Concern over power morcellation has led to new procedure methods.
Grand Rounds
Figure 1
Minimally invasive surgery for fibroids
THE AUTHOR
Dr Sam Saidi is a senior staff specialist in gynaecological oncology at the Chris O’ Brien Lifehouse, Royal Prince Alfred Hospital, Sydney, NSW.
Dr Veronica Lim is an obstetrics and gynaecology registrar at Hornsby Ku-ring-gai Hospital, NSW.
HAVE AN INTERESTING CLINICAL CASE?
Email the editor at jo. hartley @ adg. com. au. We pay $ 400 for each case and photos are encouraged.
GYNAECOLOGICAL ONCOLOGY
Concern over power morcellation has led to new procedure methods.
Case one A 59-YEAR-old postmenopausal woman is referred to the gynaecological oncology department for enlarging fibroids.
Examination reveals a BMI of 26 with a palpable abdominal mass. She is referred for a pelvic MRI as part of a preoperative workup( figure 1). The MRI demonstrates multiple fibroids, some up to 10cm in size.
She opts for surgical management over surveillance, specifically requesting a minimally invasive approach.
Using a laparoscopic approach( figures 2A and 2B), the uterus is excised intact and placed into a laparoscopic bag. Manual morcellation( cutting up into small pieces) is then performed with scissors vaginally, within the bag, to extract the fibroid through the vagina.
The patient is discharged the next day. Histopathology returns as consistent with benign leiomyomas with adenomyosis.
Case two A 43-year-old woman is referred to the gynaecological oncology department with atypical fibroids detected on MRI, prompted by an ultrasound for heavy menstrual bleeding.
Hysterectomy is recommended over myomectomy as there exists a risk, in the order of 10 %, of recurrent disease following conservative resection of a leiomyosarcoma( LMS).
The patient, however, is nulliparous and wishes to retain her fertility, so myomectomy is planned. This is performed through a mini-Pfannenstiel incision
( figure 3). She is discharged the next day and histopathology is returned as benign leiomyoma.
Discussion Fibroids or uterine leiomyomas are very common in women of reproductive age, affecting at least 25 % of this population. Uterine LMS is much rarer, with an estimated incidence of 0.65 per 100,000 women.
A recent meta-analysis has estimated the prevalence of sarcomatous change as 0.14 %( one in 700). 1 Sarcoma should be considered in women over 40, especially if they present with a rapidly growing pelvic mass.
MRI with contrast enhancement is the imaging of choice. Suspicious features include a large heterogeneous hypointense mass with irregular borders on T1-weighted images with areas of enhancement consistent with focal areas of necrosis and haemorrhage. 2
However, there are no radiological features pathognomonic for LMS. No available test exists to confidently distinguish it from fibroids. Although MRI is the most accurate test available to detect sarcomas preoperatively, approximately one in four will be missed. 1
The short-term benefits of minimally invasive surgery over traditional laparotomy have been well established. Laparoscopic hysterectomy is associated with a significant reduction in length of hospital stay, blood loss and wound infections, with faster recovery time. 3
A large fibroid uterus, however, poses a challenge, as it requires morcellation in order to retrieve the specimen at laparoscopic surgery. The potential for dissemination of a sarcomatous fibroid, resulting in
Figure 2B
upstaging, must therefore be a consideration.
A well-publicised case in the US, involving the wife of cardiothoracic surgeon Dr Hooman Noorchashm, has led to scrutiny of power morcellation, prompted by calls to ban the practice. 4
Recently, the TGA has released a safety update on the use of power morcellation because of the risk of disseminating potential sarcoma into the peritoneum. 5
Although this is a valid concern, a recent metaanalysis by Pritts and colleagues has not found any reliable evidence to support this view. 6 Nevertheless, the controversy itself has encouraged gynaecologists and gynaecological oncologists to rethink the methods used in minimally invasive surgery. An alternative to open surgery is in-bag morcellation. A small, prospective cohort study has dem-
Delivered in the Respimat Soft Mist ™ Inhaler 1, 2
1,2
SPIRIVA Respimat PBS Information: Restricted benefit. Chronic obstructive pulmonary disease.
SPIOLTO Respimat PBS Information: Authority required( STREAMLINED). Code 5763. Chronic obstructive pulmonary disease( COPD). Refer to PBS schedule for full authority information.
Please review Product Information before prescribing. Full Product Information is available at www. boehringer-ingelheim. com. au / PI. Further information is available from Boehringer Ingelheim Pty Ltd.
MINIMUM PRODUCT INFORMATION( COMBINED – COPD). SPIRIVA ® RESPIMAT ®( tiotropium bromide) solution for inhalation 2.5 microgram / actuation and SPIOLTO ® RESPIMAT ® [ tiotropium( as bromide monohydrate)/ olodaterol( as hydrochloride)] solution for inhalation 2.5 micrograms / 2.5 micrograms. INDICATIONS: SPIRIVA RESPIMAT: Long term maintenance treatment of bronchospasm and dyspnoea associated with chronic obstructive pulmonary disease( COPD). Prevention of COPD exacerbations. SPIOLTO RESPIMAT: Once-daily maintenance bronchodilator treatment to relieve symptoms in adult patients with COPD. CONTRAINDICATIONS: SPIRIVA RESPIMAT and SPIOLTO RESPIMAT: Hypersensitivity to tiotropium bromide, olodaterol( SPIOLTO only), atropine or its derivatives, or to any of the excipients. PRECAUTIONS: SPIRIVA RESPIMAT and SPIOLTO RESPIMAT: Should not be used: more frequently than once daily; for relief of acute symptoms, treatment of acute episodes of bronchospasm, immediate hypersensitivity reactions, paradoxical bronchospasm, narrow-angle glaucoma, prostatic hyperplasia, bladder neck obstruction, urinary retention, micturition diffi culties, recent myocardial infarction(< 6 months for SPIRIVA, < 12 months for SPIOLTO), unstable or life-threatening cardiac arrhythmia within past year, hospitalisation for heart failure within past year, moderate to severe renal impairment( CrCL ≤ 50 mL / min), pregnancy, lactation and children. Avoid solution or mist entering eyes. SPIRIVA RESPIMAT: Should not be used for: fi rst-line treatment for asthma, dry mouth. SPIOLTO RESPIMAT: Should not be used: in treatment of asthma( LABAs may increase the risk of asthma-related hospitalisations and death); initiated in acutely deteriorating COPD, severe hepatic impairment, convulsive disorders, thyrotoxicosis, QT interval prolongation, unusual responsiveness to sympathomimetic amines; increases in pulse rate, blood pressure and / or symptoms of clinically signifi cant cardiovascular effect, paroxysmal tachycardia(> 100 beats per minute), hypokalaemia, hyperglycaemia. INTERACTIONS: SPIRIVA RESPIMAT and SPIOLTO RESPIMAT: Co-administration with anticholinergic drugs. SPIOLTO RESPIMAT: Co-administration with adrenergic agents, xanthine derivatives, steroids, non-potassium sparing diuretics, beta-blockers, MAO inhibitors, tricyclic antidepressants, QTc interval prolonging drugs, LAMAs, LABAs. ADVERSE EFFECTS: SPIRIVA RESPIMAT: Common: Dry mouth, usually mild. SPIOLTO RESPIMAT: Very common: nasopharyngitis. Common: pneumonia, bronchitis, infl uenza, urinary tract infection, sinusitis, cough, dyspnoea, back pain, dry mouth. Others, see full PI. DOSAGE: SPIRIVA RESPIMAT: For oral inhalation. 5 μg tiotropium given as two puffs once daily, at the same time each day. SPIOLTO RESPIMAT: For oral inhalation. 5 μg tiotropium and 5 μg olodaterol given as two puffs once daily, at the same time each day. Do not exceed recommended dose. Cartridges to be used only with RESPIMAT inhaler. January 2017. References: 1. SPIRIVA Respimat approved Product Information( 13 September 2016). 2. SPIOLTO Respimat approved Product Information( 10 June 2015). TM Trademark. ® Registered trademark. Boehringer Ingelheim Pty Ltd. ABN 52 000 452 308. 78 Waterloo Road, North Ryde, NSW 2113. AUS / SPRES-171036. McCann Health 10724474. MARCH 2017.
14 | Australian Doctor | 12 May 2017 www. australiandoctor. com. au