Version May 2024
INTRODUCTION — Gynecologic surgery often employs tissue extraction techniques to remove a large specimen (uterus or leiomyomas) through a small incision. A common tissue extraction technique is morcellation (cutting a specimen into small pieces). Initially, morcellation was only performed using a scalpel at the time of vaginal procedures or laparotomy. As laparoscopic and robotic techniques were adopted, there was the advent of electromechanical morcellators that utilize rapidly rotating blades to quickly core and remove specimens through the small incisions utilized for these procedures. In 2014, concerns were raised that morcellation may disseminate tumor cells in cases in which an undiagnosed uterine malignancy was present. This prompted action by the US Food and Drug Administration (FDA), resulting in new guidelines for the use of electromechanical morcellators and a subsequent decrease in use of these devices [1-7].
Uterine morcellation techniques are reviewed here. General principles of the treatment of leiomyomas are discussed separately. (See "Uterine fibroids (leiomyomas): Treatment overview" and "Uterine fibroids (leiomyomas): Open abdominal myomectomy procedure" and "Uterine fibroids (leiomyomas): Laparoscopic myomectomy and other laparoscopic treatments".)
TERMINOLOGY
●Morcellation – Cutting tissue into small pieces. This is typically performed to remove a large tissue specimen through a small incision.
●Electromechanical morcellation – Morcellation of tissue with an electric device. This is usually used only in laparoscopic or robotic procedures.
●Scalpel morcellation – Morcellation of tissue using a scalpel; the specimen is cut into fewer and larger pieces, which are less likely to be distributed throughout the abdomen or left in the abdomen after surgery compared with electromechanical morcellation. In gynecologic surgery, this is typically done to remove a bulky uterine specimen during vaginal hysterectomy and sometimes during a myomectomy or hysterectomy through a minilaparotomy incision.
●Intraperitoneal morcellation – Tissue morcellation is performed within the peritoneal cavity.
●Extraperitoneal morcellation – A type of scalpel morcellation in which the specimen is grasped and brought to the intraperitoneal side of a minilaparotomy incision. It is then partially exteriorized (ie, the specimen is grasped on the other side and pulled through the incision so that it is extraperitoneal). The extraperitoneal part is then excised, and the process is repeated until the entire specimen has been removed. This has also been termed extracorporeal morcellation.
●In-bag containment system – Intraperitoneal bag used in laparoscopic surgery; morcellation is performed within bag.
CLINICAL APPLICATIONS — Tissue morcellation is performed in gynecologic surgery when a large tissue specimen must be removed through a small incision. This is done to facilitate less invasive surgical approaches, including vaginal or laparoscopic surgery. Morcellation is most commonly performed when the preoperative diagnosis is uterine fibroids because of the extensive uterine enlargement characteristic of this disease. The gynecologic procedures that typically use morcellation include:
●Laparoscopic hysterectomy – When total laparoscopic hysterectomy is performed, the uterus may be morcellated or removed via the vaginal incision. Depending on the size of the uterus, the specimen may be removed intact or may require scalpel morcellation. Subtotal laparoscopic hysterectomy requires morcellation, however, and since there is no vaginal incision morcellation, it typically occurs through an abdominal incision.
●Laparoscopic myomectomy – Removal of uterine leiomyomas (fibroids), with removal typically through an abdominal incision.
●Vaginal hysterectomy – If the uterine specimen is too large to remove via the vaginal incision, scalpel morcellation is performed.
Use of morcellation in other surgical specialties is discussed separately. (See "Instruments and devices used in laparoscopic surgery", section on 'Morcellators'.)
RISKS OF MORCELLATION — Use of uterine morcellation raises several concerns, including:
●Dissemination of tissue – If an unsuspected malignancy is present, morcellated uterine tissue may result in spillage and spread of cancer cells, thus leading to an advanced stage and potentially a worsened prognosis. This is of particular concern with electromechanical morcellators, since use of these devices results in multiple tissue fragments, and the rotational force of the device may distribute the fragments around the peritoneal cavity. However, scalpel morcellation or any other type of disruption of uterine tissue (supracervical hysterectomy, myomectomy) may lead to tissue spread. Dissemination of tissue can also occur with nonmalignant tissues, such as endometriosis and myomas. (See "Uterine fibroids (leiomyomas): Differentiating fibroids from uterine sarcomas", section on 'Do techniques that disrupt a mass disseminate tissue and worsen prognosis?'.)
●Disruption of the tissue specimen for pathology evaluation – Morcellated tissue is in fragments; thus, gross pathology, relationship of fragments to each other and the uterus, and margins are not clear, and pathologic evaluation may be difficult. Morcellation impacts the ability to determine specimen size and renders problematic determining depth of invasion of carcinoma (if present) and presence of circumscription (eg, in order to distinguish endometrial stromal nodule from endometrial stromal sarcoma).
●Surgical complications – Electromechanical morcellators must be used carefully to avoid injury to adjacent structures.
Tissue dissemination and worsened prognosis — The main concern regarding uterine morcellation is the dissemination of tissue in patients operated on for presumed benign leiomyomas who are found postoperatively to have uterine sarcoma or other malignancy. This is a clinical challenge since leiomyomas are very common (female lifetime prevalence of 70 to 80 percent) and are difficult to differentiate preoperatively from uterine sarcoma, which is a rare and aggressive malignancy. In addition, patients with no uterine mass who undergo surgery for benign indications may have an unsuspected uterine cancer. The concern regarding morcellation has broadened beyond dissemination of uterine sarcomas to encompass dissemination of other benign and malignant lesions from intraperitoneal morcellation (leiomyoma variants and endometrial carcinoma).
Uterine sarcoma — In studies and systematic reviews of patients undergoing hysterectomy or myomectomy for presumed benign leiomyomas, the prevalence of sarcoma is approximately 0.20 percent (1 in 500) in most studies or reviews, and estimates of the prevalence range from 0.05 (1 in 2000) to 0.28 percent (1 in 352) depending upon which studies are included or excluded [8-23]. The majority of cases are leiomyosarcoma, a highly aggressive cancer, but there are also reports of cases of endometrial stromal sarcoma, generally a more indolent cancer. Sarcoma risk increases with increasing age and is higher in postmenopausal patients. (See "Uterine fibroids (leiomyomas): Differentiating fibroids from uterine sarcomas", section on 'Prevalence of sarcoma in patients undergoing surgery for benign indications'.)
Morcellation of uterine sarcoma appears to be associated with a worsened prognosis [19,24-31]. However, there are few data, and the available studies often include both scalpel and electromechanical morcellation with hysterectomy or for myomectomy. Most studies are from referral centers, which may include patients with a worse prognosis. Representative studies include:
●A meta-analysis of four observational studies in patients with uterine sarcoma found that morcellation (scalpel or power methods) compared with no morcellation was associated with a significantly higher recurrence rate (61 versus 39 percent, odds ratio [OR] 3.16, 95% CI 1.38-7.26) and mortality rate (48 versus 29 percent, OR 2.42, 95% CI 1.19-4.92) [29]. The intra-abdominal recurrence rate was significantly higher in patients who had undergone morcellation compared with other patients, while the extra-abdominal recurrence rate showed a trend toward being higher in patients who had not undergone morcellation.
●A population-based study of a health care system included 125 hysterectomies with detection of an occult uterine sarcoma [30]. The majority of patients had stage I disease (64 percent). The risk of recurrence was significantly higher in patients who underwent any type of morcellation (power or nonpower) compared with no morcellation (34 versus 21 percent, 2.4-fold higher at one year and 62 versus 53 percent, 1.9-fold higher at three years). At one year, the risk of death was significantly higher for any type of morcellation compared with no morcellation (18 versus 5 percent, 4.8-fold) and for electromechanical morcellation compared with nonelectromechanical morcellation (25 versus 16 percent, 5.1-fold).
●A retrospective cohort study of 30 patients with uterine sarcoma diagnosed postoperatively who underwent myomectomy with morcellation (power or scalpel morcellation) were compared with patients who underwent total hysterectomy [31]. At five years, patients in the myomectomy with morcellation group had a significantly lower overall survival rate (38 versus 43 percent); no statistically significant difference was found in recurrence-free survival (24 versus 46 percent), but the trend was toward a lower rate with myomectomy and morcellation.
●A retrospective study included in the analysis of patients with uterine sarcoma confined to the uterus at presentation (19 had intraperitoneal scalpel or electromechanical morcellation; 38 had total abdominal hysterectomy) found that morcellation was associated with a significant decrease in the median time to recurrence (10.8 versus 39.6 months) [26].
●A retrospective study of patients with uterine leiomyosarcoma compared those who did or did not undergo morcellation [32]. Patients in the morcellation group (n = 15) had no statistically significant difference in five-year overall survival (76 versus 55 percent) or recurrence-free survival (64 versus 43 percent), although there was a trend toward a worse prognosis with morcellation.
●A retrospective study of patients with incidentally diagnosed sarcomas following uterine-sparing surgery followed by re-exploration (n = 15) and staging was compared with patients undergoing hysterectomy as the primary procedure (n = 30) [33]. Thirty-six percent of the patients having uterine-sparing procedures were found to have residual seromas, and none had disseminated disease. There was no difference in progression-free survival over a median of 41 months between the two modes of surgery with re-exploration.
Leiomyoma variants — In addition to uterine sarcoma, there is concern about morcellation of uterine smooth muscle tumors of uncertain malignant potential (STUMP) and disseminated growth of ordinary leiomyoma implants [34,35]. In a systematic review that included 39 studies of morcellation and leiomyoma variants, the risk of parasitic myoma was 0.9 percent and there were rare reports of cases that resembled disseminated peritoneal leiomyomatosis [36]. Several other studies of patients with STUMP who underwent morcellation and then had a subsequent surgical re-exploration have reported that most patients have smooth muscle peritoneal implants [15,37,38]. (See "Uterine fibroids (leiomyomas): Variants and smooth muscle tumors of uncertain malignant potential".)
There is also concern about benign fibroids being iatrogenically spread via uncontained electromechanical morcellation (eg, resembling disseminated peritoneal and/or retroperitoneal leiomyomatosis, parasitic myomas), which may require additional surgical intervention [39-41].
Endometrial carcinoma — Endometrial carcinoma or hyperplasia is typically diagnosed preoperatively since endometrial sampling is a simple and effective diagnostic method and should be performed in all patients preoperatively, if indicated (table 1). However, unsuspected endometrial carcinoma is occasionally diagnosed postoperatively, particularly in asymptomatic patients and in those who undergo hysterectomy for indications other than abnormal uterine bleeding (eg, pelvic organ prolapse) [42-45].
Other conditions — Other conditions may be disseminated by morcellation. These include endometriosis or adenomyosis [46]. In a systematic review that included 11 studies regarding these conditions following morcellation, there was a 1.4 percent risk of spread of endometriosis and 0.6 percent risk for adenomyosis [36].
Surgical complications — There are few data regarding the frequency of power morcellator injuries. While injuries do occur, there is no evidence that this type of device is associated with a higher than acceptable visceral or vascular injury rate. In a study of the US Food and Drug Administration (FDA) device databases between 1993 and 2013, there were 55 surgical complications involving electromechanical morcellators reported; 21 were bowel injuries and 27 were vascular [34].
Rates of complications may be higher when a containment bag is used. In a retrospective study including over 37,000 patients undergoing laparoscopic supracervical hysterectomy with power morcellation in the United States from 2010 to 2018, those performed with (6 percent) versus without a containment bag had higher rates of short-term surgical complications (4.5 versus 3.3 percent, adjusted relative risk 1.35, 95% CI 1.12-1.64) [7]. The study had several limitations, including that all complications (ie, surgical and medical) that occurred during the index hospitalization were included in this analysis. Furthermore, the preoperative indication for surgery was not known, which is critical in the decision-making for morcellation as well as containment bag use.
Power versus scalpel morcellation — Most studies that have evaluated the risks of morcellation include data from both power and scalpel morcellation.
Studies that examined scalpel morcellation alone include:
●One study included patients who underwent vaginal or laparoscopic-assisted vaginal hysterectomy (n = 1629) [47]. Morcellation was performed in 19 percent of patients. Postoperative diagnoses included two sarcomas, three STUMPs, and eight endometrial carcinomas. Among these, only one of the STUMPs was morcellated. The two patients with sarcomas had no evidence of disease at 2 and 16 months, respectively, and the STUMPs had no evidence of disease.
●A study of patients who underwent total hysterectomy for presumed benign leiomyomas who were found to have uterine sarcoma included 18 patients, most of whom had transvaginal scalpel morcellation [48]. Follow-up data at 17 to 54 months were available for 15 patients, all of whom had no evidence of disease.
Other procedures — There are no data or guidelines regarding the risk of dissemination of potentially malignant tissue with hysteroscopic morcellation. The risk of this is likely lower since the uterus is mostly contained, although tissue and fluid may extrude from the fallopian tubes. This has been raised as a potential concern when hysteroscopy is used in the evaluation of abnormal uterine bleeding. (See "Uterine fibroids (leiomyomas): Hysteroscopic myomectomy", section on 'Tissue extraction device' and "Overview of hysteroscopy", section on 'Dissemination of tumor'.)
POLICY STATEMENTS — The risk of a dissemination of malignant cells in patients with an incidental finding of malignancy associated with electromechanical morcellation of uterine tissue has been the focus of review and statements by the US Food and Drug Administration (FDA), American College of Obstetricians and Gynecologists (ACOG), American Association of Gynecologic Laparoscopists (AAGL), Society of Gynecologic Oncology (SGO), European Society for Gynaecological Endoscopy (ESGE), French College of Obstetrics and Gynecology (CNGOF), and German Society for Gynecology and Obstetrics (DGGG) [8,21,49-54]. All of these statements emphasize the importance of several key preoperative steps when morcellation is planned, including appropriate evaluation for uterine and cervical cancer, assessment for uterine sarcoma risk factors, and informed consent regarding the risk of tumor dissemination. In addition, all organizations have acknowledged the need to gather more data regarding the risks of morcellation. However, the limitations on uterine morcellation have been the subject of controversy [55-57].
Government agencies — In July 2014, the FDA convened a public meeting of the Obstetrics and Gynecology Medical Devices Advisory Committee. Based on this meeting and a review of the use of electromechanical morcellation [8], in November 2014, the FDA published an updated safety communication, which was reaffirmed in December 2020, with the following recommendations [40,58]:
●Laparoscopic electromechanical morcellators are contraindicated for removal of uterine tissue in patients who are peri- or postmenopausal or are candidates for en bloc tissue removal: for example, through the vagina or minilaparotomy incision.
●Laparoscopic electromechanical morcellators are contraindicated in gynecologic surgery in which the tissue to be morcellated is known or suspected to contain malignancy.
●Be aware of the following boxed warning recommended by the FDA: The FDA warns that uterine tissue may contain unsuspected cancer. The use of laparoscopic electromechanical morcellators during fibroid surgery may spread cancer and decrease the long-term survival of patients. This information should be shared with patients when considering surgery with the use of these devices.
●Carefully consider all the available treatment options for patients with uterine fibroids.
●Thoroughly discuss the benefits and risks of all treatments with patients. Be certain to inform the small group of patients for whom laparoscopic electromechanical morcellation may be an acceptable therapeutic option that their fibroid(s) may contain unexpected cancerous tissue and that laparoscopic electromechanical morcellation may spread the cancer, significantly worsening their prognosis. This population might include some younger patients who want to maintain their fertility or patients not yet perimenopausal who wish to keep their uterus after being informed of the risks.
The clinical impact of the FDA recommendations appears to be a decrease in laparoscopic procedures [59]. As an example, a survey found that many surgeons are not using electromechanical morcellation, often due to hospital mandate, and laparotomy rates have increased [60]. The majority of survey respondents did not think the recommendations have led to improved patient outcomes, and some thought that they had led to harm.
In December 2017, the FDA released an updated systematic review of the incidence of uterine sarcoma in patients undergoing surgery for presumed benign fibroids. There was no change in recommendations [61].
In May 2014, Health Canada issued a statement to hospital leadership regarding use of electric morcellators during laparoscopic hysterectomy and myomectomy with the following recommendations [62]:
●Recognize the prevalence of unsuspected uterine sarcoma in patients under consideration for hysterectomy or myomectomy for the treatment of uterine fibroids.
●Consider the treatment alternatives for patients with symptomatic uterine fibroids, and review these options with each prospective surgical patient. Some surgeons use closed electromechanical or scalpel morcellation in a bag as a way to reduce the risk of inadvertent spread of uterine tissue. Alternative surgical procedures, such as laparotomy, can also be used to avoid the need for morcellation.
●Be aware and inform patients that laparoscopic electric morcellation of unsuspected uterine sarcoma during hysterectomy or myomectomy may disseminate the disease and negatively impact prognosis.
Professional societies — The 2014 ACOG statement addressed both the risks and benefits of morcellation and was updated in March 2021; the following are excerpts from the revised guideline [50,63]:
●Preoperative evaluation includes risk stratification and the appropriate use of imaging, cervical cancer screening, and endometrial tissue sampling to identify malignancy, although leiomyosarcoma is not reliably identified preoperatively.
●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.
The AAGL statement regarding the FDA safety communication includes the following [51]:
●The following information needs to be clarified: a specific definition of perimenopausal patients; the role of electromechanical morcellation in the large group of reproductive-age patients who undergo myomectomy for fertility-sparing surgery; use of electromechanical morcellation in patients with nonfibroid uteri who may have refractory uterine bleeding, prolapse, or adenomyosis; guidance regarding the use of containment bags; and guidance regarding the role of nonelectromechanical morcellation (use of a manual cold knife scalpel in vaginal or minilaparotomy tissue extraction).
●Abandoning electromechanical morcellation technology for many patients undergoing minimally invasive myomectomy, supracervical hysterectomy, or hysterectomy for a large uterus will be a setback in the care of patients with gynecologic conditions. With meticulous adherence to preoperative patient selection guidelines and informed consent, the AAGL believes appropriately performed electromechanical morcellation outweighs the risk of laparotomy in low-risk patients and is an option to be carefully considered by patients and their gynecologists.
PREOPERATIVE EVALUATION — Patients planned for gynecologic surgery should undergo assessment for gynecologic cancers, including appropriate screening tests and evaluation of symptoms. This evaluation may not identify all cancers. The detection rate of endometrial carcinoma is high with office endometrial biopsy. However, uterine sarcoma is difficult to differentiate from uterine leiomyomas; thus, morcellation of a malignant tumor may occur even in low-risk patients.
Counseling of patients with presumed uterine fibroids includes discussion of the risks and benefits of all available treatment options and appropriate assessment for endometrial carcinoma and uterine sarcoma, including evaluation for current disease and risk factors. (See "Uterine fibroids (leiomyomas): Differentiating fibroids from uterine sarcomas", section on 'Clinical features' and "Uterine fibroids (leiomyomas): Differentiating fibroids from uterine sarcomas", section on 'Diagnostic methods'.)
Evaluation for uterine cancer — A medical history, risk factors for uterine cancer, and presenting symptoms should be elicited. We recommend not using electromechanical morcellation of uterine tissue for patients with significant risk factors for uterine sarcoma, including (see "Uterine fibroids (leiomyomas): Differentiating fibroids from uterine sarcomas", section on 'Risk factors'):
●Postmenopausal status
●History of ≥2 years of tamoxifen therapy
●History of pelvic irradiation
●History of childhood retinoblastoma
●Personal history of hereditary leiomyomatosis and renal cell carcinoma syndrome
In addition, electromechanical morcellation should not be performed if there are preoperative findings suspicious for uterine malignancy. These include:
●Pelvic imaging findings suspicious for uterine cancer – This is challenging because there are no reliable imaging findings that are specific for uterine sarcoma. However, magnetic resonance imaging has a high negative predictive value for excluding a sarcoma [64]. (See "Uterine fibroids (leiomyomas): Differentiating fibroids from uterine sarcomas", section on 'Imaging'.)
●Endometrial sampling findings of endometrial hyperplasia, carcinoma, or uterine sarcoma, or nondiagnostic sampling in patients at high risk of endometrial cancer.
All patients undergoing gynecologic surgery should undergo appropriate screening and evaluation preoperatively, including:
●Cervical cancer screening, as appropriate. (See "Screening for cervical cancer in resource-rich settings".)
●Pelvic imaging, as appropriate for evaluation of abnormal uterine bleeding, pelvic pain, pelvic mass, or surgical planning.
●Endometrial sampling for patients with signs, symptoms, or risk factors for endometrial carcinoma or uterine sarcoma (table 1 and table 2).
Any patient in whom uterine cancer is suspected should be referred to a surgeon with experience in gynecologic oncology procedures and treatment, as appropriate.
Most, but not all, patients are evaluated with pelvic imaging at some point prior to gynecologic surgery. Endometrial biopsy is not a sensitive test for uterine sarcoma but will detect this condition in up to 60 percent of patients. Since endometrial biopsy is a minimally invasive procedure and is already indicated in many patients with abnormal uterine bleeding to exclude endometrial neoplasia, we suggest sampling in patients in whom sarcoma is suspected or for whom the planned procedure includes intraperitoneal morcellation.
These measures will likely detect most patients with endometrial carcinoma but will miss many of those with sarcoma, since it is difficult to differentiate sarcoma from benign leiomyomas preoperatively. Differentiating uterine leiomyomas from sarcomas is discussed in detail separately. (See "Uterine fibroids (leiomyomas): Differentiating fibroids from uterine sarcomas".)
Patient selection — Electromechanical morcellation is an option only for selected premenopausal patients under the age of 50 with uterine fibroids and no significant uterine sarcoma risk factors or clinical features suspicious for other uterine malignancy. For those patients who desire uterine preservation and are candidates for laparoscopic/robotic myomectomy, we offer patients myomectomy with morcellation rather than myomectomy via laparotomy. For those who desire laparoscopic hysterectomy and in whom intact removal of the specimen through the vagina is not possible, we offer laparoscopic hysterectomy with morcellation rather than laparotomy.
An area of uncertainty regarding morcellation is how to manage perimenopausal patients; the US Food and Drug Administration (FDA) advises against electromechanical morcellation in perimenopausal and postmenopausal patients. The perimenopausal transition can occur over approximately eight years, extending from the time of regular menstrual cycles to the final menstrual period (which is not considered final until one year has passed) (figure 1). However, there is no evidence that perimenopausal patients are at an increased risk of uterine sarcoma, and in fact there are many patients in this phase who do not know they have entered perimenopause. The principal basis of the increased risk in menopausal patients is that uterine fibroids are unlikely to increase in size or become symptomatic in a hypoestrogenic state, which is not the case during the menopausal transition, during which hormone levels can fluctuate significantly. Thus, we suggest that, for the purpose of this topic, patients be considered perimenopausal if they have significant menstrual irregularity with amenorrhea >60 days, consistent with the late menopausal transition phase. (See "Clinical manifestations and diagnosis of menopause".)
In addition, the FDA advises against electromechanical morcellation in patients who are candidates for en bloc tissue removal (removal of the entire uterus and cervix without any disruption of the specimen). This mainly applies to total hysterectomy, and en bloc tissue removal is preferable whenever possible. It is often possible to do this using a less invasive approach if the uterus is small. In a vaginal hysterectomy or total laparoscopic hysterectomy, the uterus may be able to be removed intact via the vaginal incision.
However, if intact removal is not possible, then the choice is between morcellation or laparotomy. For patients who have no significant risk factors for uterine sarcoma, use of laparotomy rather than a less invasive approach solely to avoid morcellation may expose patients to higher risks of morbidity and mortality and certainly to a longer recovery period that may affect quality of life [65].
In addition, for patients who desire uterine preservation, myomectomy using any surgical approach generally involves a great deal of disruption of the specimen(s). If future childbearing is desired, hysterectomy is not an option. There are no data regarding whether laparoscopic myomectomy with electromechanical morcellation or open myomectomy results in a differential risk of tissue dissemination. (See "Uterine fibroids (leiomyomas): Differentiating fibroids from uterine sarcomas", section on 'Myomectomy'.)
Patients should be counseled about medical and surgical treatment options. In appropriately selected and counseled patients, if morcellation is an option, patient preference should be a major determining factor regarding whether this is used. Based upon appropriate counseling regarding risks and benefits of morcellation versus laparotomy, the patient can then make an informed choice regarding the surgical approach.
If a surgical option using electromechanical morcellation is elected, counseling and shared decision-making should include the risk of dissemination of malignant cells if a malignancy is incidentally detected [49,50,66-68]. In cases in which the postoperative pathology shows malignancy, the patient should be referred to a gynecologic oncologist for further evaluation and treatment as soon as possible.
MORCELLATION DEVICES AND TECHNIQUES
Power morcellation — Electromechanical morcellators use rapidly rotating blades to quickly remove cores of the specimen through small abdominal incisions. With this technology, larger specimens can be removed via laparoscopic or robotic procedures quickly. However, in response to concerns about dissemination of malignant tissue with morcellation (see 'Tissue dissemination and worsened prognosis' above), some institutions in the United States have suspended use of power morcellation in patients with uterine masses, and some surgeons have chosen to voluntarily avoid its use [69].
In an attempt to avoid tumor dissemination, electromechanical morcellation has been performed with the uterine specimen contained and morcellated in a laparoscopic bag (picture 1) [70-75]. The safety and efficacy of use of a laparoscopic bag for power morcellation require further study. Concerns include:
●Limited ability to visualize the tissue being morcellated and structures outside the bag – This may lead to injury if the bag is penetrated by the morcellator blade; such complications have been reported [34].
●Efficacy of tissue containment – It is controversial whether using a bag adequately contains tissue, including microscopic cells. In addition, if the bag is disrupted by the morcellator blade or by the insertion of ports or instruments, tissue may be disseminated.
●The use of a containment system may increase procedure duration slightly [76,77].
There are no high-quality data regarding electromechanical morcellation containment systems in gynecology. Tissue spread with use of a containment system has been evaluated using pelvic washings or dye. The largest study to evaluate this was a multicenter prospective study of 76 patients who underwent contained electromechanical morcellation for hysterectomy or myomectomy [78]. In this study, the bag had two punctures: one for the morcellator and one for the laparoscope; 5 mL of blue dye was injected into the bag. Spillage of tissue or dye was assessed by gross visualization and was found in 9.2 percent of cases although containment bags were intact. Several smaller clinical studies and an in vitro study have found no leakage of smooth muscle cells or dye [79-81]. A small study of in-bag morcellation via the vaginal incision during total laparoscopic hysterectomy, using a scalpel technique, found ruptures of the bag in 4 of 12 procedures [82].
An in-bag electromechanical morcellation device (ie, PneumoLiner) using a single port was approved by the US Food and Drug Administration (FDA) in April 2016 [83]. The FDA requires the manufacturer to warn patients and health care providers that PneumoLiner has not been proven to reduce the risk of spreading cancer during these procedures. Other devices and techniques are being developed [84-87].
Scalpel morcellation — Scalpel morcellation is the cutting of the uterine specimen into pieces, typically to remove a large uterus during a vaginal hysterectomy. It can be performed with or without a containment system (eg, Alexis Contained Extraction System). Sparse data regarding safety and efficacy are available. In a systematic review of two small trials comparing in-bag scalpel morcellation versus uncontained power morcellation in 176 premenopausal patients undergoing laparoscopic myomectomy, the in-bag group had slightly longer morcellation operative time, but total operating time was similar for both groups [88]. There were no intraoperative complications or leiomyosarcomas in either group.
The technique for vaginal hysterectomy is discussed in detail separately. (See "Hysterectomy: Vaginal", section on 'Myometrial coring for intraoperative uterine size reduction'.)
ALTERNATIVE TECHNIQUES — Alternatives to electromechanical morcellation include these en bloc resection techniques:
●Intact removal of a specimen using minimally invasive approaches that do not require electromechanical morcellation – These include removing the specimen intact via minilaparotomy or colpotomy (following vaginal hysterectomy or total laparoscopic hysterectomy) [50].
●Extracorporeal morcellation, in which a specimen is brought to a minilaparotomy incision or colpotomy and morcellated via the incision – Some experts advise use of a circumferential wound retractor to facilitate this technique [68,89-91]. This may require containing the specimen in an intracorporeal specimen bag to avoid dissemination of tissue [92,93].
●Laparotomy – This is an option but is associated with a larger incision, more postoperative pain, a longer recovery period, and potentially more complications than minimally invasive approaches [65].
In addition, for patients without risk factors for cancer, other nonsurgical alternatives for uterine fibroid treatment include:
●Medical treatments aimed at symptomatic control
●Uterine artery embolization
●Magnetic resonance-guided focused ultrasound
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Uterine fibroids (leiomyomas)".)
SUMMARY AND RECOMMENDATIONS
●Counseling of patients with presumed uterine fibroids includes discussion of all available treatment options, including the risks and benefits of different surgical approaches. Appropriate preoperative assessment for endometrial carcinoma and uterine sarcoma should be performed, including evaluation for current disease and risk factors. (See 'Preoperative evaluation' above.)
●Surgical techniques that disrupt the uterine specimen (scalpel or electromechanical morcellation, supracervical hysterectomy) should not be performed in patients with known or suspected uterine or other gynecologic cancer. We recommend not using electromechanical morcellation of uterine tissue for patients who have significant risk factors for uterine sarcoma (eg, postmenopausal status, history of ≥2 years of tamoxifen therapy, history of pelvic irradiation, history of childhood retinoblastoma, or personal history of hereditary leiomyomatosis and renal cell carcinoma syndrome) (Grade 1C). (See 'Preoperative evaluation' above.)
●For premenopausal patients with uterine fibroids and no significant uterine sarcoma risk factors, based on appropriate counseling and shared decision-making regarding risks and benefits of morcellation versus laparotomy, the patient can then make an informed choice regarding the surgical approach (see 'Preoperative evaluation' above):
•For those who desire uterine preservation and are candidates for laparoscopic myomectomy, in our practice, we offer patients myomectomy with morcellation as an alternative to myomectomy via laparotomy.
•For those who are not candidates for vaginal hysterectomy and desire laparoscopic hysterectomy and in whom intact removal of the specimen through the vagina is not possible, in our practice, we offer laparoscopic hysterectomy with morcellation.
●If a surgical option using electromechanical morcellation is elected, counseling should include the risk of dissemination of malignant cells, if a malignancy is incidentally detected. (See 'Preoperative evaluation' above.)
●Electromechanical morcellation devices that have a tissue containment system are available, but their safety, particularly in patients at high risk of uterine cancer, requires further investigation. (See 'Power morcellation' above.)
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