This year’s John and Marney Mathers Lecture will consider the risks and rewards of power morcellation.
“Morcellation Debate,” coming on the heels of last year’s FDA safety communication about the procedure, takes place at 3:15 pm today in Hall D and features Keith B. Isaacson, director of minimally invasive gynecologic surgery and infertility and Newtown-Wellesley Hospital in Boston, and Javier F. Magrina, MD, professor of obstetrics-gynecology at the Mayo Clinic in Arizona. They will debate power morcellation’s benefits, concerns, sequelae, prevention of complications and the use of alternate techniques.
The communication, first released in April 2014 and updated in November, warned against using laparoscopic power morcellators in most patients undergoing hysterectomy or myomectomy for uterine fibroids because of a risk of spreading unsuspected cancerous tissue, notably uterine sarcomas, outside the uterus. Contraindications include suspicion of cancer, menopause and small uterus.
The risk of sarcoma in a fibroid exists, and morcellation of that fibroid may spread and upstage the disease, Dr. Isaacson said, but the treatment decision should rest with the patient and her health-care provider.
“We just don’t have enough additional information to say that this is considered bad medicine because there are many advantages to a smaller incision, depending upon the patient’s preferences and her lifestyle and priorities, she may elect to do that,” said Dr. Isaacson, who was on the FDA panel that looked into power morcellation but didn’t work on the final document.
The FDA document lists several contraindications. But for many younger or perimenopausal women, the procedure has great benefits that must be considered.
The FDA and physician statements from ACOG, the AAGL and other organizations that have examined existing data still provide an opportunity for the informed patient to make the final call.
“I don’t care what number you pick. Let’s say the risk of cancer is 1 in 10 instead of 1 in 8,000,” he said. “I still think the patient should be involved in the decision-making process after a discussion of the benefits vs. the risks.”
Dr. Magrina opposes any morcellation that takes place outside an endobag. He will argue that morcellation safety will improve with use of endobags to contain the morcellated material.
“Stopping only power morcellation doesn’t stop the problems that happen with morcellation by other means, such as using a regular cold knife if what you’re morcellating is exposed to the intraperitoneal cavity,” he said.
Dr. Magrina said that the FDA missed an opportunity in its safety communication by not addressing the use of endobags. More companies are working with contained morcellation concepts that will improve patient safety.
“I’m actually con and pro depending on how you do it — contained or uncontained,” he said. “The point that I’m making has never been discussed at the FDA level.”
While concerns about spreading and upstaging cancer have grabbed most of the attention, Dr. Magrina said that more people develop benign conditions such as endometriosis and peritoneal leiomyomatosis that spread into the peritoneal cavity during morcellation done without an endobag.
“The problem is not only with cancer,” he said. “And it makes no difference whether the morcellation is by knife or power morcellator.”