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Risks, benefits of power morcellation differ based on patient age
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Minimally invasive hysterectomies with electric power morcellation have varying risks and benefits depending on a woman’s age, according to results of a cohort stimulation modeling study.
Overall, the risks associated with the procedure appeared greater in older women, whereas the benefits appeared greater in younger women.
Jason D. Wright
Power morcellation grinds up uterine fibroids — or benign tumors within the uterus — and allows for their removal via a laparoscope. However, the FDA issued an “immediately in effect” guidance in November 2014 that warns against the use of morcellators in hysterectomies or myomectomies in the majority of women due to the potential that they can spread undetected uterine sarcomas.
“We know that while morcellation is associated with a risk of dissemination of occult cancer compared to abdominal hysterectomy, the ability to undergo a minimally invasive procedure is beneficial in that it is associated with fewer postoperative complications,” Jason D. Wright, MD, chief of the division of gynecologic oncology and associate professor of obstetrics and gynecology at Columbia University Medical Center, told HemOnc Today
Wright and colleagues used a state transition Markov cohort simulation model — which accounted for perioperative morbidity, mortality, risk of cancer and dissemination, and outcomes in women with an underlying malignancy — to compare the risks and benefits of three different hysterectomy modalities for presumed benign disease: total abdominal, laparoscopic and laparoscopic with a power morcellator.
The researchers found laparoscopic hysterectomy without morcellation was the most beneficial and cost-effective strategy. Per 10,000 women, laparoscopic hysterectomy with morcellation appeared more costly, decreased quality of life, and lowered overall life-years compared with laparoscopic hysterectomy without morcellation.
The procedure with power morcellation was associated with 80.83 (95% CI, 21.35-138.03) more intraoperative complications. However, that modality also was associated with 199.64 (95% CI, 301.70-107.52) fewer perioperative complications and 241.8 (95% CI, 257.50-227.25) fewer hospital readmissions than abdominal hysterectomy per 10,000 women.
Age matters
Wright and colleagues then evaluated the efficacy of each the procedures stratified by patient age.
Per 10,000 women aged younger than 40 years, power morcellation appeared associated with 1.57 more cases of disseminated cancer and 0.94 more cancer-associated deaths, but 0.97 fewer overall deaths than abdominal hysterectomy.
Excess cases of disseminated cancer with power morcellation compared with abdominal surgery increased with age from 3.75 cases per 10,000 women aged 40 to 49 years, to 12.97 cases per 10,000 women 50 to 59 years, and to 47.54 cases per 10,00 women aged 60 years or older. Compared with abdominal hysterectomy, these data equated to 0.3 (age 40-49), 5.07 (age 50-59) and 18.14 (age 60 and older) excess deaths per 10,000 women.
Results of a sensitivity analysis showed a 25% increase in cancer prevalence in each age group produced comparable mortality data. However, if a 25% reduction in cancer prevalence occurred, power morcellation would be the preferred treatment modality among women aged 40 to 49 years based on 0.05 fewer deaths per 10,000 women.
Laparoscopic hysterectomy with morcellation also became the preferred strategy in that age group if the risk for tumor dissemination was only 10%, based on 0.51 fewer deaths per 10,000 women than abdominal hysterectomy.
In a scenario analysis in which 75% of occult tumors were deemed to be sarcomas, morcellation appeared to be the more favorable option for women aged younger than 40 years, based on 0.93 fewer deaths per 10,000 women than abdominal hysterectomy.
“We noted that in women aged younger than 40 years, the benefits of morcellation compared to abdominal hysterectomy appear to outweigh the risks,” Wright said. “As the incidence of cancer increases with age, morcellation is associated with more harm than benefit in women 50 years of age or older. Women aged 40 to 49 represent a grey zone.”
In a cost-effectiveness analysis, morcellation was less costly than abdominal hysterectomy in all age groups. For every 10,000 women, use of laparoscopic hysterectomy with morcellation resulted in an increase of 4.49 life-years for women aged younger than 40 years, but 0.47 fewer life-years in the 40-to-49 age group, 20.64 fewer life-years in the 50-to-59 group and 91.19 fewer life-years in the 60-and-older group.
When considering quality of life, morcellation became a more favorable strategy for women in the 40-to-49 age group based on an improvement of 11.22 quality-adjusted life-years compared with abdominal hysterectomy.
Implications
These findings are in accordance with the FDA advisory statement that warned against power morcellation use in peri- and postmenopausal women, the researchers wrote.
Overall, age is a main consideration when deciding the best course of action for a hysterectomy, Wright said.
“Our findings suggest that morcellation may be beneficial in some young women who would otherwise require laparotomy for hysterectomy,” he said. “However, in older women — those aged older than 50 years — the procedure should be avoided.”
These data will help better define the risks for patients because researchers evaluated harms and benefits of each the three surgical modalities, David Mutch, MD, professor of obstetrics and gynecology and division chief of gynecologic oncology at Washington University School of Medicine in St. Louis, wrote in an accompanying editorial.
“More data, such as those produced here, are needed to better define the real risk so that women give informed consent before undergoing a procedure,” Mutch wrote. “Additionally, as other techniques such as morcellating the uterus in a containment bag become more common, we should obtain data on their safety and efficacy.”– by Anthony SanFilippo
Disclosure: The researchers and Mutch report no relevant financial disclosures.
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