Vaginal Morcellation Inside Protective Pouch: A Safe Strategy for Uterine Extration in Cases of Bulky Endometrial Cancers: Operative and Oncological Safety of the Method.
OBJECTIVE
To evaluate the operative and oncologic outcomes of an innovative technique for organ morcellation in patients scheduled for laparoscopic treatment of uterine malignancies.


BACKGROUND
Endoscopy is currently considered the standard of care for the operative treatment of endometrial cancer; however, the use of minimal invasive surgery (MIS) is restricted in patients with a bulky uterus or narrow vagina. Conventional unprotected intraperitoneal uterine fragmentation is indeed contraindicated in these cases. Consequently, oncologically safe methods to render these patients eligible for MIS are urgently needed.


METHODS
Prospective study of women with histologically proven endometrial cancer in which uterus removal was a realistic concern owing to both organ size and proportionality. The patients underwent laparoscopic staging, including retroperitoneal lymphadenectomy, total hysterectomy, and bilateral salpingo-oophorectomy, followed by vaginal morcellation of the uterus inside a protective pouch (LapSac).


RESULTS
In our series of 30 cases, we achieved successful completion in all patients, without conversion to laparotomy. No surgery-related casualty or intraoperative morbidity was observed. The mean organ size was 246 g (range, 148-420 g), and the average additional operative time related to vaginal morcellation was 16 minutes (range, 9-28 minutes). Proper histopathological staging according to 2009 FIGO staging guidelines could be performed in all specimens. Two patients (6%) presented with significant postoperative complications, 1 each with vesicovaginal fistula and vaginal vault dehiscence. Fourteen patients (46%) needed adjuvant therapy. After a median follow-up of 20 months (range, 6-38 months), the 12-month and 24-month overall survival was 100% and 73.4% (95% confidence interval, 51%-96%), respectively. Four patients with positive lymph nodes died of distant metastasis. No case of pelvic or local relapse was observed.


CONCLUSIONS
Vaginal morcellation following oncologic principles is a feasible method that permits rapid uterine extraction and potentially avoids unnecessary laparotomies. This series suggests that the technique may be oncologically safe and also can be used in cases of uterine pathology of uncertain malignancy.
Department of Gynecology, Instituto do Câncer do Estado de São Paulo-ICESP Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil; Department of Advanced Gynecologic Surgery and Oncology, Asklepios Hospital, Hamburg, Germany. Electronic address: gdifavero@hotmail.com.
Giovanni
G
Favero
Department of Gynecology, Instituto do Câncer do Estado de São Paulo-ICESP Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
Giovanni
G
Miglino
Department of Advanced Gynecologic Surgery and Oncology, Asklepios Hospital, Hamburg, Germany.
Christhardt
C
Köhler
Department of Gynecology, Instituto do Câncer do Estado de São Paulo-ICESP Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil; Department of Advanced Gynecologic Surgery and Oncology, Asklepios Hospital, Hamburg, Germany.
Tatiana
T
Pfiffer
Department of Gynecology, Instituto do Câncer do Estado de São Paulo-ICESP Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
Alexandre
A
Silva e Silva
Department of Gynecology, Instituto do Câncer do Estado de São Paulo-ICESP Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
Altamiro
A
Ribeiro
Department of Advanced Gynecologic Surgery and Oncology, Asklepios Hospital, Hamburg, Germany.
Xin
X
Le
Department of Gynecology, Instituto do Câncer do Estado de São Paulo-ICESP Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
Cristina
C
Anton
Department of Gynecology, Instituto do Câncer do Estado de São Paulo-ICESP Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
Edmund Chada
EC
Baracat
Department of Gynecology, Instituto do Câncer do Estado de São Paulo-ICESP Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
Jesus Paula
JP
Carvalho
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016889:Endometrial Neoplasms / Q000473:pathology / Q000601:surgery*; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D007044:Hysterectomy / Q000379:methods*; D010535:Laparoscopy / Q000379:methods; D008197:Lymph Node Excision / Q000379:methods; D008875:Middle Aged; D000069577:Morcellation / Q000379:methods*; D009364:Neoplasm Recurrence, Local / Q000601:surgery; D061214:Patient Safety; D011446:Prospective Studies; D014594:Uterine Neoplasms / Q000473:pathology / Q000601:surgery*; D014621:Vagina
Endoscopy; Protective pouch; Uterine cancer; Vaginal morcellation