FDA Information on Power Morcellators

In gynecologic surgery, power morcellation is sometimes used during hysterectomy and myomectomy (fibroid tumor removal) to facilitate the removal of the uterus, fibroids (leiomyomas) and/or fallopian tubes and ovaries. It is a well-established as a minimally invasive surgical technique that reduces risk of intraoperative and postoperative morbidity and mortality. Without power morcellation, some patients may be ineligible for minimally invasive surgery and would be only eligible for an abdominal incision which carries higher risks of infection, bleeding, hernia formation and other morbidities. Mortality occurs at 3x the rate in open gynecologic surgery as with minimally invasive techniques. Power morcellation continues to be an option for some patients when performing hysterectomy or myomectomy. At the same time, it is critical to minimize the risks for patients undergoing these surgeries who may have occult gynecologic cancer.

Power morcellators use rapidly rotating blades or electrical energy within a tube, through which tissue is extracted. During morcellation, small fragments of tissue may be inadvertently disseminated

Power morcellation has come under recent scrutiny because of concern about the risk of intraperitoneal dissemination of malignant tissue, particularly uterine sarcoma. Various sources cite estimates of occult sarcomas from 2:1,000 to 1:350 cases. The overall incidence of uterine sarcomas is 0.64 per 100,000 women. With morcellation and dissemination, the 5 year survival rate is 15%; even without morcellation, a diagnosis of uterine sarcoma has a poor 5 year survival rate of 40%.

As with all procedures, a thorough patient evaluation is crucial and may include appropriate measures to diagnose a malignancy before surgery. Tests may include cervical cytology, endometrial sampling, and pelvic imaging. Other preoperative considerations may include age >35 years, menopausal status, uterine size, rapid uterine growth, or certain treatments or hereditary conditions. Although preoperative evaluation may improve detection of cancer, it has limitations and does not eliminate the possibility of an occult cancer, particularly sarcomas, if sarcoma is suspected or there is a known malignancy, power morcellation should not be used. Even screening for cervical or endometrial cancers may not be 100% detectable with morcellation.

Alternative treatment options to power morcellation may include manual extra peritoneal tissue morcellation which has been safely practiced for decades during both vaginal and open or mini-laparotomy cases and no definitive studies have shown dissemination of malignant tissue intraperitoneally. Although bags are in development to reduce dissemination risk during power morcellation, they have their limitations.

All inpatient surgical procedures are performed at St. Luke’s Hospital or St. Vincent Medical Center unless your insurance requires you go elsewhere.  A surgical consent must be signed in the office prior to having your procedure scheduled.

 

You may stay in hospital for 1 night or longer.  Or, you may go home the same day.  The length of stay depends on the nature of your surgery.  You will have an intravenous line to provide fluids, and a urinary catheter to drain your bladder.  Drains may be present to help drain fluid from your incision.  Medication to relieve pain and nausea will be available throughout your hospital stay.  

 

After surgery, give yourself a chance to adjust and recover.  Some women feel fine within a month.  Many need a little extra time.  Morcellation can have both physical and emotional effects that may be brief or long term.  After morcellation, periods will stop with hysterectomy and reduce with myomectomy.  A depressive emotional reaction to loss of the uterus, and remorse about permanent sterility is not uncommon or abnormal.  Please discuss any concerns with your health care provider if persistent.  Sexual response may change after hysterectomy.  If pain and bleeding have been a problem, you may feel better and have more energy as your body heals.  Once you have fully recovered, you can focus on enjoying your life.

Laparoscopic Uterine Power Morcellation in Hysterectomy and Myomectomy: FDA Safety Communication

Date Issued: April 17, 2014

Audience:

  • Health Care Providers
  • Medical Professional Associations
  • Cancer Advocacy Organizations
  • Health Care Facilities/Hospitals
  • Women with Symptomatic Uterine Fibroids who are Considering Surgical Options
  • Manufacturers of Devices used for Minimally Invasive Surgeries

Medical Specialties: Pathology, Internal Medicine, Nursing, Obstetrics/Gynecology, Oncology

Product:
Laparoscopic power morcellators are medical devices used during different types of laparoscopic (minimally invasive) surgeries. These can include certain procedures to treat uterine fibroids, such as removing the uterus (hysterectomy) or removing the uterine fibroids (myomectomy). Morcellation refers to the division of tissue into smaller pieces or fragments and is often used during laparoscopic surgeries to facilitate the removal of tissue through small incision sites.

Purpose:
When used for hysterectomy or myomectomy in women with uterine fibroids, laparoscopic power morcellation poses a risk of spreading unsuspected cancerous tissue, notably uterine sarcomas, beyond the uterus. Health care providers and patients should carefully consider available alternative treatment options for symptomatic uterine fibroids. Based on currently available information, the FDA discourages the use of laparoscopic power morcellation during hysterectomy or myomectomy for uterine fibroids.

Summary of Problem and Scope:
Uterine fibroids are noncancerous growths that develop from the muscular tissue of the uterus. Most women will develop uterine fibroids (also called leiomyomas) at some point in their lives, although most cause no symptoms1. In some cases, however, fibroids can cause symptoms, including heavy or prolonged menstrual bleeding, pelvic pressure or pain, and/or frequent urination, requiring medical or surgical therapy.

Many women choose to undergo laparoscopic hysterectomy or myomectomy because these procedures are associated with benefits such as a shorter post-operative recovery time and a reduced risk of infection compared to abdominal hysterectomy and myomectomy2. Many of these laparoscopic procedures are performed using a power morcellator.

A number of additional treatment options are available for women with symptomatic uterine fibroids including traditional surgical hysterectomy (performed either vaginally or abdominally) and myomectomy, laparoscopic hysterectomy and myomectomy without morcellation, laparotomy using a smaller incision (minilaparotomy), deliberate blocking of the uterine artery (catheter-based uterine artery embolization), high-intensity focused ultrasound, and drug therapy. Evidence demonstrates that, when feasible, vaginal hysterectomy is associated with comparable or better results and fewer complications than laparoscopic or abdominal hysterectomy3.

 Importantly, based on an FDA analysis of currently available data, it is estimated that 1 in 350 women undergoing hysterectomy or myomectomy for the treatment of fibroids is found to have an unsuspected uterine sarcoma, a type of uterine cancer that includes leiomyosarcoma. If laparoscopic power morcellation is performed in women with unsuspected uterine sarcoma, there is a risk that the procedure will spread the cancerous tissue within the abdomen and pelvis, significantly worsening the patient’s likelihood of long-term survival. For this reason, and because there is no reliable method for predicting whether a woman with fibroids may have a uterine sarcoma, the FDA discourages the use of laparoscopic power morcellation during hysterectomy or myomectomy for uterine fibroids.

Recommendations for Health Care Providers:

  • Be aware that based on currently available information, the FDA discourages the use of laparoscopic power morcellation during hysterectomy or myomectomy for the treatment of women with uterine fibroids.
  • Do not use laparoscopic uterine power morcellation in women with suspected or known uterine cancer.
  • Carefully consider all the available treatment options for women with symptomatic uterine fibroids.
  • Thoroughly discuss the benefits and risks of all treatments with patients.
  • For individual patients for whom, after a careful benefit-risk evaluation, laparoscopic power morcellation is considered the best therapeutic option: 
  •  Inform patients that their fibroid(s) may contain unexpected cancerous tissue and that laparoscopic power morcellation may spread the cancer, significantly worsening their prognosis.
  • Be aware that some clinicians and medical institutions now advocate using a specimen “bag” during morcellation in an attempt to contain the uterine tissue and minimize the risk of spread in the abdomen and pelvis.

Recommendations for Women:

  • Ask your health care provider to discuss all the options available to treat your condition and discuss the risks and benefits of each.
  • If laparoscopic hysterectomy or myomectomy is recommended, ask your health care provider if power morcellation will be performed during your procedure, and to explain why he or she believes it is the best treatment option for you.
  • If you have already undergone a hysterectomy or myomectomy for fibroids, tissue removed during the procedure is typically tested for the presence of cancer. If you were informed these tests were normal and you have no symptoms, routine follow-up with your physician is recommended. Patients with persistent or recurrent symptoms or questions should consult their health care provider.

FDA Actions:
The FDA is concerned about women undergoing laparoscopic power morcellation for the treatment of uterine fibroids and the risk of inadvertent spread of unsuspected cancer to the abdominal and pelvic cavities. In an effort to enhance understanding of the problem and provide information on the appropriate use of laparoscopic power morcellators, the FDA:

  • Instructed manufacturers of power morcellators used during laparoscopic hysterectomy and myomectomy to review their current product labeling for accurate risk information for patients and providers;

 Will convene a public meeting of the Obstetrics and Gynecological Medical 

Device Advisory Committee to discuss: 1) the clinical role of laparoscopic power morcellation in the treatment of uterine fibroids, 2) whether surgical techniques and/or use of accessories, such as morcellation/specimen bags, can enhance the safe and effective use of these devices, and 3) whether a “boxed warning” related to the risk of cancer spread should be required for laparoscopic power morcellators;

  • Will continue to review adverse event reports, peer-reviewed scientific literature, and information from patients, health care providers, gynecologic and surgical professional societies, and medical device manufacturers.

Reporting Problems to the FDA:
Prompt reporting of adverse events can help the FDA identify and better understand the risks associated with medical devices. If you suspect that a morcellator and/or specimen bag has malfunctioned or contributed to a serious injury or adverse outcome, the FDA encourages you to file a voluntary report through MedWatch, the FDA Safety Information and Adverse Event Reporting program.

Health care professionals employed by facilities that are subject to the FDA’s user facility reporting requirements should follow the reporting procedures established by their facilities.

Other Resources:

References:
1 NIH Fact Sheet on Uterine Fibroids. March 2013. Available at http://report.nih.gov/nihfactsheets/viewfactsheet.aspx?csid=50
2 Nieboer TE, Johnson N, Lethaby A, et al. Surgical approach to hysterectomy for benign gynecological disease. Cochrane Database Syst Rev. 2009;(3):CD003677.
3 Ibid.