Concerns are increasing among doctors about the safety of a procedure performed on tens of thousands of women a year in the United States who undergo surgery to remove fibroid tumors from the uterus, or to remove the entire uterus.
The procedure, morcellation, cuts tissue into pieces that can be pulled out through tiny incisions. The technique is part of minimally invasive surgery, which avoids big incisions, shortens recovery time and reduces the risks of blood loss, infection and other complications.
Surgeons can perform morcellation by hand with a knife, or with an electrical device that has a rapidly spinning blade. But problems have emerged with the procedure, most likely from the power device, according to two articles published on Thursday in The Journal of the American Medical Association. The technique can spray bits of uterine tissue or fibroids around inside the abdomen like seeds. Even benign tissue (fibroids are benign) can take hold and grow on organs where it does not belong, causing pain, infection or bowel obstruction.
In a few cases, a rare and hard-to-diagnose uterine tumor called a sarcoma was hidden in the uterus or mistaken for a fibroid, and morcellation apparently spread cancer cells through the patient’s abdomen. Advanced cancer followed.
The blades on power morcellators have also injured abdominal organs and blood vessels.
According to the American College of Obstetricians and Gynecologists, about 498,000 women in the United States had hysterectomies to remove the uterus in 2010, and about 11 percent of those operations involved morcellation.
Dr. Kimberly Kho, an author of one of the journal articles and an assistant professor of obstetrics and gynecology at the University of Texas Southwestern Medical Center, said that she and a colleague became concerned several years ago when they began seeing patients with abdominal problems following morcellation of fibroids or the uterus by other surgeons. The women needed additional surgery to remove lumps of uterine tissue or fibroids that were growing on the liver, appendix or bladder. Some had multiple growths sprouting inside the abdomen. The true incidence of these problems after morcellation is not known, but a case in Boston, reported in December by The Wall Street Journal, has drawn considerable attention to the cancer risk.
In that case, a patient who had morcellation to remove fibroids was later found to have advanced cancer, apparently from a hidden sarcoma that might have been spread by the procedure. These uterine sarcomas are rare and are often not diagnosed until after the surgery is done and the tissue is analyzed by a pathologist.
The patient and her husband are both doctors, and have been trying to persuade surgeons to stop using morcellation.
But Dr. Kho said she did not think the technique should be banned, because minimally invasive surgery has so many benefits for patients.
“I do think, however, that we could be more prudent and conservative with whom we use these instruments on and more systematic about preoperative evaluation to prevent morcellating detectable cancers,” she said.
One approach that she and other doctors favor involves enclosing the tissue that is to be removed in a bag and then morcellating it inside the bag, to keep the tissue from being dispersed. That technique, known as closed morcellation, is already used by other types of surgeons, said Dr. Robert Barbieri, the chairman of obstetrics and gynecology at Brigham and Women’s Hospital in Boston. But he said few gynecologists know how to perform it, and it takes months to learn.
In the meantime, Dr. Barbieri said, doctors at his hospital are discussing the procedure’s risks with patients. They estimate that in one in 1,000 cases, a woman with fibroids will have a hidden sarcoma, but say the risk could be as high as 1 in 400. Some women, he said, have already heard about the issue and say, “Hey, that morcellation thing, I don’t want that.” And they prefer open surgery in which the tissue is removed intact.
But other women think the risk estimate is not so bad, dread the larger incision and want to get back to work quickly.
“I don’t think this is the end of the story,” Dr. Barbieri said. “I think we’ll develop technology that will use closed morcellation."