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Purpose of Review: Minimally invasive gynecologic procedures, in particular laparoscopic hysterectomy and myomectomy, often require tissue morcellation., Recent Findings: Whether morcellated or not, myometrial cells can be found in the abdomen and pelvis after either laparoscopic or open myomectomy. Following morcellation, careful inspection for and removal of tissue fragments and copious irrigation and suctioning of fluid can remove residual tissue and cells without the use of containment bags. The dogma of not 'cutting-through' cancer is not correct for many surgical specialties and irrelevant with regards to leiomyosarcoma (LMS) and minimally invasive gynecologic surgery. Eliminating residual disease in the pelvis and abdomen should be the goal of myomectomy or hysterectomy., Summary: Morcellation of excised tissue is necessary for many women with symptomatic fibroids who choose to undergo laparoscopic myomectomy or hysterectomy. LMS is an uncommon disease, with a poor prognosis due to early hematogenous metastasis to lung, bone and liver. Preoperatively, it is often difficult to differentiate from benign fibroids. LMS has a high propensity for local recurrence despite performance of total hysterectomy. Efforts to remove all tissue and cells from the pelvis and abdomen should be the goal of minimally invasive surgery with morcellation.

In November 2014, the Food and Drug Administration (FDA) calculated that for every 498 women having surgery for presumed fibroids, one woman would be found to have an occult leiomyosarcoma (LMS). The FDA issued a safety communication warning against the use of laparoscopic morcellators in the majority of women undergoing myomectomy or hysterectomy for treatment of fibroids. This communication was prompted by concern that if a patient had an occult LMS, the morcellator might spread tumor cells within the peritoneal cavity. We submit that the FDA directive was based on a flawed and misleading analysis. More rigorous evidence estimates the prevalence of LMS among women operated upon for presumed uterine fibroids at approximately one in 2000 women, significantly lower than the FDA's estimate. In addition, there is no reliable evidence that morcellation influences survival or that power-morcellation is inferior to vaginal or mini-lap morcellation with a scalpel. Recent publication shows that open surgery carries more risk for women when compared with minimally invasive surgery. Although the possibility of occult LMS should be considered by women and their gynecologists, we suggest that current morcellation techniques be continued for women who wish to benefit from minimally invasive surgery. Investigation into new and, hopefully, better morcellating devices may make the procedure safer for women.

The U.S. Food and Drug Administration (FDA) is warning against the use of laparoscopic power morcellators in the majority of women undergoing myomectomy or hysterectomy for the treatment of leiomyomas because of the concern for inadvertent spread of tumor cells if an undiagnosed cancer were present. The authors, representing a 45-member review group, reviewed the current literature to formulate prevalence rates of leiomyosarcoma in women with presumed leiomyomas and to asses reliable data regarding patient survival after morcellation. The authors disagree with the FDA's methodology in reaching their conclusion and provide clinical recommendations for care of women with leiomyomas who are planning surgery.

There is concern that morcellation of occult leiomyosarcomas during surgery to treat presumed myomas may substantially worsen patient outcome. We reviewed the existing medical literature to better understand whether such a risk was demonstrable and, if so, what the magnitude of that risk might be. We identified 4864 articles initially, of which 60 were evaluated in full. Seventeen were found to have outcomes information and are included in this review. Six studies addressed the question of whether morcellation of occult leiomyosarcomas resulted in inferior outcomes as compared with en bloc uterine and tumor removal. In these 6 studies, results suggested that en bloc removal may result in improved survival and less recurrence; however, the data are highly biased and of poor quality. There is no reliable evidence that morcellation, power or otherwise, substantially results in tumor upstaging. There is no evidence from these 17 studies that power morcellation differs in any way from other types of morcellation or even simple myomectomy insofar as patient outcome. Whether electromechanical morcellation poses a unique danger to the patient with occult leiomyosarcoma is an unanswered question and one clearly in need of more extensive investigation before conclusions are drawn and policies created., (Copyright © 2015 AAGL. Published by Elsevier Inc. All rights reserved.)

Leiomyomas are the most common pelvic tumors in women. These tumors are not always symptomatic but can cause abnormal uterine bleeding and anemia, pelvic pressure and pain, urinary frequency, and adverse reproductive outcomes-symptoms that can diminish the quality of life of women. Myomectomy is the primary treatment modality for women with symptomatic leiomyomas who are of reproductive age and desire future fertility. Myomectomy can significantly improve symptoms and quality of life and, in some clinical situations, improve reproductive outcomes. There are robust surgical outcome data supporting the use of a minimally invasive approach such as laparoscopy and hysteroscopy over laparotomy. Perioperative outcomes and return to normal activity are significantly better with a minimally invasive approach. Reproductive outcomes are not adversely affected. Detailed preoperative imaging is required for minimally invasive procedures to be successful. There are several evidence-based techniques that can be used to reduce blood loss during surgery. The role of robotic technology in enhancing surgical outcomes has not been clearly defined.

Determination of the reasonable treatment options and the appropriate clinical treatment of women with uterine fibroid tumors often depends on the ability of imaging modalities to accurately detect and localize fibroid tumors. Magnetic resonance imaging (MRI) gives the most complete evaluation (sizes, positions, number) of submucous, intramural, and subserosal myomas and is the most sensitive modality for the detection of small fibroid tumors. MRI allows the evaluation of fibroid tumor proximity to the bladder, rectum, and endometrial cavity, helps define what can be expected at surgery, and may help the gynecologist avoid missing fibroid tumors during surgery. MRI can also make the diagnosis of adenomyosis reliably and may be able to identify uterine sarcoma when present., (Copyright © 2012 Mosby, Inc. All rights reserved.)

Case reports for uterine rupture subsequent to laparoscopic myomectomy were reviewed to determine whether common causal factors could be identified. Published cases were identified via electronic searches of PubMed, Google Scholar, and hand searches of references, and unpublished cases were obtained via E-mail queries to the AAGL membership and AAGL Listserve participants. Nineteen cases of uterine rupture after laparoscopic myomectomy were identified. The removed myomas ranged in size from 1 through 11 cm (mean, 4.5 cm). Only 3 cases involved multilayered closure of uterine defects. Electrosurgery was used for hemostasis in all but 2 cases. No plausible contributing factor could be found in one case [corrected]. It seems reasonable for surgeons to adhere to techniques developed for abdominal myomectomy including limited use of electrosurgery and multilayered closure of the myometrium. Nevertheless, individual wound healing characteristics may predispose to uterine rupture., (Copyright © 2010 AAGL. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate the effect of fibroids on fertility and of myomectomy in improving outcomes., Design: Systematic literature review and meta-analysis of existing controlled studies., Setting: Private center for Reproductive endocrinology and infertility., Patient(s): Women with fibroids and infertility., Intervention(s): A systematic literature review, raw data extraction and data analysis., Main Outcome Measure(s): Clinical pregnancy rate, spontaneous abortion rate, ongoing pregnancy/live birth rate, implantation rate, and preterm delivery rate in women with and without fibroids, and in women who underwent myomectomy., Result(s): Women with subserosal fibroids had no differences in their fertility outcomes compared with infertile controls with no myomas, and myomectomy did not change these outcomes compared with women with fibroids in situ. Women with intramural fibroids appear to have decreased fertility and increased pregnancy loss compared with women without such tumors, but study quality is poor. Myomectomy does not significantly increase the clinical pregnancy and live birth rates, but the data are scarce. Fibroids with a submucosal component led to decreased clinical pregnancy and implantation rates compared with infertile control subjects. Removal of submucous myomas appears likely to improve fertility., Conclusion(s): Fertility outcomes are decreased in women with submucosal fibroids, and removal seems to confer benefit. Subserosal fibroids do not affect fertility outcomes, and removal does not confer benefit. Intramural fibroids appear to decrease fertility, but the results of therapy are unclear. More high-quality studies need to be directed toward the value of myomectomy for intramural fibroids, focusing on issues such as size, number, and proximity to the endometrium.

A patient conceived 7 years after undergoing a routine laparoscopic myomectomy of an 11-cm pedunculated myoma. Monopolar modulated current (coagulating) was used for hemostasis, and no suturing was necessary. The pregnancy was uneventful until the 34th week, when pain and contractions signaled uterine rupture. Mother and baby did well after emergency cesarean section. A wide area of adjacent tissue injury after complete hemostasis with monopolar modulated current (coagulating) was felt to be responsible for poor myometrial healing and subsequent rupture.

Most women develop myomas during their lifetimes; however, 80% are asymptomatic. When symptoms are determined to be caused by myomas, a number of management options exist that include "watchful waiting," medical therapy, surgery, or more recently uterine artery embolization and focused ultrasound. Myomectomy, either abdominal or laparoscopic, is an approach particularly suited for those women who wish future fertility. It seems clear that, in well trained and experienced hands, well-selected patients can have myomectomy performed under laparoscopic direction. Very large myomas are not as suitable for the laparoscopic approach, but are amenable to a uterine conserving procedure via laparotomy that is facilitated by a number of preoperative and intraoperative measures aimed to minimize or replace operative blood loss. These techniques should provide selected women a uterine conserving procedure with reduced morbidity.

Objective: To evaluate feasibility and safety of abdominal myomectomy with uterine myomas equal to or greater than 16 weeks in size., Design: Retrospective chart review., Setting: Private hospital., Patient(s): Women with uterine fibroids equal to or larger than 16 weeks in size., Intervention(s): Abdominal myomectomy performed by one surgeon between March 1, 1998-February 28, 2003., Main Outcome Measure(s): Operating time, estimated blood loss, transfusion, cell-saver use, number and weight of fibroids removed, complications, pathology, and hospital stay were evaluated., Result(s): Ninety-one abdominal myomectomies met criteria. Mean operating time was 236 minutes (range, 120-390 minutes). Mean estimated blood loss was 794 mL (range, 50-3,000 mL). Seven (8%) women required homologous transfusion. Complications included one bowel injury, one bladder injury, one wound infection, and one reoperation for incarcerated small bowel. No woman had a uterine sarcoma or adenocarcinoma, and none required conversion to hysterectomy., Conclusion(s): Large uterine size does not preclude abdominal myomectomy and the results compare favorably with prior studies of hysterectomy for similar size uteri.