Laparascopic hysterectomies are less invasive than abdominal ones, with fewer perioperative morbidities and faster recovery, but, in some cases, the uterus cannot be removed without prior morcellation (the cutting of the organ into small pieces). The use of electric power morcellators was approved by the FDA in 1995 but has become controversial because of the risk of dissemination of occult uterine cancer. However, the risks and benefits of this procedure may vary with age, according to a study published October 8 in the Journal of the National Cancer Institute.
To assess the risks and benefits of three types of hysterectomy procedures, laparascopy, laparascopy with morcellation, and abdominal hysterectomy, Jason D. Wright, of the Division of Gynecologic Oncology, Columbia University College of Physicians and Surgeons and New York Presbyterian Hospital, New York, NY, and colleagues, developed a model simulating morbidity, mortality, quality of life, and cost for women younger than 40, 40-49, 50-59, and 60 years and older who underwent hysterectomy for presumed benign gynecologic disease. The authors used cancer incidence and survival rates from Surveillance, Epidemiology, and End Results (SEER) data, as well as clinical, epidemiological, and oncological data from the literature.
Overall, laparascopic hysterectomy without morcellation was the most effective and least costly of the three procedures. Laparascopic hysterectomy with power morcellation was associated with approximately 81 more intraoperative complications per 10,000 women but fewer perioperative complications and readmissions than abdominal hysterectomy. Compared to abdominal hysterectomy, laparoscopic hysterectomy with morcellation was associated with 2, 4, 13, and 47 excess cases of disseminated cancer for women under 40, 40-49, 50-59, and 60 years of age and over, respectively. However, when the risk of mortality from cancer as well as operative complications were analyzed, morcellation was associated with 1 death less than abdominal hysterectomy in women younger than 40 and 0.3, 5, and 18 excess deaths in women 40-49, 50-59, and 60 years of age or older, respectively.
Wright et al. were unable to stratify by other variables such as race and uterine size because data are lacking on characteristics of women who have undergone the procedure, and they write "The controversy around electric power morcellation clearly demonstrates the need for better data and heightened regulation before new devices are allowed to diffuse into widespread practice." The authors suggest that "Surgical technique should be individualized, and all patients should be thoroughly counseled regarding the risk of electric power morcellation."
In an accompanying editorial, David G. Mutch of the Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, writes that this work will help to better define the risks to patients by taking both the risk of cancer dissemination and the risks of abdominal hysterectomy into account. He agrees that more studies on the real risks of this procedure are needed so that women will be better able to weigh the risks and benefits.