Morcellation for myomectomy or hysterectomy

Q 1. What is myomectomy?

A. Myomectomy is the surgical removal of fibroids from your uterus (womb).

Myomectomy can be done laparoscopically (keyhole surgery), by laparotomy (open surgery with a larger cut on your abdomen) or, in specific situations, vaginally.

Q 2. What is hysterectomy?

A. Hysterectomy is the surgical removal of your uterus.

It can be done laparoscopically (keyhole surgery), by laparotomy (open surgery with a larger cut on your abdomen) or vaginally.

A total hysterectomy involves the removal of your uterus as well as your cervix while a subtotal hysterectomy involves removal of the uterus only.

Your ovaries and fallopian tubes may or may not be removed depending on your individual situation and your preferences.

Q 3. What is morcellation?

A. Morcellation involves cutting uterine or fibroid tissue into smaller pieces to allow removal laparoscopically, vaginally or through smaller cuts on your abdomen. This is often done using a device called a morcellator which electrically or mechanically cuts the tissue into smaller pieces.

Morcellation is usually only considered if you are having a laparoscopic total hysterectomy and your uterus is too big to be removed through your vagina, if you are having a laparoscopic subtotal hysterectomy (where the cervix is left in place) or if you are having a laparoscopic myomectomy.

However, sometimes even if you are having an open hysterectomy or myomectomy, or if you are having a vaginal hysterectomy or myomectomy, the uterus or fibroids may need to be cut into smaller pieces to allow them to be removed more easily. This is considered a type of morcellation.

Q 4. What are the benefits of morcellation?

A. Morcellation allows the removal of a large fibroid or uterus through small cuts on your abdomen (keyhole surgery) or through your vagina. This means:

• Less pain after surgery
• Reduced risk of infection
• Reduced risk of blood clots in the legs or lungs
• A shorter hospital stay
• Quicker recovery.

Q 5. What are the risks of morcellation?

A. Morcellation has following risks:

• Small pieces of benign (non-cancerous) fibroid tissue could be left inside your abdomen. These may then attach to the internal organs in your abdomen where they can continue to grow. You may then require additional surgery to remove these fibroids. The risk of this happening is thought to be 1 in 120 (uncommon) to 1 in 1200 (rare).
• Morcellation of uterine tissue or a fibroid that could contain an unexpected cancer called uterine sarcoma. Before considering morcellation, your healthcare professional will have offered you investigations that may include an ultrasound scan, a magnetic resonance imaging (MRI) scan, an endometrial biopsy (biopsy of the uterus lining) and a cervical smear test. However, none of the currently available tests can reliably diagnose uterine sarcoma before surgery.

The risk of unexpected uterine sarcoma in fibroids depends on your age and is higher around the time of and after your menopause. Various studies have quoted this risk as ranging from:

• 1 in 65 to 1 in 278 (if you are over 60 years of age),
• 1 in 158 to 1 in 303 (if you are between 50 and 59)
• 1 in 304 to 1 in 1250 (if you are younger than 50).

While these studies don’t give us exact risk figures, they do tell us that the risk increases significantly with age. If you are over 50 years of age, your risk is higher and continues to increase as you get older.

If an unexpected uterine sarcoma is morcellated then it can potentially cause the cancer to spread and worsen your chances of survival.

Q 6. What might affect my risk of having a uterine sarcoma?

A. The following factors may mean that you have a higher risk of uterine sarcoma. Your doctor will check for these and discuss with you before considering morcellation.

• Fibroids that are growing quickly
• Findings suspicious of uterine sarcoma on your ultrasound or mri scan
• If certain types of breast, ovarian or bowel cancer run in your family (such as brca mutations or lynch syndrome)
• Your age, as your risk is higher around the time of and after your menopause
• Your ethnicity – fibroids are more common in black women and the chances of uterine sarcoma may also be higher
• If you have ever used the drug tamoxifen
• If your fibroid continues to grow despite medical treatment
• If you have had radiotherapy to your pelvis
• Bleeding after your menopause or irregular vaginal bleeding.

If you have a fibroid that appears suspicious, your doctor may discuss your case with a multidisciplinary team (MDT) of specialists to help to decide what treatment to recommend to you.

Q 7. What are my alternatives to morcellation?

A. Depending on your individual circumstances, your doctor will discuss treatment options with you that include having no treatment, ‘waiting and watching’, medical treatment (such as tablets, injections or a hormone coil) or surgery.

An alternative to myomectomy or hysterectomy using morcellation is to choose open surgery where a larger cut is made on your abdomen to remove your fibroids or uterus. The risks and benefits of laparoscopic, vaginal and open surgery will vary depending on your individual situation and will be fully discussed with you by your doctor.

Before deciding on any treatment, you will be given the chance to ask any questions you may have and to discuss any concerns so that you can make a choice that is right for you.

Q 8. What are the key points to remember?

A. The key points to remember are:

• If you are having a hysterectomy (an operation to remove your uterus) or a myomectomy (an operation to remove fibroids), you may be offered a procedure called morcellation.
• Morcellation is when tissue such as your uterus or fibroids are cut into smaller pieces to allow them to be removed more easily. This can be done using an instrument called a morcellator.
• The use of morcellation may mean you can have your operation done laparoscopically (using small cuts on your abdomen) or vaginally. This can mean a quicker recovery for you than having open surgery (with a large cut on your abdomen).
• There are risks with morcellation including the chance that an undiagnosed cancer, called uterine sarcoma, can be spread during the surgery.