Minimal Invasive Myomectomy with Morcellation for Giant Myoma: A Challenge or a Questionable Approach?

Abstract

This study aimed to discuss the possible role of morcellation for a giant myoma in the minimal invasive approach. Current literature, including U.S. Food and Drug Administration guidelines, was reviewed. We found that safety of morcellation for a giant myoma is questionable. The risk and benefits of morcellation as well as alternative treatment options should be discussed with each individual patient.

With great deal of interest we read the article entitled: “The Largest Uterine Leiomyoma Removed by Robotic-Assisted Laparoscopy in the Late Reproductive Age: A Case Report” by Jeong et al. [1].

The authors present their technically demanding myomectomy in a perimenopausal patient with a 28 cm subserosal fibroid by using excellent new technology including da Vinci Xi™, RUMI® uterine manipulator, Tropian Single port RUS-300® , Stratafix™ barbed suture and an electric morcellator (Morce Power Plus™).

We agree that there is a decreasing trend towards hysterectomy and in favor of myomectomy in patients with fibroids but with what criteria of patient's age, need for fertility preservation, size of fibroid and risk of malignancy [2]. We disagree that a myomectomy via minimal invasive approach could become best practice for a 50-year-old perimenopausal patient. The standard of care we consider to be total abdominal hysterectomy with bilateral salpingo-oophorectomy (although bilateral oophorectomy in a 50-year-old woman who has not yet menopause might be questioned) [3] as there are technically difficulties regarding safe cleavage, removal and repair of myometrial defect and furthermore the benefits of open approach overcome the risks of minimal invasive approach especially if we exclude cosmesis and enhanced recovery.

As already mentioned in the article since 2014, U.S. Food and Drug Administration (FDA) issued the warning against power morcellation of fibroids due to the risk of tumor dissemination in the scenario of unsuspected leiomyosarcoma. More specifically, laparoscopic morcellators are contraindicated for removal of uterine tissue containing suspected fibroids in patients who are post-menopausal or over 50 years of age, or candidates for en bloc tissue removal through the vagina or via a mini-laparotomy incision. The risk of occult cancer, including uterine sarcoma, increases with age, particularly in women over 50 years of age. After reviewing additional studies, FDA highlighted in 2017 that 1 in 225 to 1 in 580 women who undergo hysterectomy or myomectomy may have uterine sarcoma [4].

Some of the main concerns include delayed diagnosis because of misinterpretation of the initial pathologic specimen, seeding of sarcoma cells throughout the abdominal cavity and upstaging secondary to peritoneal spread [5]. At this case scenario, reoperation for completion staging is considered essential and around 15% could be upstaged because of findings of disseminated peritoneal sarcomatosis [6]. The prognosis of patients with peritoneal sarcomatosis even after systemic chemotherapy is generally poor with a reported median survival of 6–15 months and the recurrence rate even after complete resection can be high reaching 40%–60% [7].

Power morcellation within an endoscopic bag could be suggested; however, there is still a risk of contamination during the myomectomy itself. More specifically, FDA recommended that minimal invasive power morcellation for myomectomy or hysterectomy can be performed only with a tissue containment system only in appropriately selected patients.

The authors have used several factors to preoperatively exclude malignancy including patient's body mass index, neutrophil to lymphocyte ratio, presumed subserosal myoma that was separated from the endometrium on magnetic resonance imaging, tumor markers (e.g., CA 125 or lactate dehydrogenase [LDH]). However, at the moment there is no method that can definitively differentiate sarcomas preoperatively in patients who are going to be operated with a preliminary diagnosis of uterine fibroid [8].

This was a successfully performed challenging operation that could be considered as the exception of the rule and could be performed by experienced surgeons in robotic approach and after informed consent of the patient regarding the possible treatment alternatives, benefits and possible risk of contamination especially when fertility preservation is not considered of high importance as in a case of a perimenopausal patient [9].

Once again, we would like to thank the authors for their well-presented case report.