title: Options on fibroid morcellation: a literature review.
abstract: In laparoscopy, specimens have to be removed from the abdominal cavity. If the trocar opening or the vaginal outlet is insufficient to pass the specimen, the specimen needs to be reduced. The power morcellator is an instrument with a fast rotating cylindrical knife which aims to divide the tissue into smaller pieces or fragments. The Food and Drug Administration (FDA) issued a press release in April 2014 that discouraged the use of these power morcellators. This article has the objective to review the literature related to complications by power morcellation of uterine fibroids in laparoscopy and offer recommendations to laparoscopic surgeons in gynaecology. This project was initiated by the executive board of the European Society of Gynaecological Endoscopy. A steering committee on fibroid morcellation was installed and experienced ESGE members requested to chair an action group to address distinct clinical questions. Clinical questions were formulated with regards to the sarcoma risk in presumed uterine fibroids, diagnosis of sarcoma, complications of morcellation and future research. A literature review on the different subjects was conducted, systematic if appropriate and feasible. It was concluded that the true prevalence of uterine sarcoma in presumed fibroids is not known given the wide range of prevalences (0.45-0.014 %) from meta-analyses mainly based on retrospective trials. Age and certain imaging characteristics such as 'lacunes' suggesting necrosis and increased central vascularisation of the tumour are associated with a higher risk of uterine sarcoma, although the risks remain low. There is not enough evidence to estimate this risk in individual patients. Complications of morcellation are rare. Reported are direct morcellation injuries to vessels and bowel, the development of so-called parasitic fibroids requiring reintervention and the spread of sarcoma cells in the abdominal cavity, which may possibly or even likely upstaging the disease. Momentarily in-bag morcellation is investigated as it may possibly prevent morcellation complications. Because of lack of evidence, this literature review cannot give strong recommendations but offers only options which are condensed in a flow chart. Prospective data collection may clarify the issue on sarcoma risk in presumed fibroids and technology to extract tissue laparoscopically from the abdominal cavity should be perfected.
authors.affiliation: Department of Gynaecology, VU University Medical Centre, de Boelelaan 1117, 1181HV Amsterdam, The Netherlands.
authors.forename: Hans
authors.initials: H
authors.lastname: Brölmann
authors.affiliation: Department of Obstetrics and Gynaecology, Aretaeio Hospital, St George's Medical School, Nicosia University, Nicosia, Cyprus.
authors.forename: Vasilios
authors.initials: V
authors.lastname: Tanos
authors.affiliation: Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Thessaloniki, Greece.
authors.forename: Grigoris
authors.initials: G
authors.lastname: Grimbizis
authors.affiliation: Department of Gynaecological Oncology, Royal Marsden Hospital, London, UK.
authors.forename: Thomas
authors.initials: T
authors.lastname: Ind
authors.affiliation: Spire Hull and East Riding Hospital, London, UK.
authors.forename: Kevin
authors.initials: K
authors.lastname: Philips
authors.affiliation: Catholic University Leuven, Leuven, Belgium.
authors.forename: Thierry
authors.initials: T
authors.lastname: van den Bosch
authors.affiliation: Donauisar Klinikum Deggendorf-Dingolfing-Landau, Deggendorf, Germany.
authors.forename: Samir
authors.initials: S
authors.lastname: Sawalhe
authors.affiliation: Leiden University Medical Centre, Leiden, The Netherlands.
authors.forename: Lukas
authors.initials: L
authors.lastname: van den Haak
authors.affiliation: Leiden University Medical Centre, Leiden, The Netherlands.
authors.forename: Frank-Willem
authors.initials: FW
authors.lastname: Jansen
authors.affiliation: Elisabeth-twee steden Hospital, Tilburg, The Netherlands.
authors.forename: Johanna
authors.initials: J
authors.lastname: Pijnenborg
authors.affiliation: Department for Women's Health, University Hospital Tuebingen, Eberhard Karls University, Tübingen, Germany.
authors.forename: Florin-Andrei
authors.initials: FA
authors.lastname: Taran
authors.affiliation: Department for Women's Health, University Hospital Tuebingen, Eberhard Karls University, Tübingen, Germany.
authors.forename: Sara
authors.initials: S
authors.lastname: Brucker
authors.affiliation: IRCAD, Strassburg, France.
authors.forename: Arnaud
authors.initials: A
authors.lastname: Wattiez
authors.affiliation: Leuven Institute for Fertility and Embryology (LIFE), Leuven, Belgium.
authors.forename: Rudi
authors.initials: R
authors.lastname: Campo
authors.affiliation: M.E.R.I.T. Centre, Bradford Royal Infirmary, Bristol, UK.
authors.forename: Peter
authors.initials: P
authors.lastname: O'Donovan
authors.affiliation: Pius Hospital, Oldenburg, Germany.
authors.forename: Rudy Leon
authors.initials: RL
authors.lastname: de Wilde
keywords: Complication; Endometrial stromal sarcoma; Laparoscopy; Leiomyoma uteri; Leiomyosarcoma; Morcellation; Power morcellation