The Officers and Council of the British Society for Gynaecological Endoscopy (BSGE) have decided to issue this additional statement in light of ongoing debate on power morcellation during laparoscopic myomectomy and hysterectomy procedures. As some of our members are aware, the Food and Drug Administration (FDA) in the USA issued an additional statement on 24 November 2014 advising against power morcellation, particularly in peri- and postmenopausal women. The BSGE has been working with the European Society for Gynaecological Endoscopy (ESGE) Morcellation Taskforce to prepare a report which will be released soon. Meanwhile we would like to remind our members of the keypoints on our position on this issue.
- A recent Cochrane review comparing laparoscopic with open myomectomy demonstrated less pain and less fever with a laparoscopic approach. There was no difference in the recurrence of fibroids.
- The risk of leiomyosarcoma (LMS) in a presumed fibroid is low.
- Evidence for this risk is conflicting in the literature.
- The overall risk of 1 in 350 quoted by the FDA is probably an overstatement.
- The overall risk of an inadvertent LMS is probably less than 1 in 500, and this figure could be as low as 1:7400.
- The risk of an inadvertent LMS is dependent on a woman’s age.
- Inadvertent LMS in women under 40 is less than 1 in 1000.
- The risk of inadvertent LMS in women having a myomectomy is lower than in those having a hysterectomy probably because this represents a younger group of women who want to preserve their fertility.
- There is no single investigation that can warn of potential LMS.
- LMS is a poor prognostic tumour in any event.
- Non-enbloc dissection of uterine fibroids by myomectomy or with any form of morcellation probably carries a worse prognosis in the event of an inadvertent LMS being present.
- Currently, there is no clear evidence that high powered morcellation carries a worse prognosis than any other form of non-enbloc dissection, but as there is such a paucity of evidence, absolute guidance on best practice is not possible.
- Seeding of benign fibroids and the development of parasitic fibroids following high powered morcellation is recognised.
- The significance of morcellation in the presence of a smooth muscle tumours of unknown malignant potential (STUMP) or atypical myoma (AM) is unknown.
- A risk also exists for the presence of an inadvertent LMS in a presumed fibroid when other conservative approaches are undertaken such as observation, uterine artery embolization and MRI guided focused ultrasound.
- The evidence supporting in-bag morcellation is scant with some advocating its use to reduce the risk of possible tumorous spread and others against it due to perceived increased risks of visceral and vascular damage.
As a result of the perceived best evidence available, the BSGE recommends;
- There is a place for power morcellation in the management of women with uterine fibroids.
- Best evidence supports the use of a laparoscopic approach to myomectomy. However, the surgical approach in myomectomy should be decided on an individual basis and will depend on a patient’s surgical & medical co-morbidity as well as the site, size, number and location of the fibroids, and the experience of the surgeon.
- Women undergoing surgery for fibroids should be informed of the evidence listed above.
- Surgeons who use power morcellators should be trained in its use.
- Surgeons who perform laparoscopic myomectomy and hysterectomy should have received formal training in these procedures.
- All surgeons who use power morcellators should participate in surgical audit and the clinical governance structures in place in the institutions they work in.
- Informed consent is a process not an event and the evidence above should be explained prior to surgery.
- Morcellation (of any type) should not be performed if a uterine malignancy is suspected or diagnosed.