Prevalence of occult malignancy within morcellated specimens removed during laparoscopic sacrocolpopexy
Vaneesha Vallabh-Patel DO, Cristina Saiz MD, Charbel Salamon MD, MS, Amanda Francis DO, Jennifer Pagnillo, RN, BSN, Patrick Culligan MD,
Division of Urogynecology and Pelvic Reconstructive Surgery, Atlantic Health System, Morristown, NJ
The objective of our study was to determine the prevalence of occult malignancy found in morcellated specimens removed in the context of pelvic organ prolapse repair operations.
Retrospective study including all women who underwent a supracervical hysterectomy with laparoscopic power morcellation as part of a robotic-assisted laparoscopic supracervical hysterectomy & sacrocolpopexy at our institution from October 2006 through to July 2015.
Study subjects were identified from case logs maintained by each attending surgeon, and also by query of Atlantic Health System billing system. The hospital records of all potential study subjects were reviewed to verify their eligibility for inclusion.
For patients diagnosed with an occult malignancy in their morcellated specimen, all subsequent treatments were recorded. In addition, each of these patients were interviewed by their attending surgeons to verify their survival as well as to identify any continued surveillance protocols they may be following.
Between October 2006 and July 2015, 786 women underwent robotic-assisted laparoscopic supracervical hysterectomy and sacrocolpopexy plus power morcellation through our division . Demographic and operative pathology data are illustrated in Tables 1 and 2 respectively.
Among these 786 cases, 4 occult malignancies were identified including 3 endometrial adenocarcinomas of the uterus and 1 papillary serous carcinoma of the uterus. All 3 adenocarcinoma cases were FIGO grade 1 stage 1. The overall rate of occult malignancy within morcellated specimens was 0.5% (4/786). None of these patients had undergone a pre-operative screening endometrial biopsy, because they did not have any identifiable risk factors for occult malignancy.
By way of subsequent cancer treatments and/or operations, the patient with papillary serous carcinoma underwent laparoscopic BSO, trachelectomy and partial removal of mesh, as well as chemotherapy (Carbotaxol), and has remained cancer free for 2.5 years since her diagnosis.
Of the 3 patients identified with endometrial adenocarcinoma, one had a subsequent prophylactic laparoscopic BSO without incident, another had a subsequent trachelectomy with pelvic washings and appendectomy and the third was followed with only pelvic exams and endocervical curettage. All 3 of these patients have remained cancer-free for greater than 5 years.
The perceived benefits of cervical preservation during laparoscopic hysterectomy / sacrocolpopexy cases include decreased rates of significant blood loss, mesh exposure and lower urinary tract injury. When supracervical hysterectomy is chosen for these reasons, the next decision has to do with removal of the specimen. One may either use a laparoscopic power morcellator through one of the trocar sites or enlarge one of the incisions and remove the specimen by hand. The obvious benefits of morcellation have to do with decreased incision size and therefore decreased morbidity. The obvious risks of power morcellation have to do with potential upstaging of occult malignancy.1
Only one other published series focused exclusively on prolapse patients who received supracervical hysterectomy, morcellation and sacrocolpopexy. In that study, Hill et al reported an occult malignancy rate of 3.2% among just 63 cases.1 Although their inclusion criteria were very similar to ours, we feel that our higher number of study patients lends credibility to our findings.
We believe it is reasonable to offer patients power morcellation when performing laparoscopic supracervical hysterectomy and sacrocolpopexy as long as patients are screened with endometrial biopsy and pelvic ultrasound.
1. Siedhoff MT, Wheeler SB, Rutstein SE et al. Laparoscopic hysterectomy with power morcellation vs abdominal hysterectomy for presumed fibroid tumors in premenopausal women: a decision analysis. Am J Obstet Gynecol 2015;212:591.e1-8
2. Hill, JA, Carroll AW, Matthews CA. Unanticpated uterine pathology findings after morcellation during robotic assisted supracervical hysterectomy and cervicosacropexy for uterine prolaplse. FPMRS 20(2): 113-15, Mar/Apr 2014