title: Impact of morcellation on survival outcomes of patients with unexpected uterine leiomyosarcoma: a systematic review and meta-analysis.
abstract: OBJECTIVE
  To review the current evidence on the effects of intra-abdominal morcellation on survival outcomes of patients affected by unexpected uterine leiomyosarcoma (ULMS) and to estimate the risk of recurrence in those patients.
  
  
  METHODS
  PubMed (MEDLINE), Scopus, Embase, Web of Science databases as well as ClinicalTrials.gov, were searched for data evaluating the effects of intra-abdominal morcellation on survival outcomes of patients with undiagnosed ULMS. Studies were evaluated per the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) and the American College of Obstetricians and Gynecologists (ACOG) guidelines.
  
  
  RESULTS
  Sixty manuscripts were screened, 11 (18%) were selected and four (7%) were included. Overall, 202 patients were included: 75 (37%) patients had morcellation of ULMS, while 127 (63%) patients had not. A meta-analysis of these studies showed that morcellation increased the overall (62% vs. 39%; OR: 3.16 (95% CI: 1.38, 7.26)) and intra-abdominal (39% vs. 9%; OR: 4.11 (95% CI: 1.92, 8.81)) recurrence rates as well as death rate (48% vs. 29%; OR: 2.42 (95% CI: 1.19, 4.92)). No between-group difference in cumulative extra-abdominal recurrence (OR: 0.34 (95% CI: 0.07, 1.59)) rate was observed.
  
  
  CONCLUSIONS
  Our data support a significant correlation between uterine morcellation and an increased risk of intra-abdominal recurrence in patients affected by unexpected ULMS. However, the limited data on this issue and the absence of high level of evidence suggest the need of further studies designed to estimate the risk to benefit ratio of morcellation in patients with uterine fibroids and undiagnosed ULMS.
authors.affiliation: Programme in Oncology and Experimental Medicine, University of Insubria, Varese, Italy.
authors.forename: Giorgio
authors.initials: G
authors.lastname: Bogani
authors.affiliation: Gynecologic Surgery Unit, Mayo Clinic, Rochester, MN, USA.
authors.forename: William A
authors.initials: WA
authors.lastname: Cliby
authors.affiliation: Department of Gynecologic Oncology, IEO, Milan, Italy. Electronic address: giovanni.aletti@ieo.it.
authors.forename: Giovanni D
authors.initials: GD
authors.lastname: Aletti
mesh_terms: D005260:Female; D006801:Humans; D007890:Leiomyosarcoma / Q000473:pathology* / Q000601:surgery*; D019060:Minimally Invasive Surgical Procedures / Q000009:adverse effects / Q000379:methods; D009364:Neoplasm Recurrence, Local / Q000473:pathology*; D009366:Neoplasm Seeding; D015996:Survival Rate; D016896:Treatment Outcome; D014594:Uterine Neoplasms / Q000473:pathology* / Q000601:surgery*
keywords: Leiomyosarcoma; Morcellation; Power morcellator; Recurrence; Uterine sarcoma