Morcellation for myomectomy or hysterectomy

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. 

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.

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,
• You are having a laparoscopic subtotal hysterectomy (where the cervix is left in place) or,
• 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.

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,
• A quicker recovery.

• Small pieces of non-cancerous fibroid tissue could be left inside your abdomen. These may then attach to the internal organs in your abdomen where they can keep growing. You may then need to have surgery again 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. Currently, there is no test that can diagnose uterine sarcoma before surgery.
• The risk of unexpected uterine sarcoma in fibroids increases significantly with age and is higher around the time of and after your menopause. If you are over 50 years of age, your risk is higher and continues to increase as you get older. This risk ranges 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).
• For this reason, morcellation is not recommended during surgery for women who are over the age of 50, or are postmenopausal.
• If an unexpected uterine sarcoma is morcellated then it can potentially cause the cancer to spread and lower your chances of survival. 

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

• Fibroids that are getting bigger quickly before your menopause
• 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
• Irregular vaginal bleeding.

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

Depending on your individual circumstances, your healthcare professional 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 healthcare professional.

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.