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"UPDATE ON MINIMALLY INVASIVE GYNECOLOGY" AMY GARCIA, MD (APRIL 2014)
Mucocele in cesarean scar can cause pain, bladder urgency, dyspareunia
Like Dr. Garcia, I too, have seen many cesarean-scar defects; most were diagnosed prior to surgery by my in-house technicians during vaginal ultrasonography.
I would like to add that, in addition to these defects, some patients who have undergone cesarean delivery also may form a mucocele in the scar that causes pain, bladder urgency, and dyspareunia. These defects also can be seen by ultrasonography, but in some cases may erroneously be labeled “nabothian cysts” by a radiologist. Most mucoceles probably are caused by incorporation of endocervical glands within a very low transverse uterine incision. Discovery and removal of these mucoceles during hysterectomy result in a very satisfied patient whose pain and urinary symptoms are resolved.
David G. Bryan, MD
Monroe, Louisiana
Oxytocin protocol decreased postpartum hemorrhage rates
We commend Dr. Barbieri for his April 2014 editorial, “Following cesarean delivery, what is the optimal oxytocin infusion duration to prevent postpartum bleeding?” because he addresses a critical gap in the evidence regarding oxytocin administration postpartum. Standardized protocols for such administration are lacking at many facilities.
Our multidisciplinary team developed a standardized postpartum oxytocin administration protocol to prevent postpartum hemorrhage (PPH) based on limited evidence from trials in which 10 units to 80 or more units of oxytocin were given (from <1 to 12 hours) postpartum.1–5 Our protocol is a “middle of the road’’ approach in which a total of oxytocin 60 U is administered intravenously postdelivery, including a bolus of oxytocin 15 U in 250 mL of lactated Ringers solution (LR) at delivery followed by an additional oxytocin 15 U in 250 mL LR over the next hour, then oxytocin 30 U in 500 mL LR at a rate of 125 mL/hr for the following 4 hours. Thus, the total time for oxytocin administration postdelivery is 5 hours, within Dr. Barbieri’s recommendation of 4 to 8 hours
We have since performed a retrospective quality improvement assessment comparing PPH rates at 6-months preprotocol (n = 1267) with rates at 6-months postprotocol (n = 1440) implementation. PPH was defined as PPH treatment by pharmaceutical, mechanical, or surgical methods. Inclusion criteria included all deliveries at greater than 23 weeks’ gestation from April 2012 to March 2013. Patient characteristics for both cohorts were similar for race, age, parity, gestational age, delivery type, and neonatal weight.
The PPH rate decreased 37% after protocol implementation (adjusted relative risk [ARR], 0.63; 95% confidence interval [CI], 0.46–0.91). Administration of misoprostol, carboprost, methylergonovine maleate, and blood products decreased postprotocol implementation by 36%, 38%, 32%, and 22%, respectively. The PPH rate for women with a vaginal delivery decreased significantly after protocol implementation (5.9% preprotocol vs 3.8% postprotocol; P = .03). The PPH rate for women undergoing cesarean delivery increased, but not significantly, after protocol implementation (6.9% preprotocol vs 8.6% postprotocol; P = .34).
We did not control for some PPH risk factors, including abnormal insertion of placenta, preeclampsia, and multiple gestation. Despite this limitation, our PPH rate for women undergoing cesarean delivery is lower than other published rates.6,7 These findings are the preliminary step in a larger, more comprehensive 4-year study.
Our team is encouraged by these results and believes our protocol warrants further study. Thank you for your attention to this topic. We hope our experience can offer support for future practice change and research.
Enas Ramih, MD, MPH; Jennifer Doyle, MSN, WHNP; Tiffany Kenny, MSN;
Michele McCarroll, PhD; Vivian von Gruenigen, MD
Summa Health System Akron City Hospital
Women’s Health Services
Akron, Ohio
References
1. Tita AT, Szychowski JM, Rouse DJ, et al. Higher-dose oxytocin and hemorrhage after vaginal delivery: a randomized controlled trial. Obstet Gynecol. 2012;119(2 pt 1):293–300.
2. Munn MB, Owen J, Vincent R, Wakefield M, Chestnut DH, Hauth JC. Comparison of two oxytocin regimens to prevent uterine atony at cesarean delivery: a randomized controlled trial. Obstet Gynecol. 2001;98(3):386–390.
3. Murphy DJ, MacGregor H, Munishankar B, McLeod G. A randomised controlled trial of oxytocin 5IU and placebo infusion versus oxytocin 5IU and 30IU infusion for the control of blood loss at elective caesarean section: pilot study. ISRCTN 40302163. Eur J Obstet Gynecol Reprod Biol. 2009;142(1):30–33.
4. King KJ, Douglas MJ, Waldmar U, Wong A, King RAR. Five-unit bolus oxytocin at cesarean delivery in women at risk of atony: a randomized, double-blind, controlled trial. Anesth Analg. 2010;111(6):1460–1466.
5. Gungorduk K, Asicioglu O, Celikkol O, Olgac Y, Ark C. Use of additional oxytocin to reduce blood loss at elective caesarean section: a randomized control trial. Aust N Z J Obstet Gynaecol. 2010;50(1):36–39.
6. Dagraca J, Malladi V, Nunes K, Scavone B. Outcomes after institution of a new oxytocin infusion protocol during the third stage of labor and immediate postpartum period. Int J Obstet Anesth. 2013;22(3):194–199.
7. Sheehan SR, Montgomery AA, Carey M, et al. Oxytocin bolus versus oxytocin bolus and infusion for control of blood loss at elective caesarean section: double blind, placebo controlled, randomised trial. BMJ. 2011;343:d4661. doi:10.1136/bmj.d4661.
Dr. Barbieri responds
I deeply appreciate the very important clinical observation provided by the Summa Health System team. Implementation of a standardized 5-hour protocol of oxytocin administration following delivery resulted in a reduction in the rate of diagnosis of PPH following vaginal delivery, but not cesarean delivery, and a reduction in the use of adjuvant misoprostol, caboprost, and methylergonovine maleate. The quality improvement intervention initiated by the Summa Health System team and their ability to assess before and after outcomes demonstrates how high-quality clinical networks can develop and disseminate best practices, thereby improving the health of all the pregnant women in our care. Thank you for sharing this important clinical observation with our readers.
“FDA, HOSPITALS CAUTION AGAINST LAPAROSCOPIC POWER MORCELLATION DURING HYSTERECTOMY AND MYOMECTOMY”
JANELLE YATES (MAY 2014)
The right to choose the appropriate tools and techniques should remain in the capable hands of qualified surgeons!
I'm sorry to say it, but your piece on morcellators is slanted. Many of us believe the FDA is wrong. The incidence of occult sarcoma came from nowhere. In properly selected, evaluated, and surgically managed cases, the use of an open power morcellator is an excellent option and the risks of a bad outcome are extremely small (especially the risk of worsening an occult leiomyosarcoma). Incidentally, we face the same risk of finding and possibly worsening an occult cancer in every gynecologic surgery we do.
Possible spillage, contamination, or outright tumor rupture is possible no matter what route or incision size. Minimally invasive surgeons understand the risk−benefit ratio very well. We use our judgment and patient informed consent in every case and should not be unnecessarily obstructed by government agencies. The right to choose the appropriate tools and techniques should remain in the capable hands of qualified surgeons!
The controversy here is reminiscent of the issues brought up about breast implants in the 70s, IUDs in the 80s, estrogen in 2004, vaginal mesh in 2012, and robotics and hysterectomy approach recently. Show me some real data that are convincing against the use of morcellators, or support the physician’s choice in how to care for our patients.
Michael Swor, MD
Sarasota, Florida
Ms. Yates responds
I appreciate Dr. Swor’s response to the article on actions by the FDA and various hospitals to limit the use of power morcellation during hysterectomy and myomectomy. That article was not endorsing those actions, nor was it condemning them—it was simply a report of the latest events in a sea change taking place in minimally invasive gynecologic surgery.
Since the article was published, new data have become available on the likelihood of occult uterine malignancy among women who undergo minimally invasive hysterectomy with electric power morcellation. Wright and colleagues found a rate of uterine cancer of 27 cases per 10,000 women at the time of the procedure.1 That figure translates into one case of undetected uterine cancer in every 368 women undergoing hysterectomy.1
In a two-part series on tissue extraction at the time of hysterectomy and myomectomy, Dr. Jason Wright, the author of the study just mentioned, and other expert panelists discuss this issue in more depth.2,3 They also note, as does Dr. Swor, that spillage, contamination, or outright tumor rupture is possible regardless of the route of hysterectomy.
References
1. Wright JD, Tergas AI, Burke WM, et al. Uterine pathology in women undergoing minimally invasive hysterectomy using morcellation [published online ahead of print July 22, 2014]. JAMA. doi: 10.1001/jama.2014.9005.
2. Advincula AP, Bradley LD, Iglesia C, Kho K, Wright JD. Tissue extraction during minimally invasive Gyn surgery: Best practices for an environment in flux. OBG Manage. 2014;26(9):44–51.
3. Advincula AP, Bradley LD, Iglesia C, Kho K, Wright JD. Tissue extraction during minimally invasive Gyn surgery: Counseling the patient. OBG Manage. 2014;26(10):41–45.
Share your thoughts on this or other articles! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
"UPDATE ON MINIMALLY INVASIVE GYNECOLOGY" AMY GARCIA, MD (APRIL 2014)
Mucocele in cesarean scar can cause pain, bladder urgency, dyspareunia
Like Dr. Garcia, I too, have seen many cesarean-scar defects; most were diagnosed prior to surgery by my in-house technicians during vaginal ultrasonography.
I would like to add that, in addition to these defects, some patients who have undergone cesarean delivery also may form a mucocele in the scar that causes pain, bladder urgency, and dyspareunia. These defects also can be seen by ultrasonography, but in some cases may erroneously be labeled “nabothian cysts” by a radiologist. Most mucoceles probably are caused by incorporation of endocervical glands within a very low transverse uterine incision. Discovery and removal of these mucoceles during hysterectomy result in a very satisfied patient whose pain and urinary symptoms are resolved.
David G. Bryan, MD
Monroe, Louisiana
Oxytocin protocol decreased postpartum hemorrhage rates
We commend Dr. Barbieri for his April 2014 editorial, “Following cesarean delivery, what is the optimal oxytocin infusion duration to prevent postpartum bleeding?” because he addresses a critical gap in the evidence regarding oxytocin administration postpartum. Standardized protocols for such administration are lacking at many facilities.
Our multidisciplinary team developed a standardized postpartum oxytocin administration protocol to prevent postpartum hemorrhage (PPH) based on limited evidence from trials in which 10 units to 80 or more units of oxytocin were given (from <1 to 12 hours) postpartum.1–5 Our protocol is a “middle of the road’’ approach in which a total of oxytocin 60 U is administered intravenously postdelivery, including a bolus of oxytocin 15 U in 250 mL of lactated Ringers solution (LR) at delivery followed by an additional oxytocin 15 U in 250 mL LR over the next hour, then oxytocin 30 U in 500 mL LR at a rate of 125 mL/hr for the following 4 hours. Thus, the total time for oxytocin administration postdelivery is 5 hours, within Dr. Barbieri’s recommendation of 4 to 8 hours
We have since performed a retrospective quality improvement assessment comparing PPH rates at 6-months preprotocol (n = 1267) with rates at 6-months postprotocol (n = 1440) implementation. PPH was defined as PPH treatment by pharmaceutical, mechanical, or surgical methods. Inclusion criteria included all deliveries at greater than 23 weeks’ gestation from April 2012 to March 2013. Patient characteristics for both cohorts were similar for race, age, parity, gestational age, delivery type, and neonatal weight.
The PPH rate decreased 37% after protocol implementation (adjusted relative risk [ARR], 0.63; 95% confidence interval [CI], 0.46–0.91). Administration of misoprostol, carboprost, methylergonovine maleate, and blood products decreased postprotocol implementation by 36%, 38%, 32%, and 22%, respectively. The PPH rate for women with a vaginal delivery decreased significantly after protocol implementation (5.9% preprotocol vs 3.8% postprotocol; P = .03). The PPH rate for women undergoing cesarean delivery increased, but not significantly, after protocol implementation (6.9% preprotocol vs 8.6% postprotocol; P = .34).
We did not control for some PPH risk factors, including abnormal insertion of placenta, preeclampsia, and multiple gestation. Despite this limitation, our PPH rate for women undergoing cesarean delivery is lower than other published rates.6,7 These findings are the preliminary step in a larger, more comprehensive 4-year study.
Our team is encouraged by these results and believes our protocol warrants further study. Thank you for your attention to this topic. We hope our experience can offer support for future practice change and research.
Enas Ramih, MD, MPH; Jennifer Doyle, MSN, WHNP; Tiffany Kenny, MSN;
Michele McCarroll, PhD; Vivian von Gruenigen, MD
Summa Health System Akron City Hospital
Women’s Health Services
Akron, Ohio
References
1. Tita AT, Szychowski JM, Rouse DJ, et al. Higher-dose oxytocin and hemorrhage after vaginal delivery: a randomized controlled trial. Obstet Gynecol. 2012;119(2 pt 1):293–300.
2. Munn MB, Owen J, Vincent R, Wakefield M, Chestnut DH, Hauth JC. Comparison of two oxytocin regimens to prevent uterine atony at cesarean delivery: a randomized controlled trial. Obstet Gynecol. 2001;98(3):386–390.
3. Murphy DJ, MacGregor H, Munishankar B, McLeod G. A randomised controlled trial of oxytocin 5IU and placebo infusion versus oxytocin 5IU and 30IU infusion for the control of blood loss at elective caesarean section: pilot study. ISRCTN 40302163. Eur J Obstet Gynecol Reprod Biol. 2009;142(1):30–33.
4. King KJ, Douglas MJ, Waldmar U, Wong A, King RAR. Five-unit bolus oxytocin at cesarean delivery in women at risk of atony: a randomized, double-blind, controlled trial. Anesth Analg. 2010;111(6):1460–1466.
5. Gungorduk K, Asicioglu O, Celikkol O, Olgac Y, Ark C. Use of additional oxytocin to reduce blood loss at elective caesarean section: a randomized control trial. Aust N Z J Obstet Gynaecol. 2010;50(1):36–39.
6. Dagraca J, Malladi V, Nunes K, Scavone B. Outcomes after institution of a new oxytocin infusion protocol during the third stage of labor and immediate postpartum period. Int J Obstet Anesth. 2013;22(3):194–199.
7. Sheehan SR, Montgomery AA, Carey M, et al. Oxytocin bolus versus oxytocin bolus and infusion for control of blood loss at elective caesarean section: double blind, placebo controlled, randomised trial. BMJ. 2011;343:d4661. doi:10.1136/bmj.d4661.
Dr. Barbieri responds
I deeply appreciate the very important clinical observation provided by the Summa Health System team. Implementation of a standardized 5-hour protocol of oxytocin administration following delivery resulted in a reduction in the rate of diagnosis of PPH following vaginal delivery, but not cesarean delivery, and a reduction in the use of adjuvant misoprostol, caboprost, and methylergonovine maleate. The quality improvement intervention initiated by the Summa Health System team and their ability to assess before and after outcomes demonstrates how high-quality clinical networks can develop and disseminate best practices, thereby improving the health of all the pregnant women in our care. Thank you for sharing this important clinical observation with our readers.
“FDA, HOSPITALS CAUTION AGAINST LAPAROSCOPIC POWER MORCELLATION DURING HYSTERECTOMY AND MYOMECTOMY”
JANELLE YATES (MAY 2014)
The right to choose the appropriate tools and techniques should remain in the capable hands of qualified surgeons!
I'm sorry to say it, but your piece on morcellators is slanted. Many of us believe the FDA is wrong. The incidence of occult sarcoma came from nowhere. In properly selected, evaluated, and surgically managed cases, the use of an open power morcellator is an excellent option and the risks of a bad outcome are extremely small (especially the risk of worsening an occult leiomyosarcoma). Incidentally, we face the same risk of finding and possibly worsening an occult cancer in every gynecologic surgery we do.
Possible spillage, contamination, or outright tumor rupture is possible no matter what route or incision size. Minimally invasive surgeons understand the risk−benefit ratio very well. We use our judgment and patient informed consent in every case and should not be unnecessarily obstructed by government agencies. The right to choose the appropriate tools and techniques should remain in the capable hands of qualified surgeons!
The controversy here is reminiscent of the issues brought up about breast implants in the 70s, IUDs in the 80s, estrogen in 2004, vaginal mesh in 2012, and robotics and hysterectomy approach recently. Show me some real data that are convincing against the use of morcellators, or support the physician’s choice in how to care for our patients.
Michael Swor, MD
Sarasota, Florida
Ms. Yates responds
I appreciate Dr. Swor’s response to the article on actions by the FDA and various hospitals to limit the use of power morcellation during hysterectomy and myomectomy. That article was not endorsing those actions, nor was it condemning them—it was simply a report of the latest events in a sea change taking place in minimally invasive gynecologic surgery.
Since the article was published, new data have become available on the likelihood of occult uterine malignancy among women who undergo minimally invasive hysterectomy with electric power morcellation. Wright and colleagues found a rate of uterine cancer of 27 cases per 10,000 women at the time of the procedure.1 That figure translates into one case of undetected uterine cancer in every 368 women undergoing hysterectomy.1
In a two-part series on tissue extraction at the time of hysterectomy and myomectomy, Dr. Jason Wright, the author of the study just mentioned, and other expert panelists discuss this issue in more depth.2,3 They also note, as does Dr. Swor, that spillage, contamination, or outright tumor rupture is possible regardless of the route of hysterectomy.
References
1. Wright JD, Tergas AI, Burke WM, et al. Uterine pathology in women undergoing minimally invasive hysterectomy using morcellation [published online ahead of print July 22, 2014]. JAMA. doi: 10.1001/jama.2014.9005.
2. Advincula AP, Bradley LD, Iglesia C, Kho K, Wright JD. Tissue extraction during minimally invasive Gyn surgery: Best practices for an environment in flux. OBG Manage. 2014;26(9):44–51.
3. Advincula AP, Bradley LD, Iglesia C, Kho K, Wright JD. Tissue extraction during minimally invasive Gyn surgery: Counseling the patient. OBG Manage. 2014;26(10):41–45.
Share your thoughts on this or other articles! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
"UPDATE ON MINIMALLY INVASIVE GYNECOLOGY" AMY GARCIA, MD (APRIL 2014)
Mucocele in cesarean scar can cause pain, bladder urgency, dyspareunia
Like Dr. Garcia, I too, have seen many cesarean-scar defects; most were diagnosed prior to surgery by my in-house technicians during vaginal ultrasonography.
I would like to add that, in addition to these defects, some patients who have undergone cesarean delivery also may form a mucocele in the scar that causes pain, bladder urgency, and dyspareunia. These defects also can be seen by ultrasonography, but in some cases may erroneously be labeled “nabothian cysts” by a radiologist. Most mucoceles probably are caused by incorporation of endocervical glands within a very low transverse uterine incision. Discovery and removal of these mucoceles during hysterectomy result in a very satisfied patient whose pain and urinary symptoms are resolved.
David G. Bryan, MD
Monroe, Louisiana
Oxytocin protocol decreased postpartum hemorrhage rates
We commend Dr. Barbieri for his April 2014 editorial, “Following cesarean delivery, what is the optimal oxytocin infusion duration to prevent postpartum bleeding?” because he addresses a critical gap in the evidence regarding oxytocin administration postpartum. Standardized protocols for such administration are lacking at many facilities.
Our multidisciplinary team developed a standardized postpartum oxytocin administration protocol to prevent postpartum hemorrhage (PPH) based on limited evidence from trials in which 10 units to 80 or more units of oxytocin were given (from <1 to 12 hours) postpartum.1–5 Our protocol is a “middle of the road’’ approach in which a total of oxytocin 60 U is administered intravenously postdelivery, including a bolus of oxytocin 15 U in 250 mL of lactated Ringers solution (LR) at delivery followed by an additional oxytocin 15 U in 250 mL LR over the next hour, then oxytocin 30 U in 500 mL LR at a rate of 125 mL/hr for the following 4 hours. Thus, the total time for oxytocin administration postdelivery is 5 hours, within Dr. Barbieri’s recommendation of 4 to 8 hours
We have since performed a retrospective quality improvement assessment comparing PPH rates at 6-months preprotocol (n = 1267) with rates at 6-months postprotocol (n = 1440) implementation. PPH was defined as PPH treatment by pharmaceutical, mechanical, or surgical methods. Inclusion criteria included all deliveries at greater than 23 weeks’ gestation from April 2012 to March 2013. Patient characteristics for both cohorts were similar for race, age, parity, gestational age, delivery type, and neonatal weight.
The PPH rate decreased 37% after protocol implementation (adjusted relative risk [ARR], 0.63; 95% confidence interval [CI], 0.46–0.91). Administration of misoprostol, carboprost, methylergonovine maleate, and blood products decreased postprotocol implementation by 36%, 38%, 32%, and 22%, respectively. The PPH rate for women with a vaginal delivery decreased significantly after protocol implementation (5.9% preprotocol vs 3.8% postprotocol; P = .03). The PPH rate for women undergoing cesarean delivery increased, but not significantly, after protocol implementation (6.9% preprotocol vs 8.6% postprotocol; P = .34).
We did not control for some PPH risk factors, including abnormal insertion of placenta, preeclampsia, and multiple gestation. Despite this limitation, our PPH rate for women undergoing cesarean delivery is lower than other published rates.6,7 These findings are the preliminary step in a larger, more comprehensive 4-year study.
Our team is encouraged by these results and believes our protocol warrants further study. Thank you for your attention to this topic. We hope our experience can offer support for future practice change and research.
Enas Ramih, MD, MPH; Jennifer Doyle, MSN, WHNP; Tiffany Kenny, MSN;
Michele McCarroll, PhD; Vivian von Gruenigen, MD
Summa Health System Akron City Hospital
Women’s Health Services
Akron, Ohio
References
1. Tita AT, Szychowski JM, Rouse DJ, et al. Higher-dose oxytocin and hemorrhage after vaginal delivery: a randomized controlled trial. Obstet Gynecol. 2012;119(2 pt 1):293–300.
2. Munn MB, Owen J, Vincent R, Wakefield M, Chestnut DH, Hauth JC. Comparison of two oxytocin regimens to prevent uterine atony at cesarean delivery: a randomized controlled trial. Obstet Gynecol. 2001;98(3):386–390.
3. Murphy DJ, MacGregor H, Munishankar B, McLeod G. A randomised controlled trial of oxytocin 5IU and placebo infusion versus oxytocin 5IU and 30IU infusion for the control of blood loss at elective caesarean section: pilot study. ISRCTN 40302163. Eur J Obstet Gynecol Reprod Biol. 2009;142(1):30–33.
4. King KJ, Douglas MJ, Waldmar U, Wong A, King RAR. Five-unit bolus oxytocin at cesarean delivery in women at risk of atony: a randomized, double-blind, controlled trial. Anesth Analg. 2010;111(6):1460–1466.
5. Gungorduk K, Asicioglu O, Celikkol O, Olgac Y, Ark C. Use of additional oxytocin to reduce blood loss at elective caesarean section: a randomized control trial. Aust N Z J Obstet Gynaecol. 2010;50(1):36–39.
6. Dagraca J, Malladi V, Nunes K, Scavone B. Outcomes after institution of a new oxytocin infusion protocol during the third stage of labor and immediate postpartum period. Int J Obstet Anesth. 2013;22(3):194–199.
7. Sheehan SR, Montgomery AA, Carey M, et al. Oxytocin bolus versus oxytocin bolus and infusion for control of blood loss at elective caesarean section: double blind, placebo controlled, randomised trial. BMJ. 2011;343:d4661. doi:10.1136/bmj.d4661.
Dr. Barbieri responds
I deeply appreciate the very important clinical observation provided by the Summa Health System team. Implementation of a standardized 5-hour protocol of oxytocin administration following delivery resulted in a reduction in the rate of diagnosis of PPH following vaginal delivery, but not cesarean delivery, and a reduction in the use of adjuvant misoprostol, caboprost, and methylergonovine maleate. The quality improvement intervention initiated by the Summa Health System team and their ability to assess before and after outcomes demonstrates how high-quality clinical networks can develop and disseminate best practices, thereby improving the health of all the pregnant women in our care. Thank you for sharing this important clinical observation with our readers.
“FDA, HOSPITALS CAUTION AGAINST LAPAROSCOPIC POWER MORCELLATION DURING HYSTERECTOMY AND MYOMECTOMY”
JANELLE YATES (MAY 2014)
The right to choose the appropriate tools and techniques should remain in the capable hands of qualified surgeons!
I'm sorry to say it, but your piece on morcellators is slanted. Many of us believe the FDA is wrong. The incidence of occult sarcoma came from nowhere. In properly selected, evaluated, and surgically managed cases, the use of an open power morcellator is an excellent option and the risks of a bad outcome are extremely small (especially the risk of worsening an occult leiomyosarcoma). Incidentally, we face the same risk of finding and possibly worsening an occult cancer in every gynecologic surgery we do.
Possible spillage, contamination, or outright tumor rupture is possible no matter what route or incision size. Minimally invasive surgeons understand the risk−benefit ratio very well. We use our judgment and patient informed consent in every case and should not be unnecessarily obstructed by government agencies. The right to choose the appropriate tools and techniques should remain in the capable hands of qualified surgeons!
The controversy here is reminiscent of the issues brought up about breast implants in the 70s, IUDs in the 80s, estrogen in 2004, vaginal mesh in 2012, and robotics and hysterectomy approach recently. Show me some real data that are convincing against the use of morcellators, or support the physician’s choice in how to care for our patients.
Michael Swor, MD
Sarasota, Florida
Ms. Yates responds
I appreciate Dr. Swor’s response to the article on actions by the FDA and various hospitals to limit the use of power morcellation during hysterectomy and myomectomy. That article was not endorsing those actions, nor was it condemning them—it was simply a report of the latest events in a sea change taking place in minimally invasive gynecologic surgery.
Since the article was published, new data have become available on the likelihood of occult uterine malignancy among women who undergo minimally invasive hysterectomy with electric power morcellation. Wright and colleagues found a rate of uterine cancer of 27 cases per 10,000 women at the time of the procedure.1 That figure translates into one case of undetected uterine cancer in every 368 women undergoing hysterectomy.1
In a two-part series on tissue extraction at the time of hysterectomy and myomectomy, Dr. Jason Wright, the author of the study just mentioned, and other expert panelists discuss this issue in more depth.2,3 They also note, as does Dr. Swor, that spillage, contamination, or outright tumor rupture is possible regardless of the route of hysterectomy.
References
1. Wright JD, Tergas AI, Burke WM, et al. Uterine pathology in women undergoing minimally invasive hysterectomy using morcellation [published online ahead of print July 22, 2014]. JAMA. doi: 10.1001/jama.2014.9005.
2. Advincula AP, Bradley LD, Iglesia C, Kho K, Wright JD. Tissue extraction during minimally invasive Gyn surgery: Best practices for an environment in flux. OBG Manage. 2014;26(9):44–51.
3. Advincula AP, Bradley LD, Iglesia C, Kho K, Wright JD. Tissue extraction during minimally invasive Gyn surgery: Counseling the patient. OBG Manage. 2014;26(10):41–45.
Share your thoughts on this or other articles! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.