Association Between Power Morcellation and Mortality in Women With Unexpected Uterine Cancer Undergoing Hysterectomy or Myomectomy

Abstract

Purpose: Despite concerns that power morcellation may adversely affect prognosis of patients with occult uterine cancer, empirical evidence has been limited and inconclusive. In this study, we aimed to determine whether uncontained power morcellation at the time of hysterectomy or myomectomy is associated with increased mortality risk in women with occult uterine cancer.

Methods: By linking statewide hospital discharge records with cancer registry data in New York, we identified 843 women with occult endometrial carcinoma and 334 women with occult uterine sarcoma who underwent a hysterectomy or myomectomy for presumed benign indications during the period October 1, 2003, through December 31, 2013. Within this cohort, we compared disease-specific and all-cause mortality of women who underwent laparoscopic supracervical hysterectomy/laparoscopic myomectomy (LSH/LM), a surrogate indicator for uncontained power morcellation, with women who underwent supracervical abdominal hysterectomy and total abdominal hysterectomy (TAH), which did not involve power morcellation. Multivariable Cox regressions and propensity score method were used to adjust for patient characteristics.

Results: Among women with occult uterine sarcoma, LSH/LM was associated with a higher risk for disease-specific mortality than TAH (adjusted hazard ratio [aHR], 2.66, 95% CI, 1.11 to 6.37; adjusted difference in 5-year disease-specific survival, -19.4%, 95% CI, -35.8% to -3.1%). In the subset of women with leiomyosarcoma, LSH/LM was associated with an increased risk for disease-specific mortality compared with supracervical abdominal hysterectomy (aHR, 3.64, 95% CI, 1.50 to 8.86; adjusted difference in 5-year disease-specific survival, -31.2%, 95% CI, -50.0% to -12.3%) and TAH (aHR, 4.66, 95% CI, 1.97 to 11.00; adjusted difference in 5-year disease-specific survival, -37.3%, 95% CI, -54.2% to -20.3%). Among women with occult endometrial carcinoma, there was no significant association between surgical approach and disease-specific mortality.

Conclusion: Uncontained power morcellation was associated with higher mortality risk in women with occult uterine sarcoma, especially in those with occult leiomyosarcoma.

FIG 1.

Patient flow diagram. (*) The New York Statewide Planning and Research Cooperative System (SPARCS) redacted information on patient identifiers and dates to protect the confidentiality for abortion- or HIV-related encounters. (†) Four patients had both occult endometrial carcinoma and occult uterine sarcoma and were analyzed as uterine sarcoma patients since uterine sarcoma had worse prognosis. LSH/LM, laparoscopic supracervical hysterectomy/laparoscopic myomectomy; SAH, supracervical abdominal hysterectomy; TAH, total abdominal hysterectomy.

FIG 2.

(A) Disease-specific survival for occult endometrial carcinoma (unadjusted). Log-rank test for difference across surgical groups has P = .72. (B) Disease-specific survival for occult uterine carcinoma (unadjusted). Log-rank test for difference across surgical groups has P = .46. (C) Disease-specific survival for occult leiomyosarcoma (unadjusted). Log-rank test for difference across surgical groups has P = .53. LSH/LM, laparoscopic supracervical hysterectomy/laparoscopic myomectomy; SAH, supracervical abdominal hysterectomy; TAH, total abdominal hysterectomy.

FIG 3.

(A) Mean adjusted disease-specific survival for occult endometrial carcinoma. (B) Mean adjusted disease-specific survival for occult uterine sarcoma. (C) Mean adjusted disease-specific survival for occult leimyosarcoma. The survival curve in this figure for each surgical group reflects mean adjusted survival probability at each time point among patients in the sample. Each patient’s survival probability at a given time point was estimated based on her characteristics and regression Model 2 for disease-specific survival in Table 3, while assuming that she was in the LSH/LM, SAH, or TAH group, respectively. The sample average survival probability at each time point was then derived for each group. LSH/LM, laparoscopic supracervical hysterectomy/laparoscopic myomectomy; SAH, supracervical abdominal hysterectomy; TAH, total abdominal hysterectomy.

FIG A1.

Mean adjusted disease-specific survival curves for patients with localized cancer. (A) Occult endometrial carcinoma. (B) Occult uterine sarcoma. (C) Occult leiomyosarcoma. LSH/LM, laparoscopic supracervical hysterectomy/laparoscopic myomectomy; SAH, supracervical abdominal hysterectomy; TAH, total abdominal hysterectomy.

FIG A2.

Unadjusted Kaplan-Meier curves for all-cause survival. (A) Occult endometrial carcinoma (log-rank test for difference across surgical groups, P = .75). (B) Occult uterine sarcoma (log-rank test for difference across surgical groups, P = .75). (C) Occult leiomyosarcoma (log-rank test for difference across surgical groups, P = .99). LSH/LM, laparoscopic supracervical hysterectomy/laparoscopic myomectomy; SAH, supracervical abdominal hysterectomy; TAH, total abdominal hysterectomy.