Uterine Morcellation for Presumed Leiomyomas

ABSTRACT: Morcellation is a surgical technique used to reduce the size of the uterus or myomas by creating smaller pieces to allow the tissue to be removed through small incisions or with laparoscopic instruments. Open (uncontained) morcellation of the uterus and myomas has been scrutinized because of the possible spread of an unsuspected leiomyosarcoma while using a power morcellator during a hysterectomy or myomectomy for presumed symptomatic uterine leiomyomas. Before considering morcellation of the uterus, a woman should be evaluated to determine if she is at increased risk of malignancy of the uterine corpus. Morcellation of a malignancy is contraindicated and women should be evaluated preoperatively to identify malignancy. However, leiomyosarcoma cannot be reliably diagnosed preoperatively; thus, there is a risk that a woman with a presumed leiomyoma may have a malignancy that may be spread through morcellation, leading to a potentially worsened prognosis. Although an abdominal hysterectomy or myomectomy may reduce the chance of spreading cancer cells in women with undiagnosed leiomyosarcoma, it is associated with increased morbidity when compared with minimally invasive approaches. The obstetrician-gynecologist and patient should engage in shared decision making, including informed consent, explaining the risks and benefits of each approach to surgery for presumed leiomyomas, the risks and benefits of morcellation, and alternatives to morcellation.