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Obstetrics and Gynecology Clinics of... Sep 2016Hysterectomy is one of the most common gynecologic surgeries. Early adoption of surgical advancements in hysterectomies has raised concerns over safety, quality, and... (Review)
Review
Hysterectomy is one of the most common gynecologic surgeries. Early adoption of surgical advancements in hysterectomies has raised concerns over safety, quality, and costs. The risk of potential leiomyosarcoma in women undergoing minimally invasive hysterectomy led the US Food and Drug Administration to discourage the use of electronic power morcellator. Minimally invasive hysterectomies have increased substantially despite lack of data supporting its use over other forms of hysterectomy and increased costs. Health care reform is incentivizing providers to improve quality, improve safety, and decrease costs through standardized outcomes and process measures.
Topics: Female; Health Care Reform; Humans; Hysterectomy; Laparoscopy; Leiomyosarcoma; Medicare; Morcellation; Postoperative Complications; Practice Guidelines as Topic; Practice Patterns, Physicians'; United States; Uterine Neoplasms
PubMed: 27521886
DOI: 10.1016/j.ogc.2016.04.012 -
Best Practice & Research. Clinical... Aug 2016Morcellation is the fragmentation of tissue to facilitate removal of the specimen through small incision in minimally invasive surgery. This technique is not unique to... (Review)
Review
Morcellation is the fragmentation of tissue to facilitate removal of the specimen through small incision in minimally invasive surgery. This technique is not unique to gynecology and is used in general surgery with the goal of improved surgical outcomes including decreased pain, cost, hospital length of stay, and rapid return to normal activities and work. Gynecologic laparoscopic power morcellation (LPM) has come under increased scrutiny over the last 2 years due to widespread attention to a known but rare complication, an unanticipated dissemination of malignancy, namely occult uterine leiomyosarcoma. This chapter focuses on complications associated with gynecologic tissue morcellation from inoculation of benign or malignant tissue fragments within the peritoneal cavity and direct trauma from morcellation techniques. We also include a review of the various morcellation techniques from knife to electrical and the use of intraperitoneal specimen containment systems.
Topics: Contraindications; Female; Guidelines as Topic; Humans; Laparoscopy; Leiomyoma; Leiomyosarcoma; Morcellation; Neoplasm Seeding; Specimen Handling; United States; United States Food and Drug Administration; Uterine Neoplasms
PubMed: 26879674
DOI: 10.1016/j.bpobgyn.2015.12.002 -
Journal of Obstetrics and Gynaecology... Feb 2022We discuss five technical modifications made over 8 years in the technique of robotic myomectomy at our institution. Universal preoperative MRI was the first... (Review)
Review
We discuss five technical modifications made over 8 years in the technique of robotic myomectomy at our institution. Universal preoperative MRI was the first modification. Precise hysterotomy incisions were planned by accurate myoma mapping. The second modification was to reduce the number of ports. We performed surgery with one 12-mm-port for the camera and one 8-mm-port on either side of the patient for scissors and fenestrated bipolar forceps. Third modification was to reduce the number of robotic instruments by using laparoscopic myoma screw instead of robotic tenaculum during enucleation and discard the use of a second needle driver and prograsp forceps. So instead of six instruments in classical technique, we now use only three instruments thus reducing the cost of instruments by 40-50%. The fourth modification was to use a single 30 or 45 cm barbed suture. A single long suture efficiently managed by wristed needle driver of robot was sufficient in most cases for hysterotomy closure. This reduces the time needed for multiple needle pass and cost due to reduced number of sutures used. The fifth modification was to not use the electro mechanical morcellator and commercially available bags. We do cold knife morcellation in indigenous plastic bags. Over a period of eight years, we have made robotic myomectomy efficient and reduced the cost of instruments by 40-50% as compared to the classical technique. This has enabled wider adoption of robotic myomectomy at our institution thus reducing open myomectomy in all types of myomas.
PubMed: 35125746
DOI: 10.1007/s13224-021-01553-3 -
Journal of Minimally Invasive Gynecology 2016The objective of this study was to evaluate nonmalignant sequelae of unconfined morcellation at hysterectomy and myomectomy. We performed a systematic review following... (Review)
Review
The objective of this study was to evaluate nonmalignant sequelae of unconfined morcellation at hysterectomy and myomectomy. We performed a systematic review following the PRISMA statement key words of "morcellation, uterine leiomyoma, uterine fibroid, laparoscopic myomectomy, laparoscopic total hysterectomy, and laparoscopic supracervical hysterectomy" and their combination. Fifty-one articles met the inclusion criteria: 11 articles were related to endometriosis, adenomyosis, and endometrial hyperplasia; 30 articles parasitic myoma; and 9 disseminated peritoneal leiomyomatosis (DPL) and 1 DPL and endometriosis. We found that laparoscopic hysterectomy or myomectomy with unconfined morcellation is associated with the risk of iatrogenic endometriosis (1.4%), adenomyosis (0.57%), parasitic myoma (0.9%), and rarely DPL. Our study showed that benign sequelae of uterine or myoma morcellation could be found in up to 1% of cases. This is much higher than the prevalence of uterine sarcoma after morcellation. Benign conditions have less consequences than malignancy, yet they are more common and might require another operation. Accordingly, if morcellation is required, confined morcellation should be considered.
Topics: Adenomyosis; Adult; Endometriosis; Female; Humans; Hysterectomy; Laparoscopy; Leiomyoma; Morcellation; Treatment Outcome; Uterine Myomectomy; Uterine Neoplasms
PubMed: 26802909
DOI: 10.1016/j.jmig.2016.01.017 -
The Canadian Journal of Urology Aug 2021INTRODUCTION Holmium laser enucleation of the prostate (HoLEP) with mechanical tissue morcellation is one of the most effective surgical modalities for the treatment of...
UNLABELLED
INTRODUCTION Holmium laser enucleation of the prostate (HoLEP) with mechanical tissue morcellation is one of the most effective surgical modalities for the treatment of symptomatic BPH. HoLEP has many advantages over the historical gold standards open prostatectomy (OP) and transurethral resection of the prostate (TURP). HoLEP is an AUA guideline endorsed surgical treatment for lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH), independent of prostate size.
MATERIALS AND METHODS
We provide a detailed presentation of our experience in performing HoLEP in a teaching university hospital, with an emphasis on the surgical technique and its evolution.
RESULTS
HoLEP is an efficient and durable procedure, although it is very equipment sensitive and has a relatively long learning curve. HoLEP can be performed by several surgical approaches that can be used according to the specific anatomy of the patient. Advances in laser technology, endoscopic morcellators, and surgical technique has improved the HoLEP procedure in efficiency, hemostasis, and safety.
CONCLUSIONS
The HoLEP procedure, first introduced in 1998, has undergone significant changes including advancements in laser technology, endoscopic morcellation devices, and modifications to the surgical technique. These advancements have made HoLEP a more effective, more efficient, easier to perform, and easier to learn technique for the surgical management of BPH. The modified 2-lobe and the en-bloc techniques are a natural progression from the classic 3-lobe technique.
Topics: Holmium; Humans; Laser Therapy; Lasers, Solid-State; Male; Prostatic Hyperplasia; Transurethral Resection of Prostate; Treatment Outcome
PubMed: 34453423
DOI: No ID Found -
European Urology Focus Mar 2022Although several studies have compared different morcellators and enucleation techniques for the management of benign prostatic hyperplasia (BPH), there is sparse... (Review)
Review
CONTEXT
Although several studies have compared different morcellators and enucleation techniques for the management of benign prostatic hyperplasia (BPH), there is sparse literature on morcellation, so further experimental and clinical research is required for its optimization.
OBJECTIVE
To critically appraise the contemporary literature on prostate morcellation and to evaluate the safety and efficiency of currently available morcellators for endoscopic enucleation of the prostate (EEP) in the context of BPH.
EVIDENCE ACQUISITION
A comprehensive review of the English and French literature relevant to prostate morcellation was performed using the PubMed-MEDLINE, Cochrane Library, Web of Science, and Wiley Online Library database from 1998 to 2020 using PICOS (patient population, intervention, comparison, outcome, and study design) criteria.
EVIDENCE SYNTHESIS
We retrieved 26 studies involving 5652 patients treated with a morcellator that were eligible for data extraction and analysis. The mean patient age was 67.4 (range 61.4-72.8) yr. The weighted mean efficiency of Piranha, VersaCut, and DrillCut morcellators was 5.29, 3.95, and 5.3 g/min, respectively. Several approaches, such as en bloc, two-lobe, inverse, and improved techniques, may increase morcellation efficiency and safety. The lowest weighted mean rate of bladder wall injury was 1.24% for Piranha, followed by 1.98% for DrillCut, and 5.23% for VersaCut, while the VersaCut morcellator had the lowest weighted mean rate of device malfunction at 0.74%, compared to 2.07% for Piranha and 7.86% for DrillCut.
CONCLUSIONS
All three morcellators are efficient and safe for prostatic morcellation after EEP. Further development of devices and techniques may improve the efficiency and safety profile of morcellation. To increase safety, surgeon expertise, technical equipment, and patient characteristics should be considered. Therefore, interdisciplinary exchange of knowledge and further technological innovations are strongly encouraged.
PATIENT SUMMARY
We reviewed the safety and efficacy of devices called morcellators. These devices cut tissue into small pieces that are easier to remove from the body, and are used during laser surgery for benign enlargement of the prostate. Three morcellators are currently available on the market and are comparable in safety and efficacy.
Topics: Humans; Lasers, Solid-State; Male; Morcellation; Prostate; Prostatic Hyperplasia; Transurethral Resection of Prostate
PubMed: 33858810
DOI: 10.1016/j.euf.2021.03.021 -
Current Opinion in Obstetrics &... Aug 2016Safety concerns regarding morcellation of presumed benign fibroid disease have led to an increase in recent research activity on this topic, as well as advances in... (Review)
Review
PURPOSE OF REVIEW
Safety concerns regarding morcellation of presumed benign fibroid disease have led to an increase in recent research activity on this topic, as well as advances in surgical technique.
RECENT FINDINGS
The prevalence of occult leiomyosarcoma is debated; however, estimates from a robust meta-analysis suggest it may be in the range of 1 case per 1960-8300 fibroid surgeries. Advancing age is an important clinical risk factor for occult malignancy. The impact of tumor morcellation may vary by mode of tissue removal, though tissue fragmentation is consistently associated with poorer outcomes. Decision and cost analyses continue to support laparoscopic hysterectomy as a low-morbidity and cost-effective approach. The increased scrutiny on fibroid procedures in the past few years may lead to changes in surgical approach; however, alternative tissue extraction options are evolving, including incorporation of contained morcellation.
SUMMARY
Although the incidence of occult leiomyosarcoma is low, outcomes are poor and may be worsened by morcellation. By addressing risk factors for malignancy and incorporating evolving surgical techniques into practice, gynecologists can continue to offer patients a minimally invasive approach for fibroid management.
Topics: Cost-Benefit Analysis; Decision Support Techniques; Female; Humans; Hysterectomy; Laparoscopy; Leiomyoma; Leiomyosarcoma; Morcellation; Patient Selection; Risk Factors; Tissue Extracts; Uterine Neoplasms
PubMed: 27253236
DOI: 10.1097/GCO.0000000000000280 -
Future Oncology (London, England) Sep 2022Uterine fibroids are difficult to distinguish from malignant masses using standard ultrasonography; and morcellation carries the risk of disseminating occult cancer in a... (Review)
Review
Uterine fibroids are difficult to distinguish from malignant masses using standard ultrasonography; and morcellation carries the risk of disseminating occult cancer in a small but relevant group of women with an undetected uterine malignancy. In this context, we follow the progress of a woman diagnosed with uterine leiomyosarcoma after suboptimal initial surgery for an assumed fibroid. Evidence is reviewed that guided multidisciplinary tumor board decisions about optimal management approaches after local seeding and development of distant metastases, and informed treatment selection at each line of therapy. As the case study illustrates, choice of treatment for advanced soft tissue sarcomas frequently involves finding an appropriate balance between the efficacy and toxicity of available options, aiming to allow patients to maintain their normal lives.
Topics: Humans; Female; Leiomyosarcoma; Uterine Myomectomy; Uterine Neoplasms; Morcellation; Leiomyoma; Hysterectomy; Laparoscopy
PubMed: 36169665
DOI: 10.2217/fon-2022-0637 -
American Journal of Obstetrics and... Jun 2015Uterine sarcomas are rare uterine malignancies that are difficult to diagnose preoperatively. Because of cases of disseminated sarcoma after laparoscopic hysterectomy,... (Review)
Review
Uterine sarcomas are rare uterine malignancies that are difficult to diagnose preoperatively. Because of cases of disseminated sarcoma after laparoscopic hysterectomy, the role of power morcellators in gynecologic surgery has been questioned. Morcellation is an integral part of making laparoscopic surgery possible for the removal of large uterine leiomyomata, and the development of power morcellation has increased efficiency during these procedures. Minimally invasive surgery has demonstrated benefits that include improved pain control, decreased infection risk, and faster surgical recovery and return to work. In this review, we examine the risk of incidental sarcoma at the time of surgery, the quality of the data, the accuracy of clinical and radiologic predictors of uterine sarcoma, and the impact of morcellation on the prognosis of uterine sarcoma.
Topics: Female; Gynecologic Surgical Procedures; Humans; Sarcoma; Uterine Neoplasms
PubMed: 25582101
DOI: 10.1016/j.ajog.2015.01.012 -
Minerva Ginecologica Jun 2016Uterine leiomyoma is a highly prevalent benign gynecologic neoplasm that affects women of reproductive age. Surgical procedures commonly employed to treat symptomatic... (Review)
Review
Uterine leiomyoma is a highly prevalent benign gynecologic neoplasm that affects women of reproductive age. Surgical procedures commonly employed to treat symptomatic uterine fibroids include myomectomy or total or sub-total hysterectomy. These procedures, when performed using minimally invasive techniques, reduce the risks of intraoperative and postoperative morbidity and mortality; however, in order to remove bulky lesions from the abdominal cavity through laparoscopic ports, a laparoscopic power morcellator must be used, a device with rapidly spinning blades to cut the uterine tissue into fragments so that it can be removed through a small incision. Although the minimal invasive approach in gynecological surgery has been firmly established now in terms of recovery and quality of life, morcellation is associated with rare but sometimes serious adverse events. Parts of the morcellated specimen may be spread into the abdominal cavity and enable implantation of cells on the peritoneum. In case of unexpected sarcoma the dissemination may upstage disease and affect survival. Myoma cells may give rise to 'parasitic' fibroids, but also implantation of adenomyotic cells and endometriosis has been reported. Finally the morcellation device may cause inadvertent injury to internal structures, such as bowel and vessels, with its rotating circular knife. In this article it is described how to estimate the risk of sarcoma in a presumed fibroid based on epidemiologic, imaging and laboratory data. Furthermore the first literature results of the in-bag morcellation are reviewed. With this procedure the specimen is contained in an insufflated sterile bag while being morcellated, potentially preventing spillage of tissue but also making direct morcellation injuries unlikely to happen.
Topics: Female; Humans; Laparoscopy; Leiomyoma; Morcellation; Quality of Life; Sarcoma; Uterine Myomectomy; Uterine Neoplasms
PubMed: 26799759
DOI: No ID Found