes and costs,4 it is important to note that undiagnosed leiomyosarcoma accounts for approximately 0.1% to 0.2% of uterine specimens of presumed leiomyomas.1 In this scenario, 998 of 1000 women will be exposed to an increased morbidity risk. In agreement with George et al,1 risks have to be balanced and discussed with the patients. Second, we have to report that techniques to avoid intraabdominal spillage during minimally invasive surgery have been developed.5, 6 In particular, our study group suggested that a transvaginal route (without concomitant hysterectomy) achieves the endpoints of safety, feasibility, and effectiveness for myoma and uterine retrieval, thus avoiding the use of a power morcellator.5, 6 The introduction of an endobag through the posterior colpotomy minimizes the possibility of intraabdominal spillage and the loss of potentially infected or malignant debris. Moreover, accumulating evidence has suggested that transvaginal extraction upholds the effectiveness of a power morcellator, improving surgery-related outcomes and reducing surgical time as well as morbidity.5, 6 In fact, the intrinsic elasticity of vaginal tissues allows for the retrieval of large and solid masses thorough a small (measuring <2 cm) vaginal incision, thereby avoiding the enlargement of an ancillary port needed for morcellator insertion or other retrieval techniques.5, 6 Further attempts are warranted to improve the care and safety of patients by reducing the morbidity of open abdominal procedures and avoiding the use of power morcellators. No specific funding was disclosed. The authors made no disclosures. Giorgio Bogani, MD Maurizio Serati, MD Stefano Uccella, MD Fabio Ghezzi, MD Department of Obstetrics and Gynecology University of Insubria Del Ponte Hospital Varese, Italy