Introduction
Minimally invasive procedures in the treatment of symptomatic leiomyomas procure numerous benefits including avoidance of hysterectomy in those women wanting to preserve fertility. The use of power morcellation during these procedures is currently discouraged due to the potential risk of dissemination of malignant or even benign tissue 1.
Clinical description
Ms GT, 43 years old, G1P1, presented with uterine bleeding and a solid abdominal wall lesion, shown to be fibroid tissue on core biopsy. This is on background of aggressive leiomyomatous disease and a number of myomectomies over 11 years, including a laparoscopic myomectomy with morcellation in 2012. Multi-modal imaging demonstrated fibroid uterus and soft tissue masses in the pelvis and right anterior abdominal wall. Ultrasound pelvis revealed left adnexal mass not separately identified from left ovary. Tumour markers produced an increased Risk of Ovarian Malignancy Algorithm (ROMA) result. Ms GT underwent a laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, removal of multiple pelvic and anterior abdominal wall nodule, omentectomy and appendicectomy. Histopathology revealed multiple uterine and extra-uterine leiomyomas, with no evidence of malignancy. Histopathological impression was multiple parasitic leiomyomas potentially secondary to previous morcellation. Cytology of peritoneal washings showed no malignant cells.
Discussion
Leiomyomas are the most common pelvic neoplasm in women and despite having the potential to cause a number of symptoms1 are thankfully benign. Minimally invasive procedures have revolutionised the treatment of leiomyomas, however, in 2014, the American Food and Drug Administration released a warning discouraging the use of power morcellation during hysterectomy or myomectomy for uterine fibroids1. This warning is based on the potential for morcellation to disseminate both malignant or even benign tissue1. Currently, there is no reliable diagnostic technique to distinguish women with malignant masses from those presenting with benign uterine masses and as such, the risk of inadvertently spreading previously unknown malignant tissue should always be considered3. With this knowledge, power morcellation should only be engaged following careful patient selection and thorough discussion with patients regarding the risks and benefits of this procedure2.
Conclusion
Uterine leiomyomas are common benign masses which can be clinically difficult to distinguish from their rarer malignant counterparts3. Power morcellation during myomectomy or hysterectomy allows for greater practice of minimally invasive techniques2, however potentially increases the risk of tissue dissemination 1. This risk needs to be considered by both practitioners and patients prior to the decision to use this surgical technique2.