Uterine Pathology in Women Undergoing Minimally Invasive Hysterectomy Using Morcellation

Morcellation has been used for more than 20 years during minimally invasive surgery to fragment tissue into smaller pieces for easier removal. There has been controversy about the potential for morcellation to spread unsuspected uterine cancer during minimally invasive gynecologic surgery. Accurate estimates of the prevalence of undetected uterine cancer in women at the time of morcellation during hysterectomy are lacking. This research letter discusses the results of a study that investigated the prevalence of underlying uterine malignancy and other pathological abnormalities in women who underwent morcellation during hysterectomy. Between 2006 and 2012, all cases of minimally invasive hysterectomies performed with morcellation were identified using the Perspective database, a large registry that contains claims information for approximately 15% of US hospitalizations. Cases of uterine corpus cancer were identified according to the International Classification of Diseases, Ninth Revision, coding at surgery. The study also assessed the prevalence of uterine neoplasms of uncertain malignant potential, malignancies of other parts of the uterus, other gynecologic cancer, and endometrial hyperplasia. Among the cohort of 232,882 women who underwent minimally invasive hysterectomy during the study period, morcellation was performed in 36,470 (15.7%). A total of 99 cases of uterine cancer were found in the morcellation cohort; this represents a prevalence of 27/10,000 (95% confidence interval, 22–32 per 10,000). Twenty-six cases of other gynecologic malignancies were identified (prevalence: 7/10,000), 39 cases of uterine neoplasms of uncertain malignant potential (11/10,000), and 368 cases of endometrial hyperplasia (101/10,000). Advanced age was associated with underlying cancer in the morcellation cohort: Compared with women younger than 40 years, the prevalence ratio for a uterine malignancy increased from 5.0 in women aged 50 to 54 years, to 19.4 in those aged 55 to 59 years, to 21.4 in those aged 60 to 64 years, and to 36.0 for women 65 years or older. These data show that the prevalence of unsuspected uterine cancers is higher in women undergoing minimally invasive hysterectomy with morcellation than in the general population. Long-term follow-up data are needed for women with underlying uterine cancer at the time of morcellation. Surgeons should counsel patients considering morcellation about the risk of spreading undetected cancer and precancerous abnormalities.