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European Journal of Obstetrics,... Jan 2022With this publication, the International Society for Gynecologic Endoscopy (ISGE) aims to provide the clinicians with the recommendations arising from the best evidence... (Review)
Review
OBJECTIVE
With this publication, the International Society for Gynecologic Endoscopy (ISGE) aims to provide the clinicians with the recommendations arising from the best evidence currently available on hysteroscopic myomectomy (HM).
STUDY DESIGN
The ISGE Task Force for HM defined key clinical questions, which led the search of Medline/PubMed and the Cochrane Database. We selected and analyzed relevant English-language articles, published from January 2005 to June 2021, including original works, reviews and the guidelines previously published by the European Society for Gynecological Endoscopy (ESGE) and the American Association of Gynecologic Laparoscopists (AAGL), in which bibliographies were also checked in order to identify additional references, using the medical subject heading (MeSH) term "Uterine Myomectomy" (MeSH Unique ID: D063186) in combination with ''Myoma" (MeSH Unique ID: D009214) and ''Hysteroscopy" (MeSH Unique ID: D015907). We developed the recommendations through multiple cycles of literature analysis and expert discussion.
RESULTS
The ISGE Task Force did develop 10 grade 1A-C and 4 grade 2A-C recommendations. For planning HM, evaluation of the uterus with saline infusion sonohysterography (SIS) or combined assessment by transvaginal ultrasound (TVUS) and diagnostic hysteroscopy is recommended (Grade 1A). The use of STEPW (Size, Topography, Extension of the base, Penetration and lateral Wall position) classification system of submucosal leiomyoma (LM) is recommended to predict the complex surgeries, incomplete removal of the LM, long operative time, fluid overload and other major complications (grade 1B). For type 0 LMs, in addition to resectoscopy (slicing technique), morcellation is recommended, being faster and having a shorter learning curve with respect to resectoscopy (grade 1C). For type 1-2 LMs, slicing technique is currently recommended (grade 1C). A fluid deficit of 1000 mL also in case of bipolar myomectomy with saline solution, in healthy women of reproductive age, contains low risk for major complications. Lower thresholds (750 mL) for fluid deficit should be considered in the elderly and in women with cardiovascular, renal or other co-morbidities (Grade 1B).
CONCLUSION
HM is the most effective conservative minimally invasive gynecologic intervention for submucous LM. The set of 14 ISGE recommendations can significantly contribute to the success of HM and the safety of patients for whom the choice of appropriate surgical technique, as well as the surgeon's awareness and measures to prevent complications are of the utmost importance.
Topics: Aged; Endoscopy; Female; Humans; Hysteroscopy; Leiomyoma; Morcellation; Pregnancy; Uterine Myomectomy; Uterine Neoplasms
PubMed: 34902749
DOI: 10.1016/j.ejogrb.2021.11.434 -
Current Opinion in Obstetrics &... Feb 2018Controversy exists surrounding extraction of tissue in gynecologic surgery using morcellators following cases of disseminated uterine cancers discovered after the use of... (Review)
Review
PURPOSE OF REVIEW
Controversy exists surrounding extraction of tissue in gynecologic surgery using morcellators following cases of disseminated uterine cancers discovered after the use of electromechanical morcellators. This chapter traces the history of tissue extraction in gynecology and reviews the evolving scientific data and opinions regarding the future of morcellation.
RECENT FINDINGS
Since the initial Food and Drug Administration warning about morcellation in 2014, subsequent studies do not support the Food and Drug Administration's high incidence of occult uterine cancer. Current research continues, focusing on methods of contained tissue morcellation, both laparoscopically and vaginally.
SUMMARY
Minimally invasive surgical techniques have revolutionized gynecology, drastically reducing the need for open procedures. To maximize patient safety while preserving the rapid recovery and low morbidity of laparoscopic and vaginal approaches, optimal methods of tissue extraction need to be developed and promulgated.
Topics: Contraindications, Procedure; Delayed Diagnosis; Female; Genital Diseases, Female; History, 19th Century; History, 20th Century; History, 21st Century; Humans; Hysterectomy; Laparoscopy; Morcellation; Patient Safety; Risk Assessment; United States; United States Food and Drug Administration; Uterine Neoplasms
PubMed: 29232258
DOI: 10.1097/GCO.0000000000000425 -
JSLS : Journal of the Society of... 2015Transvaginal uterine morcellation has been described in the literature for more than a century. Despite an extensive body of literature documenting its safety and...
BACKGROUND AND OBJECTIVES
Transvaginal uterine morcellation has been described in the literature for more than a century. Despite an extensive body of literature documenting its safety and feasibility, concerns about morcellating occult malignant entities have raised questions regarding this technique. In this study, we looked at a single teaching institution's experience with transvaginal morcellation for leiomyomatous uteri. In addition, we reviewed the published literature for outcomes associated with transvaginal morcellation techniques.
METHODS
This study was a retrospective case series. Charts of women who underwent total laparoscopic hysterectomy, robot-assisted laparoscopic hysterectomy, and laparoscopic-assisted vaginal hysterectomy for leiomyoma from July 1, 2011, through December 31, 2013, were reviewed. Cases were included if transvaginal morcellation was performed. Morcellation was performed by bringing the uterus into the vagina and by performing a wedge resection technique to reduce the volume of the specimen. Baseline demographics and intra- and postoperative outcomes were abstracted from the charts. A PubMed search from January 1, 1970 to October 31, 2014 was performed to review the literature regarding transvaginal morcellation.
RESULTS
Sixty-four women who underwent laparoscopy for leiomyomatous uteri with transvaginal morcellation were identified from July 1, 2011 through December 31, 2013. Mean operative time was 210 minutes (SD 75.5; range, 93-420). The mean blood loss was 153 mL (SD 165; range, 25-1000). The mean uterine size was 608 g (SD 367; range, 106-1834). There were no surgical complications directly attributed to morcellation. The literature search yielded 22 articles describing outcomes after transvaginal morcellation, with a total of 1953 morcellated specimens.
CONCLUSIONS
Transvaginal uterine morcellation appears to be a safe alternative to laparotomy for the removal of large uterine specimens in select patients.
Topics: Adult; Aged; Blood Loss, Surgical; Female; Humans; Leiomyoma; Middle Aged; Morcellation; Operative Time; Organ Size; Retrospective Studies; Uterine Neoplasms; Uterus
PubMed: 26005318
DOI: 10.4293/JSLS.2014.00255 -
Current Opinion in Obstetrics &... Feb 2018Since the recent black-box warning regarding the use of electromechanical morcellation, there has been a hesitancy to utilize the product and even to perform other types... (Review)
Review
PURPOSE OF REVIEW
Since the recent black-box warning regarding the use of electromechanical morcellation, there has been a hesitancy to utilize the product and even to perform other types of morcellation by gynecologists. Unfortunately, this Food and Drug Administration action and the continued public criticisms of this procedure are grounded in poor data and faulty reasoning. To truly perform informed consent to patients considering procedures involving morcellation, a thorough review of the facts, not alternative facts, must be communicated.
RECENT FINDINGS
Misrepresentation of the ethics surrounding this procedure, the role of informed consent and the risks and benefits as determined by evidence-based medicine have led to confusion and poor public policy. Today's evidence suggests that the procedure is indeed ethical when full disclosure of the risks and benefits is presented via informed consent. Risks of the procedure have been exaggerated significantly, and little attention has been paid to the risks of denying morcellation procedures to patients. Attempts to condemn gynecologists as acting contrary to established surgical principles do not coincide with facts.
SUMMARY
Morcellation is a controversial technique which undoubtedly has a role as well as limitations. To appropriately determine if the procedure is indicated and acceptable to the patient, full disclosure of the best available evidence is necessary.
Topics: Contraindications, Procedure; Delayed Diagnosis; Evidence-Based Medicine; Female; Fraud; Humans; Informed Consent; Leiomyoma; Leiomyosarcoma; Morcellation; Patient Acceptance of Health Care; Patient Safety; Practice Guidelines as Topic; Risk Assessment; Truth Disclosure; Tumor Burden; United States; United States Food and Drug Administration; Uterine Neoplasms; Uterus
PubMed: 29227303
DOI: 10.1097/GCO.0000000000000436 -
Minimally Invasive Therapy & Allied... Oct 2022The laparoscopic approach for the treatment of uterine leiomyoma is increasingly practiced. The necessity to remove large specimens from the small laparoscopic incision... (Review)
Review
The laparoscopic approach for the treatment of uterine leiomyoma is increasingly practiced. The necessity to remove large specimens from the small laparoscopic incision has always been one of the main limits of this procedure. The unrestricted use of morcellation, to overtake this weak point of minimally invasive surgery, has opened in recent years a broad debate, especially on the risk of unintended dissemination of cells that could in some cases lead to extremely negative repercussions. This review analyzes these aspects and the principal recommendations from the major gynecological society on this topic surveying their effects. Furthermore, the purpose of this article is to provide an overview of the different morcellation techniques and how they are performed, evaluating their advantages and disadvantages. Contained morcellation seems to overcome many limits; however, based on recent data, an appropriate evaluation and selection of patients, as well as complete counseling before the surgery, are mandatory.
Topics: Female; Humans; Hysterectomy; Laparoscopy; Leiomyoma; Morcellation; Sarcoma; Uterine Myomectomy; Uterine Neoplasms
PubMed: 35815667
DOI: 10.1080/13645706.2022.2095872 -
Current Oncology Reports Jun 2020This paper aims to review recent findings related to uterine morcellation. (Review)
Review
PURPOSE OF REVIEW
This paper aims to review recent findings related to uterine morcellation.
RECENT FINDINGS
In 2014, the US Food and Drug Administration (FDA) issued a safety communication warning against the use of laparoscopic power morcellators. A risk of occult uterine sarcoma in women is 1/770 to 1/10,000. Our goal is to minimize the risk of spillage due to morcellation and balance it with other risks due to different surgical approaches. In case of a presence of sarcoma risk factors, any form of morcellation should be contraindicated. Power morcellation should be limited to myomectomies. In peri- and postmenopausal age, an endometrial biopsy is highly recommended before surgery with expected morcellation. It is important to explain to the patient the risks of morcellation and the risks and benefits of different surgical approaches. Finally, women should be informed that the prognosis of leiomyosarcoma is poor regardless of the method of removal.
Topics: Female; Humans; Laparoscopy; Morcellation; Sarcoma; Uterine Myomectomy; Uterine Neoplasms; Uterus
PubMed: 32514869
DOI: 10.1007/s11912-020-00927-6 -
Current Opinion in Obstetrics &... Feb 2018This review was written in an effort to describe the evolution of power morcellation equipment from their creation to their current state. In addition, this review... (Review)
Review
PURPOSE OF REVIEW
This review was written in an effort to describe the evolution of power morcellation equipment from their creation to their current state. In addition, this review addresses the continuously evolving equipment involved with power morcellation and looks to describe where the field is headed in the future. In addition, recent professional and federal recommendations have changed the way power morcellation is being approached and has led to the development of contained morcellation systems, which, although in their infancy, are also being proven to be well tolerated options.
RECENT FINDINGS
This article will review the most current research on electronic power morcellation and the multiple attempts to prove superiority from the many different types of equipment, and also the many different approaches to morcellation. In addition, with the adaptation to contained morcellation, this review will cover research focused on optimizing a containment system and the techniques involved.
SUMMARY
In summary, this review is aimed at describing many of the currently available power morcellation products and contained morcellation systems in an effort to allow physicians to understand the different options available, and to discuss well tolerated, effective, and clinically proven techniques that can lead to improved surgical outcomes in the future.
Topics: Contraindications, Procedure; Delayed Diagnosis; Equipment Design; Female; Genital Diseases, Female; Genital Neoplasms, Female; History, 20th Century; History, 21st Century; Humans; Intraoperative Complications; Laparoscopy; Morcellation; Patient Safety; United States; United States Food and Drug Administration
PubMed: 29194076
DOI: 10.1097/GCO.0000000000000435 -
Current Opinion in Obstetrics &... Feb 2018As the Food and Drug Administration raised concern over the power morcellator in 2014, the field has seen significant change, with patients and physicians questioning... (Review)
Review
PURPOSE OF REVIEW
As the Food and Drug Administration raised concern over the power morcellator in 2014, the field has seen significant change, with patients and physicians questioning which procedure is safest and most cost-effective. The economic impact of these decisions is poorly understood.
RECENT FINDINGS
Multiple new technologies have been developed to allow surgeons to continue to afford patients the many benefits of minimally invasive surgery while minimizing the risks of power morcellation. At the same time, researchers have focused on the true benefits of the power morcellator from a safety and cost perspective, and consistently found that with careful patient selection, by preventing laparotomies, it can be a cost-effective tool.
SUMMARY
Changes since 2014 have resulted in new techniques and technologies to allow these minimally invasive procedures to continue to be offered in a safe manner. With this rapid change, physicians are altering their practice and patients are attempting to educate themselves to decide what is best for them. This evolution has allowed us to refocus on the cost implications of new developments, allowing stakeholders the opportunity to maximize patient safety and surgical outcomes while minimizing cost.
Topics: Attitude of Health Personnel; Attitude to Health; Contraindications, Procedure; Cost-Benefit Analysis; Delayed Diagnosis; Female; Genital Diseases, Female; Genital Neoplasms, Female; Health Care Costs; Humans; Hysterectomy; Intraoperative Complications; Laparoscopy; Morcellation; Operative Time; Patient Safety; United States; United States Food and Drug Administration; Uterine Myomectomy
PubMed: 29232257
DOI: 10.1097/GCO.0000000000000422 -
Journal of Minimally Invasive Gynecology Jan 2018
Topics: Female; Humans; Hysterectomy, Vaginal; Incidence; Morcellation; Uterine Neoplasms
PubMed: 28780177
DOI: 10.1016/j.jmig.2017.07.023 -
Journal of Minimally Invasive Gynecology Jan 2018
Topics: Female; Humans; Hysterectomy, Vaginal; Incidence; Morcellation; Uterine Neoplasms
PubMed: 28838803
DOI: 10.1016/j.jmig.2017.08.649