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To Morcellate or Not To Morcelatte

May 19, 2014

Since all that have weighed in have indicated directly or by lack of comment, that fibroid morcellation by any method seems safe and we know it is effective and prudent to benefit patient outcomes. These observations come with 100 years of experience without any special maneuvers at surgery. In my mind even in open cases we incise the uterus, may or may not be in the exact plane of the mass, and the tumor comes in contact with hands, instruments and other tissues. Therefore, The real question at hand is what is the risk of sarcoma in the myomectomy or hysterectomy for fibroid patient and does the benefit of minimal invasive surgery outweigh the risk in the rare patient with an undiagnosed tumor. We disagree with the assessment of risk by the FDA.

As a reproductive endocrinologists, our population may have a slightly younger age distribution than the broad experience of all gynecology (see below). We have pulled nearly 20 years worth of data and have NO sarcomas reported by path and only three cellular myomas in three different patients in whom we have no evidence of sarcomatous transformation. This group contains a significant number of degenerating myomas noted on preoperative ultrasound with no changes in technique.

One question also to ponder is whether pathology even looks at every fibroid in an open case, sometimes with 30+ fibroids? We know now with morcellation that each piece is not evaluated, when at times their might be hundreds of individual pieces of fibroid.

Mocellation and Morcellate

If we assume a rough average of 6 fibroids per case would be well over 6000 fibroids sampled.

That would represent an incidence of less than 1:1000 for sure. An incidence of 1:10,000 or less is reported by our area gynecologists. This approaches, within a factor of 2-3X the risk of death from general anesthesia. A risk we all deem acceptable.

We would encourage all high volume practitioners of myomectomy to publish their data and to establish at a minimum and age range for concern. Our data only includes 24 cases over age 50.

It is our opinion, that young patients with no other risk factors can safely undergo myomectomy with morcellation by any carefully performed method without fear of cancer or compromise in their care or outcome.

We plan to publish data and are in contact with our area pathologists to gather more numbers to effectively calculate an accurate risk. We would encourage SRS and other societies to wait for these studies to emerge and utilize the new evidence to come up with rational guidelines in contrast to the rapid response recommendations we are seeing now.

Michael Fox, MD
Reproductive Endocrine
Jacksonville, Florida

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