During some gynaecological procedures, the tissues or organs that are due to be removed are very large. Tissue or organ removal can be done via the vagina (like delivery of a baby), through a large incision in the abdomen (called a laparotomy) or through small incisions made by laparoscopy (keyhole surgery) using specialised equipment. Breaking up of these tissues (usually the uterus or fibroids) allows the procedure to continue to be minimally invasive but there are potential risks in association with this procedure – just as there are risks from any surgical approach and procedure.
Many women choose to have a minimally invasive procedure since its faster recovery and smaller wounds (resulting in less pain and less time in hospital) are advantageous. With the development of various instruments and procedures over the last 20 years, it is now possible to undertake any procedure through minimally invasive surgery – the only disadvantage is for any increase in risks. Morcellation is a technique where organs or tissues are broken down to remove them from the body. This means that if a large tissue (for example a uterus that weighs several hundred grams or a fibroid that is removed from the uterus laparoscopically) is removed, it needs to be cut down so that it will fit out either through the vagina (vaginal morcellation) or though the abdominal wounds (laparoscopic morcellation).
The methods used to undertake the morcellation procedure include a scalpel, scissors or specialised instruments called power morcellators. These are specifically created to cut the tissue with electrical or mechanical energy and remove the tissue through the laparoscopic holes – about 12-15 mm in diameter.
Studies have shown that this is an effective way to remove the tissue from the body but that these are powerful instruments and therefore carry risk with their use. These risks include damaging the surrounding organs (bowel, blood vessels, bladder) with the blade or the energy, resulting in an intraoperative injury that would need to be addressed, usually immediately. There is also the possibility of the tissue that is being removed spreading. This may, if it is a fibroid being removed, cause a condition known as leiomyomatosis, where fibroid cells grow elsewhere in the abdomen. This is a rare situation that may not present until many years after the original surgery. The second issue is that if there is cancer in the tissue removed, then this too could be spread by the morcellation process.
Morcellation and cancer
The actual risk of a cancer occurring inside the tissues that are removed at gynaecological surgery is rare, and is dependant on a number of factors. Risks for the development of this type of cancer (called a leiomyosarcoma) include:
- Age of more than 60;
- Being post-menopausal (having finished your periods);
- Having an African-American ethnicity;
- Previous types of cancer or treatment for cancer (radiation, chemotherapy, tamoxifen).
Even with risk factors and history taken into consideration, it is not possible to diagnose this type of cancer prior to surgery and therefore it is not possible to eradicate the risk from morcellation. If leiomyosarcoma is the diagnosis, then this is a particularly bad type of cancer that has a very poor prognosis (less than 50% of women survive to 5 years even with an early diagnosis) and it is poorly responsive to surgery or chemotherapy. Fortunately it is a rare cancer with estimates that it affects 1 in every 350 women to 1 in every 5000 women – compare this with breast cancer that affects 1 in 10 women for how commonly it occurs. This type of cancer does not grow out of a pre-existing fibroid, and it is always a cancer rather than starting as a fibroid and there is no need to remove all fibroids because of this risk.
If you have symptoms from a fibroid, then your doctor will take a history and do an examination, although it is not always possible to exclude a cancer such as a leiomyosarcoma. Risks factors that may increase the risk of a cancer include:
- A rapidly growing mass in the uterus – particularly in the post-menopausal time;
- Post-menopausal bleeding;
- Lymph nodes that can be felt or seen on a CT (computed tomography) or MRI (magnetic resonance imaging) scan.
If you have symptoms or signs of gynaecological disease that requires surgery and if there is a chance that a morcellator will be used, your doctor will discuss with you the risks associated with its use. There is no way to completely eradicate the risk, only reduce any risk. This is true for all procedures that involve surgery. Scans such as CT and MRI and some blood tests may be helpful, but again, there is no way of determining all cases of cancer prior to surgery. The alternatives to morcellation may be to make a large incision in the abdomen and this is a perfectly reasonable option. This would not prevent the diagnosis and the risk of dying from the cancer would still be very high. It is not the process that causes the cancer – if however it is there then it may increase the risk of spread.
Just how high that risk is remains unclear at this time. Studies report that there is a negligible to moderate increased risk of the cancer spreading if a morcellator is used. Ultimately it is taking a very bad diagnosis and making it a very bad diagnosis plus more on top. There is no way to change the diagnosis of the cancer and treatment would continue just the same.
What to do if you are having gynaecological surgery and morcellation may be used
There has been substantial discussion around this diagnosis and around this instrument being used and there has been high-profile media exposure of this particular type of procedure in the press. As for any procedure, making a decision to have surgery is the first step and it should be based on your symptoms and circumstances. If that procedure is to involve any type of morcellation (vaginal or power morcellation) then discuss the risks with your doctor regarding your specific concerns. Remember that there is no way to diagnose all cancers prior to surgery and no way to eradicate all risks. It is all about risk reduction. The alternatives should therefore be considered and the approach to tissue or organ removal. Work from our unit in Sydney shows that over the last 15 years of using the morcellator, we have never morcellated a cancer. This may be due to good case selection or good luck, but this risk has been known for some time and therefore making a decision based on risk is the best that we can do.
There are new techniques for morcellation that may reduce risk further. This would include using a bag to morcellate into. This will be almost impossible to prove in a scientific study and it may be that the initial process of surgery where tissue (such as fibroids) are removed is just as much of a problem compared with the morcellation. The alternative of a large hole in the abdomen is also not without risks and it has been estimated that the risk of complications associated with this procedure (such as blood clots or infections) are just as great, if not greater than any increased risk from morcellation spreading cancer.
So it is not just about the instrument, but rather about the underlying diagnosis. It is not always possible to know before a procedure what the outcome will be, or what the disease will be. All the diagnoses should be carefully considered before making a decision regarding how to proceed (or if to proceed) with surgery. Remember that there are risks with everything we do – whether it is driving in a car, switching on the toaster in the morning, riding a bike on a main road or having surgery. All we can do is be aware of the risks and try and reduce them, since we can never eradicate them.