Research ajog.

org

GYNECOLOGY
Uterine sarcomas and parasitic myomas
after laparoscopic hysterectomy with
power morcellation
Jasmine Tan-Kim, MD, MAS; Katherine A. Hartzell, MD; Caryl S. Reinsch, MD;
Cristina H. ODay, MD; John S. Kennedy, MD; Shawn A. Menefee, MD; Terry A. Harrison, MD

OBJECTIVE: The purpose of this study was to describe the incidence
and risk factors for uterine sarcomas and parasitic myomas at the time
of power morcellation.
STUDY DESIGN: We performed a retrospective review of 3523
women who underwent laparoscopic hysterectomy from 2001-
2012. Univariate analyses were used for the morcellation cases to
identify potential risk factors. Multivariable logistic regression was
performed.
RESULTS: Nine hundred forty-one patients underwent power mor-
cellation at the time of hysterectomy; 10 of 941 patients (1.1%) were
diagnosed subsequently with uterine sarcomas or parasitic myomas.
The overall incidence of uterine sarcoma was 6 of 941 (0.6%), with a
median age of 47 years (range, 41e52 years). There was no asso-
ciation among any of the factors analyzed and uterine sarcoma. Three
of 6 patients had sarcoma diagnosed on initial pathologic evaluation of
the morcellated specimen; 3 patients had delayed diagnosis of
sarcoma with benign disease at the time of the initial procedure
(median time to second evaluation, 6 years). For parasitic myomas
(n 4), the median age was 35 years (range, 32e40 years), and the
median time to second evaluation was 5 years. On multivariate
analysis, age <40 years (odds ratio, 26; 95% confidence interval,
2.7015e261.9; P  .01) was associated with higher risk of the
development of parasitic myomas.
CONCLUSION: Uterine sarcoma was found in 0.6% of patients who
underwent power morcellation but was not found to be associated
significantly with any preoperative factors. All 6 cases were noted to
have apparent fibroid tumors as an indication for their hysterectomy.
Age <40 years was a risk factor for parasitic myomas after power
morcellation. Patients should be counseled about these complications
before power morcellation.
Key words: laparoscopic hysterectomy, parasitic myomas, power
morcellation, uterine sarcoma

Cite this article as: Tan-Kim J, Hartzell KA, Reinsch CS, et al. Uterine sarcomas and parasitic myomas after laparoscopic hysterectomy with power morcellation. Am J
Obstet Gynecol 2015;212:.

M ore than 600,000 hysterectomies

are performed in the United
States annually, with 40% performed
laparoscopically.1,2 Laparoscopic hyster-
ectomy is associated with fewer post-
operative complications, less blood loss,
less postoperative pain, decreased hos-
pital stay, and faster recovery time when
compared with the open abdominal
approach.1,3 Power morcellation is per-
formed during laparoscopic supra-
cervical hysterectomy, laparoscopic
myomectomy, and laparoscopic total
hysterectomy when the uterus is too
large to pass through the vaginal canal.4
It involves the division of uterine tissue
with the use of a rotating circular blade
to facilitate removal of the specimen.
Power morcellation has raised concern
for potential dissemination of benign or
malignant tissue. The Food and Drug
Administration (FDA) recently issued a
warning discouraging the use of power
morcellation with uterine broid
tumors.5
Spindle cell neoplasms are tumors
of the uterine smooth muscle or

From the Divisions of Female Pelvic Medicine and Reconstructive Surgery (Drs Tan-Kim and Menefee) and Gynecologic Oncology (Dr Harrison),
Department of Obstetrics and Gynecology (Drs Hartzell, Reinsch, and Kennedy), Kaiser Permanente San Diego, San Diego, and Department of
Obstetrics and Gynecology (Dr ODay), St. Joseph Hospital, Orange, CA.
Received Aug. 18, 2014; revised Oct. 16, 2014; accepted Dec. 2, 2014.
The authors report no conict of interest.
Presented in oral format at the 43rd Global Congress on Minimally Invasive Gynecology of the American Association of Gynecologic Laparoscopists,
Vancouver, BC, Canada, Nov. 17-21, 2014; in poster format at the 61st Annual Scientic Meeting of the Society for Gynecologic Intervention, Florence,
Italy, March 26-29, 2014; in poster format at the 62nd annual meeting of the Pacic Coast Reproductive Society, Indian Wells, CA, March 19-23, 2014;
and in oral format at the annual meeting of Districts V, VI, VIII, and IX of the American Congress of Obstetricians and Gynecologists, Maui, HI, Sept.
26-28, 2013.
Corresponding author: Jasmine Tan-Kim, MD, MAS. Jasmine.X.Tan-Kim@kp.org
0002-9378/$36.00  2015 Elsevier Inc. All rights reserved.  http://dx.doi.org/10.1016/j.ajog.2014.12.002

MONTH 2015 American Journal of Obstetrics & Gynecology 1.e1

Research Gynecology
endometrial stroma. They include
parasitic myomas and uterine sarcomas.
Uterine sarcomas are malignant tumors
of uterine connective tissue and include
leiomyosarcoma, endometrial stromal
sarcoma, carcinosarcoma, and undiffer-
entiated sarcoma, with a reported inci-
dence of 0.2%.5-7 They often behave
more aggressively and are associated
with a poorer prognosis than endome-
trial cancers.8,9 There are no specic
symptoms or signs or reliable diagnostic
modalities to differentiate benign from
malignant uterine tumors before they
are morcellated and removed.10,11 Para-
sitic myomas are dened as leiomyomas
that are not attached to the uterus and
are parasitic because they receive their
blood supply from surrounding or-
gans.12 They have a reported incidence of
0.12-0.9% after laparoscopic surgery
with power morcellation.12-15
The objectives of this study were (1)
to describe the rates of spindle cell
neoplasm formation after power mor-
cellation and (2) to identify risk factors
for formation of either uterine sarcoma
or parasitic myomas at the time of
laparoscopic hysterectomy with power
morcellation.
M ATERIALS AND M ETHODS
This was an institutional review
boardeapproved, retrospective study of
women who underwent laparoscopic
hysterectomy at Kaiser Permanente San
Diego from 2001-2012.
Patient charts were reviewed after
cases were identied with the use of
surgical case logs. Demographic and
clinical characteristics, surgical tech-
niques, pathology reports, and periop-
erative complications were abstracted
by physician reviewers and individually
entered into an Access Database
(Microsoft Access 2007; Microsoft Inc,
Seattle, WA). Baseline characteristics
were collected: age, gravidity, parity,
ethnicity, body mass index, presence
of diabetes mellitus, hypertension,
collagen vascular disease, use of to-
bacco, alcohol, or drugs, presence of
sexual activity, menopausal status, use
of hormones, use of leuprolide or the
progestin intrauterine device, number
of vaginal deliveries, and history of
1.e2 American Journal of Obstetrics & Gynecology MONTH 2015
pelvic surgery or endometrial ablation.
Pathology reports were carefully re-
viewed and coded for the presence of
broid tumors, endometriosis, adeno-
myosis, endometrial hyperplasia,
cervical dysplasia, or malignancy.
Operative techniques, removal of the
ovaries, uterine specimen weight, esti-
mated blood loss, and complications
were also abstracted.
Total laparoscopic hysterectomy was
dened as removal of the uterus and
cervix. If the uterine body was too large
to t through the vagina, it was often
morcellated laparoscopically to facilitate
retrieval. Laparoscopic supracervical hys-
terectomy was dened as removal of the
uterus above the level of the cervix fol-
lowed by laparoscopic morcellation to
remove the uterine body. In this study,
bags were not used to contain morcel-
lated contents.
To address our primary objective,
we evaluated patients who underwent
power morcellation and identied those
diagnosed with either uterine sarcoma
or parasitic myomas. Fisher exact test
and Mann Whitney U test were used to
conduct univariate analyses to identify
potential risk factors for parasitic my-
omas and for uterine sarcoma. The 28
baseline characteristics listed previously
were analyzed as potential risk factors.
Multivariable logistic regression was
used to assess the independent risk fac-
tors. Variables were included if they had
a probability value of < .10 on univari-
ate analysis or if the variable was deter-
mined to be an important biologic risk
factor. Odds ratios (ORs) and 95%
condence intervals (CIs) were re-
ported. A probability value of < .05 was
considered statistically signicant. Sta-
tistical analysis was performed with
SPSS software (version 18.0, SPSS Inc,
Chicago, IL).
R ESULTS
A total of 3523 women underwent
laparoscopic hysterectomy. Of these, 941
women underwent power morcellation.
Of those who had power morcellation,
10 women were subsequently diagnosed
with uterine sarcoma or parasitic my-
omas, for an overall incidence of 1.1%
(10/941 women).
ajog.org
Uterine sarcoma
Of the 10 women who received a diag-
nosis of spindle cell neoplasms, 6 tumors
(0.6%) were uterine sarcomas. De-
mographic characteristics are shown in
Table 1. Three of the 6 uterine sarcomas
were endometrial stromal sarcomas, and
3 were leiomyosarcomas (2 low-grade
and 1 high-grade; Table 2). Only 3 of
the 6 patients received a diagnosis of
uterine sarcoma on pathologic evalua-
tion at the time of hysterectomy
with morcellation. These 3 patients un-
derwent subsequent exploratory lapa-
rotomy, trachelectomy, and bilateral
salpingo-oophorectomy (if not per-
formed at time of hysterectomy). One
patient required resection of metastatic
implants, omentectomy, appendectomy,
and adjuvant therapy with the use of
Megace (Table 3; patients #1-3). The
other 3 patients were examined from 2-7
years after hysterectomy with 1 pelvic
masses; pathologic evaluation of these
recurrent masses revealed uterine sar-
coma (patients #4-6). There were no
signicant associations among any of
the potential risk factors and uterine
sarcoma.
Uterine sarcoma with initially benign
pathologic evidence
Three of the women in the uterine
sarcoma group had benign leiomyoma
on initial pathologic evaluation and
then had a delayed presentation of 1
abdominal or pelvic masses that sub-
sequently were found to be uterine
sarcoma. Incidence of this presenta-
tion was 0.3% (3/941 women). The
median age of these patients at the
time of initial procedure was 45 years,
and the median uterine weight at the
time of morcellation was 486 g. The
median amount of time to second
evaluation was 6 years. All patients
were imaged with a computed to-
mography scan, which revealed single
or multiple pelvic masses, the largest
of which was 15  16 cm (Figure 1).
All patients underwent exploratory
laparotomy and resection of masses.
On nal pathologic evaluation, 1 pa-
tient was diagnosed with endometrial
stromal sarcoma, and 2 patients were
diagnosed with leiomyosarcoma (1 low
ajog.org Gynecology Research
of this study. It was unclear from the
TABLE 1 records whether that pathology report
Demographic characteristics of subjects with uterine sarcoma who was reviewed ofcially and left un-
underwent morcellation changed or never reviewed. Patient #6
Uterine sarcoma (high-grade leiomyosarcoma, 6 years
Variable No (n [ 935) Yes (n [ 6) P value after initial surgery) had her disease
reviewed, and high-grade leiomyo-
Mean age, y a
46  6 44  5 .65b
sarcoma was not found on the available
Body mass index, kg/m 2a
29  6 30  12 .73b tissue specimen of her original mor-
<25 kg/m2, n (%) 222 (26) 3 (50) .18c cellated uterus.
25 kg/m2, n (%) 642 (74) 3 (50) At the time of the study conclusion, 5
of the 6 patients who had morcellation of
Ethnicity, n (%) .61c uterine sarcoma were living without ev-
White 530 (57) 4 (67) idence of recurrent disease, with a min-
Hispanic 200 (21) 2 (33) imum of 31 months of follow up. The
patient with high-grade leiomyosarcoma
African American 129 (14) 0
had died of the disease 3 years after
Asian/other/unknown 76 (8) 0 diagnosis (patient #6).
Smoking (current), n (%) 95 (11) 0 .40c
Uterine sarcoma in patients who did
Diabetes mellitus, n (%) 49 (5) 0 .56c
not undergo morcellation
Hypertension, n (%) 224 (24) 1 (17) .67c Our primary objective was to describe
Menopausal, n (%) 73 (8) 1 (17) .43c the incidence of uterine sarcomas and
Hormones (at time of history and 215 (26) 2 (33) .23c parasitic myomas at the time of power
physical), n (%) morcellation. However, we thought it
Use of leuprolide, n (%) 327 (39) 2 (33) .66c would be interesting to also report the
incidence of sarcoma in the patients
Use of progestin intrauterine device, n (%) 18 (2) 0 .76c
who did not undergo morcellation in
Type of laparoscopic hysterectomy .54c our laparoscopic hysterectomy popula-
performed, n (%) tion. During the same study period, a
Total laparoscopic hysterectomy 262 (28) 1 (17) total of 2582 women underwent lapa-
Supracervical laparoscopic 673 (72) 5 (83) roscopic hysterectomy but did not have
hysterectomy power morcellation. All women un-
derwent total hysterectomy at a mean
One or both ovaries left intact, n (%) 608 (65) 3 (50) .37c
age of 46  8 years and uterine weight
Uterine weight, ga 333  261 458  248 .25b 189  141 g. Of these, 5 women received
>350 g, n (%) 262 (28) 3 (50) .36c a diagnosis of uterine sarcoma (0.19%;
Fibroid tumors (pathologic specimen), n (%) 802 (86) 5 (83)d .87c
5/2582 women). Two women received a
diagnosis of low-grade endometrial
Adenomyosis (pathologic specimen), n (%) 240 (26) 1 (17) .61c stromal sarcoma, 1 with carcinosar-
Endometriosis (pathologic specimen), n (%) 64 (7) 0 .51c coma and 2 with leiomyosarcoma
Not all variables are shown; none of the variables were significant. (1 high-grade, 1 grade not specied). In
a
Data are given as mean  standard deviation; b Mann Whitney U test; c Fisher exact test; d All 6 patients who were addition, 2 patients received a diagnosis
diagnosed with uterine sarcoma had apparent fibroid tumors before surgery. Five patients had fibroid tumors noted on of smooth muscle tumor of uncertain
pathologic specimen from initial surgery (represented in this variable); 1 patient had only sarcoma without mention of fibroid
tumors on specimen. malignant potential. At the time of
Tan-Kim. Uterine sarcomas, parasitic myomas, and power morcellation. Am J Obstet Gynecol 2015. study conclusion, 4 of the 5 patients
with a diagnosis of sarcoma and the 2
patients with smooth muscle tumor of
grade; 1 high grade.) Associated risk to have a cellular leiomyoma on her uncertain malignant potential were
factors were not found to be morcellated specimen actually had a alive without evidence of disease at a
signicant. low-grade endometrial stromal sar- minimum of 37 months of follow up.
Two of these 3 patients had their coma at the time of initial surgery. This The patient with high-grade leiomyo-
original pathologic specimens reviewed report was ofcially amended. Patient sarcoma died of the disease 2 years after
at the time of the second evaluation. #5 did not have an amended pathology diagnosis. The details of the clinical
It was determined on re-review that report, and the tissue specimen was no courses of these patients can be found in
patient #4 who was originally reported longer available for review at the time Table 4.

MONTH 2015 American Journal of Obstetrics & Gynecology 1.e3

Research Gynecology ajog.org

Parasitic myomas
The remaining 4 of 10 women diagnosed

Low-grade endometrial

Low-grade endometrial

usual type leiomyoma

Pieces of leiomyoma,
Pieces of leiomyoma
endometrial stromal
with spindle cell neoplasms were found

Cellular leiomyoma,

(review of disease:
Disease at initial

Leiomyosarcoma,
stromal sarcoma

stromal sarcoma
to have parasitic myomas (0.4%; 4/941

adenomyosis
women). The demographic characteris-
procedure

grade II-III

sarcoma)
tics of these patients are shown in
Table 5. All women with parasitic my-
omas received the diagnosis many years
after their laparoscopic hysterectomy;
weight, g

the median amount of time to evaluation

Uterine

was 5 years. The most common symp-

720

218

285

787

486

250
tom was a self-palpated mass, followed
by abdominal pain. One patient was
asymptomatic, and the recurrent my-
Laparoscopic supracervical

Laparoscopic supracervical

Laparoscopic supracervical

Laparoscopic supracervical

Laparoscopic supracervical
morcellation, left salpingo-
hysterectomy with uterine
omas were noted at the time of surgery
salpingo-oophorectomy

salpingo-oophorectomy

salpingo-oophorectomy
hysterectomy, bilateral

hysterectomy, bilateral

hysterectomy, bilateral
for pelvic organ prolapse repair. All of
Details of procedures of the 6 patients who were diagnosed with uterine sarcoma after power morcellation

Total laparoscopic

the patients who had symptoms under-

oophorectomy
went computed tomography scanning,
hysterectomy

hysterectomy
Procedure

which showed single or multiple pelvic

masses, the largest of which was 18  18
cm (Figure 2). All patients underwent
subsequent reoperation with resection of
fibroid tumor (8  9  10
(20  10  9 cm), fundal

pelvic masses; 2 of the women had lap-

Fibroid uterus, abnormal

(10  7  8 cm), 6 cm
tumors (3  4  4 cm)

Slightly enlarged uterus

Enlarged uterus (14 

posterior fibroid tumor

aroscopy, and 2 women underwent
and (5  5  4 cm)
5  7 cm), 2 fibroid
heterogeneity of the

exploratory laparotomy. Final patho-

ultrasound scan
Enlarged uterus

logic evidence for all of these patients

Preoperative

endometrium

showed benign leiomyoma, and all pa-

tients were living without evidence of
None

None
cm)

recurrence at the time of the study

conclusion.
On multivariate analysis, age <40
curettage done at time
of procedure (benign)
None: frozen section
endometrial biopsy

years was found to be a signicant risk

factor (OR, 26; 95% CI, 2.7e261.9; P
Tan-Kim. Uterine sarcomas, parasitic myomas, and power morcellation. Am J Obstet Gynecol 2015.
Preoperative

.005) for the development of parasitic

myomas. There was a trending associa-
Benign

Benign

Benign

Benign

tion between uterine weight >350 g

None

and parasitic myomas; however, this

approached but did not meet statistical
signicance (OR, 7.0; 95% CI, 0.7e69.4;
postmenopausal
Fibroid tumors,

Fibroid tumors,

Fibroid tumors,

Fibroid tumors,

Fibroid tumors,

Fibroid tumors,
hysterectomy
Indication for

P .098).
menorrhagia,
menorrhagia

menorrhagia

menorrhagia
discomfort
abdominal

pelvic pan
bleeding

C OMMENT
Our study represents one of the largest
series of laparoscopic hysterectomies
performed in a large health maintenance
Menopausal at

hysterectomy

organization (HMO) setting with long-

term follow up. With regards to uterine
time of

sarcoma, the number of cases was too

Yes
No

No

No

No

No

small to show an association with the

potential risk factors. It should be noted
Age, y

that all 6 of the patients with sarcoma

47

41

51

45

41

48

were thought to have broid uteri during

their preoperative evaluations. Five of
TABLE 2

Patient

the patients with uterine sarcoma had

broid tumors noted on their initial
1

pathologic specimen with or without

1.e4 American Journal of Obstetrics & Gynecology MONTH 2015

 ajog.org
TABLE 3
Survival status of the 6 patients who were diagnosed with uterine sarcoma after power morcellation
Sarcoma
diagnosed at Time to second Adjuvant Follow
Patient initial procedure evaluation Symptoms Restaging Tumor type treatment up, mo Survival status
1 Yes N/A N/A Yes: exploratory laparotomy, Low-grade endometrial Megace 135 Alive; no disease
trachelectomy, resection of stromal sarcoma
metastatic implants,
omentectomy, appendectomy
2 Yes N/A N/A Yes: exploratory laparotomy, Low-grade endometrial None 48 Alive; no disease
trachelectomy, bilateral stromal sarcoma
salpingo-oophorectomy; no
evidence of disease
3 Yes N/A N/A Yes: exploratory laparotomy, Leiomyosarcoma, None 31 Alive; no disease
trachelectomy; no evidence of grade II-III
disease
4 No 23 mo Pelvic pain Yes: exploratory laparotomy, Low-grade endometrial Megace 75 Alive; no disease
bilateral salpingo-oophorectomy, stromal sarcoma
resection of pelvic masses,
MONTH 2015 American Journal of Obstetrics & Gynecology

omentectomy; bowel resection

and anastomosis
5 No 7y Pelvic pressure Yes: exploratory laparotomy, Low-grade None 51 Alive; no disease
resection of abdominopelvic mass, leiomyosarcoma
bilateral salpingo-oophorectomy
6 No 6y Abdominal pain Yes: exploratory laparotomy, High-grade Chemotherapy, 36 Died of disease

Gynecology
resection of pelvic masses, leiomyosarcoma radiation, additional
appendectomy excision of
recurrent masses
N/A, not applicable.
Tan-Kim. Uterine sarcomas, parasitic myomas, and power morcellation. Am J Obstet Gynecol 2014.

Research
1.e5
Research Gynecology
FIGURE 1
A 15 3 16 cm recurrent uterine
sarcoma with initially benign
fibroid tumors on pathologic
examination
Tan-Kim. Uterine sarcomas, parasitic myomas, and power
morcellation. Am J Obstet Gynecol 2014.
sarcoma. Only 1 patient had sarcoma
without mention of broid tumors. We
also found age <40 years to be associated
with a higher risk for the development of
parasitic myomas after laparoscopic
hysterectomy with power morcellation.
The incidence of uterine sarcoma in
patients who have undergone hysterec-
tomy for presumed benign broid
tumors has been investigated recently by
several national organizations that
include the FDA and the American
Congress of Obstetrics and Gynecology
(ACOG). The FDA published a total
incidence of uterine sarcoma of 0.28%
(1/352 cases) and an incidence of leio-
myosarcoma of 0.20% (1/498 cases)
based on 9 studies of women who un-
derwent hysterectomy or myomectomy
for presumed benign leiomyoma.5
ACOG published an estimated inci-
dence of uterine sarcoma of 0.2% (2/
1000 cases), based on a review and
analysis of the available scientic evi-
dence on power morcellation and occult
malignancy in gynecologic surgery.7
Neither of these data analyses was able
to include only cases in which power
morcellation was performed. Our study
describes the incidence of uterine sar-
coma with power morcellation to be
0.6% with 95% condence intervals
0.3e1.4%. In order to understand the
1.e6 American Journal of Obstetrics & Gynecology MONTH 2015
percentage risk, we must rst closely
evaluate the denominator of this study
compared to other studies. This study
is the rst to evaluate a subgroup of
patients who all underwent power
morcellation. This risk does not apply to
all women or all women who had hys-
terectomies. Power morcellation is a
technique used to remove uteri laparo-
scopically that would otherwise not be
able to be removed via a smaller incision.
In many cases, these are enlarged broid
uteri. Not surprisingly, this primary
subgroup analyzed in our study of sub-
jects who underwent power morcella-
tion had a median uterine weight which
was 2-3 times higher than the other
hysterectomy specimens that did not
require morcellation. This subgroup
can be considered a higher risk group
because these larger uteri would be
more at risk for harboring sarcoma.
Additionally, this higher apparent inci-
dence may also be explained by the in-
clusions of 3 patients who had a delayed
evaluation of uterine sarcoma when
initial disease was benign and whose
disease was discovered because of the
captive nature of the Kaiser Healthcare
System. These 3 patients were evaluated
and treated at the same institution,
despite a median of 6 years until second
evaluation.
When we evaluate the entire laparo-
scopic hysterectomy cohort, the inci-
dence of occult uterine sarcoma is
similar to previous reports (11/3523,
0.3%). In our study, there were no cases
of morcellated endometrial or cervical
cancer. In the Kaiser system, patients are
monitored closely for preventative
maintenance and are likely to be up-to-
date on screening tests such as Papani-
colaou smears or have been evaluated
previously for symptoms such as irreg-
ular bleeding.
One major disadvantage to power
morcellation is the loss of the gross
appearance of the specimen. Generally,
pathologic specimens are examined
grossly, and the most suspicious areas are
investigated microscopically. Morcella-
tion increases the possibility of missing
the most suspicious areas for micro-
scopic evaluation. In one case (patient
#4), the initial pathology report of
ajog.org
cellular leiomyoma was later conrmed
to be the same tissue type as the endo-
metrial stromal sarcoma that was resec-
ted at the time of second evaluation.
Morcellation results in distortion of
normal tissue that makes diagnosis more
difcult and increases the possibility of
dissemination of cellular material
(benign or malignant) throughout the
peritoneal cavity. It is not known
whether the 2 patients (patients #5 and
#6) who were diagnosed with dissemi-
nated leiomyosarcoma years after their
initial disease was benign had uterine
sarcoma in the original specimen that
was missed or had malignant trans-
formation of disseminated leiomyoma.
It is our opinion that pathologists should
be alerted to the possibility of missing a
uterine sarcoma in a morcellated spec-
imen, especially that of a large uterus.
It has been suggested that supracervical
hysterectomy leads to decreased operative
complications, decreased sexual dys-
function, and urinary issues compared
with total hysterectomy, but these ad-
vantages have not been conrmed.16-19
In female pelvic reconstructive surgery,
supracervical hysterectomy has been
associated with lower vaginal cuff mesh
erosion rates than total hysterectomy
during minimally invasive laparoscopic
sacrocolpopexy (5% vs 23%).20,21 When
performed at the time of a sacrocolpo-
pexy, the indication for hysterectomy is
usually prolapse, not an enlarged broid
uterus. In this specialized group, the risks
of mesh complications need to be
weighed against the risks of power
morcellation.
In December of 2013, a high-prole
case in the Boston area, in which a pa-
tient experienced disseminated uterine
sarcoma after morcellation of an
apparent broid uterus, was reported in
the national media,22 which called the
morcellation procedure into question.
Subsequently, on April 17, 2014, the
United States FDA issued a communi-
cation that discouraged the use of mor-
cellation at the time of hysterectomy for
uterine broid tumors, because of the
possibility of an undiagnosed uterine
sarcoma.5 The FDAs statement caused
considerable concern in the gynecologic
surgery community in light of the low
 ajog.org
TABLE 4
Clinical characteristics of patients who were diagnosed with uterine sarcoma and smooth muscle tumor of uncertain malignant potential and who did
not undergo power morcellation
Menopausal Preoperative
at time of endometrial Preoperative Uterine Adjuvant Follow
Patient Age hysterectomy Indication biopsy ultrasound scan Procedure weight, g Tumor type treatment up, mo Survival
1 81 Yes Endometrial biopsy Adenosarcoma None Total laparoscopic 109 Adenosarcoma None 37 Alive; no
with adenosarcoma hysterectomy, bilateral disease
salpingo-oophorectomy
2 49 No Fibroid tumors, Benign Enlarged uterus Total laparoscopic 154 Low-grade None 65 Alive; no
pelvic pain (15  4  7 cm), hysterectomy, right endometrial stromal disease
left posterior salpingo-oophorectomy sarcoma
fibroid tumor
(3  3  4 cm)
3 49 No Enlarged uterus, Benign Enlarged uterus Total laparoscopic Unknown Low-grade None 40 Alive; no
abnormal uterine (11  8  7 cm) hysterectomy, bilateral endometrial stromal disease
bleeding salpingo-oophorectomy sarcoma
4 66 Yes Postmenopausal Benign Fundal fibroid Total laparoscopic 383 Leiomyosarcoma None 37 Alive; no
bleeding (1 y previously) tumor hysterectomy, bilateral (grade not specified) disease
(7  7  7 cm) salpingo-oophorectomy
5 54 Yes Fibroid uterus, Benign Enlarged uterus Total laparoscopic 268 High-grade Multiple rounds 23 Died of
MONTH 2015 American Journal of Obstetrics & Gynecology

postmenopausal (14  8  8 cm), hysterectomy, bilateral leiomyosarcoma and agents of disease

bleeding multiple fibroid salpingo-oophorectomy chemotherapy
tumors, largest
5.2 cm
6 44 No Fibroid tumors, Benign Multiple fibroid Total laparoscopic 184 Smooth muscle None 52 Alive; no
ovarian mass, tumors, largest hysterectomy, bilateral tumor of uncertain disease
cervical dysplasia (5  5  3 cm) salpingo-oophorectomy malignant potential

Gynecology
7 33 No Smooth muscle Leiomyoma vs Lower uterine Laparoscopic assisted 96 Smooth muscle None 46 Alive; no
tumor of uncertain stromal lesion, fibroid tumor vaginal hysterectomy tumor of uncertain disease
malignant potential favor smooth (4  5  4 cm) malignant potential
on endometrial muscle tumor of
biopsy uncertain malignant
potential

Research
Tan-Kim. Uterine sarcomas, parasitic myomas, and power morcellation. Am J Obstet Gynecol 2014.
1.e7
Research Gynecology ajog.org

TABLE 5 FIGURE 2
Demographic characteristics of subjects with parasitic myomas after An 18 3 18 cm parasitic myoma
morcellation years after power morcellation
Parasitic myomas
Variable No (n [ 937) Yes (n [ 4) P value
Age, y a
45.5  6.2 36.5  4 < .01b,c
<40 y, n (%) 109 (12) 3 (75) < .01b,d,e
Body mass index, kg/m2a 29.1  6.4 27.5  4.9 .62a
Ethnicity, n (%) .49d
White 532 (57) 2 (50)
Hispanic 200 (21) 2 (50)
African American 129 (14) 0
Asian/other/unknown 76 (8) 0
Smoking (current), n (%) 95 (10) 0 .50d
Tan-Kim. Uterine sarcomas, parasitic myomas, and power
Diabetes mellitus, n (%) 49 (5) 0 .64d morcellation. Am J Obstet Gynecol 2014.
d
Hypertension, n (%) 224 (24) 1 (25) .97
Menopausal, n (%) 75 (8) 0 .55d
Hormones (at time of history and 217 (26) 0 .23d Gynecologic Oncology published a
physical), n (%) position statement on power morcella-
Use of leuprolide, n (%) 327 (39) 2 (50) .66d tion that did not discourage the use of
Use of progestin intrauterine device, 18 (2) 0 .76d morcellation in all cases but that rec-
n (%) ommended communication with pa-
tients regarding risks, benets, and
Type of laparoscopic hysterectomy .21d
performed, n (%) alternatives.23
Indeed, the incidence of uterine sar-
Total laparoscopic hysterectomy 263 (28) 0
coma is rare, and leiomyosarcoma ac-
Supracervical laparoscopic 674 (72) 4 (100) counts for only 30% of all uterine
hysterectomy sarcomas.10 In 2009, Park et al10,11 found
One or both ovaries left intact, n (%) 607 (65) 4 (100) .14d that tumor morcellation was associated
Uterine weight, ga 334 (261) 383 (394) .71c with higher abdominopelvic recurrence
and decreased disease-free survival for
>350 g, n (%) 314 (38) 3 (75) .12d,e
both leiomyosarcoma and endometrial
Fibroid tumors (pathologic 803 (86) 4 (100) .41d stromal sarcoma but only with decreased
specimen), n (%) survival for leiomyosarcoma. In our
Adenomyosis (pathologic 241 (26) 0 .24d study, there were 6 patients who under-
specimen), n (%) went morcellation and who were subse-
Endometriosis (pathologic 64 (7) 0 .59b quently diagnosed with uterine sarcoma,
specimen), n (%) either immediately or several years later.
Not all variables are shown. Five of these 6 patients remained disease-
a
Data are given as mean  standard deviation; b Significant probability values  .05; c Mann Whitney U test; d Fisher exact free at a minimum of 31 months of
test; e Variables included in the multivariate regression model based on probability value of < .1 or biological plausibility. follow up, and only the patient with
Tan-Kim. Uterine sarcomas, parasitic myomas, and power morcellation. Am J Obstet Gynecol 2014. high-grade leiomyosarcoma died of the
disease (3 years after diagnosis). High-
grade leiomyosarcoma has a very poor
incidence of uterine sarcoma and the Occult Malignancy in Gynecologic Sur- prognosis, even when specimens are
recognized benets of minimally inva- gery that reviewed the available litera- removed intact, with a recurrence rate of
sive surgery, which sometimes requires ture and emphasized patient counseling at least 50% even in disease that is
morcellation for patients with large and informed consent and the develop- limited to the uterus at the time of
uterine broid tumors. In response, ment of technology and training to diagnosis.24 It is unknown whether the
ACOG published a special report in May reduce the risk of disseminated tissue.7 ultimate fate of this patient was altered
2014 entitled Power Morcellation and In December 2013, the Society of by the use of power morcellation. In the

1.e8 American Journal of Obstetrics & Gynecology MONTH 2015

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2582 patients in this database who did
not undergo morcellation, one patient
was also diagnosed with high-grade
uterine leiomyosarcoma. This patients
uterus was removed intact, and she also
died of the disease 2 years after diagnosis.
Only 3 of the 9 studies in the FDAs
recent analysis included uterine sar-
comas that were morcellated, and only 2
studies specied the number of morcel-
lated sarcomas compared with the total
number of patients.6,25,26 In these 2
studies, there were 5 uterine sarcomas (3
of which were leiomyosarcoma) of 1596
patients total. At the time of the publi-
cation of those studies, all 5 of those
patients who had morcellation of a
uterine sarcoma were alive with no
apparent evidence of disease.6,25
The incidence of parasitic myomas
currently reported ranges from 0.12e
0.9%, with a lower incidence being
shown when the dataset includes a
higher number of patients.12-15 In our
study, we report the incidence of para-
sitic leiomyomas to be 0.4% of 941 pa-
tients. Although their prognosis is very
good, reoperation for diagnosis and
treatment represents a signicant
morbidity. Data on these patients was
also presented so that it is noted that
recurrent masses after laparoscopic hys-
terectomy with morcellation may be
benign.
The strengths of this study include the
analysis of a large cohort of patients over
an 11-year period who underwent lapa-
roscopic morcellation within a mature
laparoscopic program at a large HMO.
Our study population consisted of pa-
tients within a captive HMO that limits
the bias introduced by loss to follow up.
The primary limitation is the very
small number of uterine sarcomas and
parasitic myomas, which limits the
strength of the conclusions that can be
drawn from this study. Associations be-
tween the disease and potential risk
factors did not reach statistical signi-
cance. Also, this study does not include
patients who underwent vaginal mor-
cellation, who underwent morcellation
through a minilaparotomy incision
without a power morcellator, or who had
laparoscopic myomectomy. Finally, the
incidence of these conditions may
actually be higher than what is reported
in this study because of lead time.
This study contributes to the growing
literature regarding this relatively rare
and unpredictable disease process. When
a patient is to undergo a minimally
invasive procedure with possible power
morcellation, the patient should be
counseled about the possible conse-
quences of morcellation of an undiag-
nosed malignancy. The patient should be
offered alternatives such as a mini-
laparotomy for removal of an intact
specimen or an open procedure. Given
the well-known advantages of laparo-
scopic surgery compared with open
procedures and the rarity of uterine
sarcomas, we do not believe that the risk
of morcellation of occult malignancy is
sufcient to abandon power morcella-
tion completely. - 13. Nezhat C, Kho K. Iatrogenic myomas: new
REFERENCES
1. Warren L, Ladapo JA, Borah BJ,
Gunnarsson CL. Open abdominal versus lapa-
roscopic and vaginal hysterectomy: analysis of a
large United States payer measuring quality and
cost of care. J Minim Invasive Gynecol 2009;16:
581-8.
2. Center for Disease Control National
Center for Health Statistics, National Hospital
Discharge Summary 2010 [Internet]. 2010 [cited
2014 May 26]. Available at: http://www.cdc.
gov/nchs/data/nhds/4procedures/2010pro4_
numberrate.pdf. Accessed Aug. 1, 2014.
3. Walsh CA, Walsh SR, Tang TY, Slack M. Total
abdominal hysterectomy versus total laparo-
scopic hysterectomy for benign disease: a
meta-analysis. Eur J Obstet Gynecol Reprod
Biol 2009;144:3-7.
4. Jacobson GF, Shaber RE, Armstrong MA,
Hung Y-Y. Hysterectomy rates for benign in-
dications. Obstet Gynecol 2006;107:1278-83.
5. Press Announcement. FDA discourages use
of laparoscopic power morcellation for removal
of uterus or uterine broids. US Food and Drug
Administration Center for Devices and Radio-
logical Health; Silver Spring, MD: Center for
Devices and Radiological Health; 2014.
6. Seidman MA, Oduyebo T, Muto MG,
Crum CP, Nucci MR, Quade BJ. Peritoneal
dissemination complicating morcellation of
uterine mesenchymal neoplasms. PLoS One
2012;7:e50058.
7. American College of Obstetricians and Gy-
necologists. Power morcellation and occult
malignancy in gynecologic surgery: a special
report [Internet]. [cited 2014 May 26]. Available
at: http://www.acog.org/Resources_And_
Publications/Task_Force_and_Work_Group_
Reports/Power_Morcellation_and_Occult_Malig
MONTH 2015 American Journal of Obstetrics & Gynecology
Gynecology Research
nancy_in_Gynecologic_Surgery. Accessed
Dec. 1, 2014.
8. Harlow BL, Weiss NS, Lofton S. The epide-
miology of sarcomas of the uterus. J Natl Cancer
Inst 1986;76:399-402.
9. Kim WY, Chang S-J, Chang K-H, et al.
Uterine leiomyosarcoma: 14-year two-center
experience of 31 cases. Cancer Res Treat
2009;41:24-8.
10. Park J-Y, Park S-K, Kim D-Y, et al. The
impact of tumor morcellation during surgery on
the prognosis of patients with apparently early
uterine leiomyosarcoma. Gynecol Oncol
2011;122:255-9.
11. Park J-Y, Kim D-Y, Kim J-H, Kim Y-M,
Kim Y-T, Nam J-H. The impact of tumor mor-
cellation during surgery on the outcomes of
patients with apparently early low-grade endo-
metrial stromal sarcoma of the uterus. Ann Surg
Oncol 2011;18:3453-61.
12. Leren V, Langebrekke A, Qvigstad E. Para-
sitic leiomyomas after laparoscopic surgery with
morcellation. Acta Obstet Gynecol Scand
2012;91:1233-6.
class of myomas? J Minim Invasive Gynecol
2010;17:544-50.
14. Donnez O, Squifet J, Leconte I, Jadoul P,
Donnez J. Posthysterectomy pelvic adenomy-
otic masses observed in 8 cases out of a series
of 1405 laparoscopic subtotal hysterectomies.
J Minim Invasive Gynecol 2007;14:156-60.
15. Cucinella G, Granese R, Calagna G,
Somigliana E, Perino A. Parasitic myomas after
laparoscopic surgery: an emerging complication
in the use of morcellator? Description of four
cases. Fertil Steril 2011;96:e90-6.
16. Learman LA, Summitt RL, Varner RE, et al.
A randomized comparison of total or supra-
cervical hysterectomy: surgical complications
and clinical outcomes. Obstet Gynecol
2003;102:453-62.
17. Thakar R, Ayers S, Clarkson P, Stanton S,
Manyonda I. Outcomes after total versus sub-
total abdominal hysterectomy. N Engl J Med
2002;347:1318-25.
18. Gimbel H, Zobbe V, Andersen BM,
Filtenborg T, Gluud C, Tabor A. Randomised
controlled trial of total compared with subtotal
hysterectomy with one-year follow up results.
BJOG 2003;110:1088-98.
19. Kuppermann M, Summitt RL, Varner RE,
et al. Sexual functioning after total compared
with supracervical hysterectomy: a randomized
trial. Obstet Gynecol 2005;105:1309-18.
20. Tan-Kim J, Menefee SA, Luber KM,
Nager CW, Lukacz ES. Prevalence and risk
factors for mesh erosion after laparoscopic-
assisted sacrocolpopexy. Int Urogynecol J
2011;22:205-12.
21. Osmundsen BC, Clark A, Goldsmith C, et al.
Mesh erosion in robotic sacrocolpopexy. Fe-
male Pelvic Med Reconstr Surg 2012;18:86-8.
22. Brody JE. A surgical procedures risks,
unmentionedeNYTimes.com [Internet]. 2014
[cited 2014 May 26]. Available at: http://
well.blogs.nytimes.com/2014/03/17/a-surgical-
1.e9
Research Gynecology
procedures-risks-unmentioned/?_phptrue&_
typeblogs&_r0. Accessed Dec. 1, 2014.
23. SGO Position Statement: morcellation
[Internet]. 2014 [cited 2014 May 26]. Available at:
https://www.sgo.org/newsroom/position-state
ments-2/morcellation/. Accessed Dec. 1, 2014.
24. Reed NS, Mangioni C, Malmstrm H, et al.
Phase III randomised study to evaluate the role
1.e10 American Journal of Obstetrics & Gynecology MONTH 2015
of adjuvant pelvic radiotherapy in the treatment
of uterine sarcomas stages I and II: an European
Organisation for Research and Treatment of
Cancer Gynaecological Cancer Group Study
(protocol 55874). Eur J Cancer 2008;44:
808-18.
25. Sinha R, Hegde A, Mahajan C, Dubey N,
Sundaram M. Laparoscopic myomectomy: do
ajog.org
size, number, and location of the myomas form
limiting factors for laparoscopic myomectomy?
J Minim Invasive Gynecol 2008;15:292-300.
26. Leung F, Terzibachian J-J. Re: The impact
of tumor morcellation during surgery on the
prognosis of patients with apparently early
uterine leiomyosarcoma. Gynecol Oncol
2012;124:172-3.