Hundreds of thousands of American women have hysterectomies every year. In fact, the Centers for Disease Control and Prevention say one in three women has undergone surgical removal of the uterus—and with it maybe also the cervix, ovaries, and fallopian tubes during the procedure—by age 60. A surgery called myomectomy is also often performed to remove uterine fibroids, those noncancerous growths found in the uterine lining, while leaving the uterus intact.
A new study published in the Journal of Clinical Oncology found that a surgical technique used in hysterectomies and myomectomies called uncontained power morcellation was associated with higher mortality or death risk in women who had a type of cancer called occult uterine sarcoma, or had its subtype, leiomyosarcoma.
Now that's a lot to take in, so let's break it down. A laparascopic power morcellator is a medical device used for minimally invasive surgeries to cut tissue into smaller pieces that are then extracted through a small incision site. It's frequently utilized for both hysterectomy and myomectomy. Research has shown that laparoscopic surgeries in general can result in both reduced recovery time and risk of infection compared to using an "open" incision on the abdomen, so they're a popular choice.
Uterine sarcoma is a type of malignant cancer that forms in the uterus. Leiomyosarcoma is a rare cancerous tumor made of smooth or involuntary muscle cells and it's a type of sarcoma most frequently found in the uterus or abdomen.
Concerns Are Not New
The U.S. Food and Drug Administration or FDA issued a warning in 2014 that said uterine sarcoma is more common in women having uterine fibroid surgery than previously thought, and to make things more challenging, it's difficult to distinguish between that cancer and a fibroid before surgery.
In those women, using morcellators with their quickly-spinning blade, could potentially spread cancerous tissue beyond the uterus to the abdominal cavity, "worsening their chances of long-term survival without cancer." Based upon recent research, the agency estimates a hidden uterine sarcoma could be present in approximately 1 in 225 to 1 in 580 women having fibroid surgery, and that leiomyosarcoma could be present in 1 in 495 to 1 in 1100 women having that surgery.
Because these two surgeries are so common, "it is very important to ensure patient safety during these procedures," said Xiao Xu, lead author on the new study, and associate professor of obstetrics, gynecology, and reproductive sciences at Yale, in a statement.
How the Study Was Done
Xu and her fellow researchers linked New York State hospital discharge records with cancer registry data. They identified 843 women with previously undetected occult endometrial carcinoma and 334 with occult uterine sarcoma who underwent both surgeries for "presumed benign indications" between Oct. 1, 2003 and Dec. 31, 2013.
They found that women with undetected uterine sarcoma, especially leiomyosarcoma, whose procedure was done with uncontained power morcellation, were associated with a higher risk of death. Among the women with occult endometrial carcinoma, there was no significant association between the type of surgical approach and disease-specific mortality (aka all the deaths that occur in a population from a specific illness).
With morcellation, it's not only the potential for cancer to spread that's worrisome, but those little fragments are challenging for a pathologist to stage—as in Stages of cancer 0, II and III, and IV—and to assess malignancy.
Postmenopausal women are at higher risk for uterine cancer, so Xu suggests they "avoid uncontained power morcellation if possible."
No matter the age, she stresses that careful preoperative assessment is crucial to make sure any woman undergoing hysterectomy or myomectomy doesn't have uterine cancer. The researchers also note that for younger women whose uterine cancer risk is much lower, laparoscopic hysterectomy with power morcellation may still make sense, and that laparoscopic hysterectomies can be done without power morcellation.
Complications of Hysterectomy
The American College of Obstetricians and Gynecologists (ACOG) reminds us that all hysterectomies can result in other complications including:
- Fever and infection
- Heavy bleeding during or after surgery
- Injury to the urinary tract or nearby organs
- Blood clots in the leg that can travel to the lungs
- Breathing or heart problems related to anesthesia
Some problems related to the surgery may not show up until a few days, weeks, or even years after surgery, such as formation of a blood clot in the wound or bowel blockage, says ACOG.
Complications are more common after an abdominal hysterectomy, one of the four types. In addition to abdominal and laparoscopic, the two others are vaginal hysterectomy—actually called a laparoscopic-assisted vaginal hysterectomy—and robotic hysterectomy, another version of laparoscopy.