A new study that modeled outcomes for treatment of fibroids with laparoscopic plus morcellation versus an abdominal procedure indicates that risks of an open procedure outweigh those associated with potentially morcellating a leiomyosarcoma. The findings, for a hypothetical cohort of 100,000 premenopausal women with a 5-year time horizon, could help better inform decision-making about morcellation.
Published in the American Journal of Obstetrics & Gynecology, the decision-tree analysis predicted fewer overall deaths with laparoscopic hysterectomy than with an abdominal procedure (98 vs 103 per 100,000). Risk of leiomyosarcoma-related deaths was higher with laparoscopy (86 vs 71 per 100,000) but risk of hysterectomy-related death was higher with an abdominal procedure (32 vs 12 per 100,000). The authors chose the study design because of the challenge inherent in doing a prospective study in this area but noted that data are lacking on the incidence of occult leiomyosarcoma associated with uterine procedures for “benign” fibroids and on how morcellation impacts those masses.
For the study, researchers from the University of North Carolina School of Medicine focused on a cohort of 100,000 because an estimated 200,000 hysterectomies are performed annually in the United States. Existing published data—largely from high-quality studies and more recent publications—were analyzed and morbidity and mortality outcomes were evaluated extending out 5 years. In arriving at the conclusion about risks, the model took into account the reality that women can experience multiple adverse events simultaneously.
Transfusion, abdominal wound infection, vaginal cuff dehiscence, venous thromboembolism (VTE), incisional hernia, leiomyosarcoma and death from leiomyosarcoma or hysterectomy were the surgical outcomes assessed. For laparoscopic surgery, rates of transfusion, VTE, and incisional hernia were lower for laparoscopic surgery than for abdominal hysterectomy (2400 vs 4700, 1500 vs 6300, and 710 vs 8800, respectively, all per 100,000), whereas rates of vaginal cuff dehiscence were higher (640 vs 290 per 100,000).
Estimates of death from leiomyosarcoma were based on data from Surveillance, Epidemiology and End Results reports and incidence of leiomysarcoma in women undergoing hysterectomy for presumed fibroids was based on data from 10 studies.
“On average,” the authors stated, “women who undergo laparoscopic hysterectomy experience an additional 0.85 quality-adjusted life years over 5 years (1.02 months), compared with women who undergo abdominal hysterectomy.” In concluding, they acknowledged a need for further researcher on morcellation, calling for “new diagnostics to preoperatively distinguish benign from malignant myomata” and “enhanced methods of tissue extraction.”