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Current Pharmaceutical Design

Editor-in-Chief

ISSN (Print): 1381-6128
ISSN (Online): 1873-4286

Review Article

The Medical Device Applied to Uterine Fibroids Morcellation: Analysis of Critical Biological Issues and Drawbacks from A Medical-Legal Prospective

Author(s): Ospan A. Mynbaev, Radmila Sparic, Michael Stark, Antonio Malvasi, Enrico Marinelli, Simona Zaami and Andrea Tinelli*

Volume 26 , Issue 3 , 2020

Page: [318 - 325] Pages: 8

DOI: 10.2174/1381612826666200204093737

Price: $65

Abstract

Following the FDA safety communication of 2014 increasing attention has been to the treatment of uterine fibroids, due to the suspicion of a potential leiomyosarcoma (ULM). FDA banned the use of power morcellation in the US, since this technique is likely to spread malignant cells from an unsuspected ULM. We criticized the medical legal consequences of this banning among gynecologists and patients, focusing on the drawbacks of biology and surgery. The authors analyzed literature data on one side, on the incidence, diagnosis and treatment of leiomyoma and ULM, and the other side, on the power morcellations and related critical issues, trying to highlight their main controversial aspects and to outline the possible impact on patients and on medical responsibility. The alternative methods to power morcellation are more invasive surgical solutions (as mini laparotomy or culdotomy), which inevitably involve associated risks with the surgical procedure as such and always request the containing bags. Although the in-bag morcellation is a promising technique, currently the used devices are largely off-label. This highlights the surgical risk, in case of complications, of suffering for malpractice claims both for not having used a containment system, favoring the spread of the neoplasm, and for its off-label use. Since the diagnosis of ULM is by histology after surgery, the fear of legal consequences or medical malpractice for unknown ULM power morcellation, should be targeted to analyze, in terms of cost/benefit ratio, the surgical priority. It should focus on the prevention of the risk of having a rare and statistically limited ULM or on the surgical-related complications, often linked to a slowdown minimally invasive surgery, or on the use of the authorized in-bag morcellations.

Keywords: Uterine fibroid, leiomyosarcoma, power morcellation, laparoscopic myomectomy, in bag morcellation, medical liability.

[1]
Sparic R, Mirkovic L, Malvasi A, Tinelli A. Epidemiology of uterine myomas: a review. Int J Fertil Steril 2016; 9(4): 424-35.
[PMID: 26985330]
[2]
Commandeur AE, Styer AK, Teixeira JM. Epidemiological and genetic clues for molecular mechanisms involved in uterine leiomyoma development and growth. Hum Reprod Update 2015; 21(5): 593-615.
[http://dx.doi.org/10.1093/humupd/dmv030] [PMID: 26141720]
[3]
Laganà AS, Vergara D, Favilli A, et al. Epigenetic and genetic landscape of uterine leiomyomas: a current view over a common gynecological disease. Arch Gynecol Obstet 2017; 296(5): 855-67.
[http://dx.doi.org/10.1007/s00404-017-4515-5] [PMID: 28875276]
[4]
Barlin JN, Zhou QC, Leitao MM, et al. Molecular subtypes of uterine leiomyosarcoma and correlation with clinical outcome. Neoplasia 2015; 17(2): 183-9.
[http://dx.doi.org/10.1016/j.neo.2014.12.007] [PMID: 25748237]
[5]
Worhunsky DJ, Gupta M, Gholami S, et al. Leiomyosarcoma: one disease or distinct biologic entities based on site of origin? J Surg Oncol 2015; 111(7): 808-12.
[http://dx.doi.org/10.1002/jso.23904] [PMID: 25920434]
[6]
Hodge JC, Morton CC. Genetic heterogeneity among uterine leiomyomata: insights into malignant progression. Hum Mol Genet 2007; 16(Spec No 1): R7-R13.
[http://dx.doi.org/10.1093/hmg/ddm043] [PMID: 17613550]
[7]
Robboy SJ, Bentley RC, Butnor K, Anderson MC. Pathology and pathophysiology of uterine smooth-muscle tumors. Environ Health Perspect 2000; 108(Suppl. 5): 779-84.
[http://dx.doi.org/10.1289/ehp.00108s5779] [PMID: 11035982]
[8]
Parker WH, Kaunitz AM, Pritts EA, et al. Leiomyoma Morcellation Review Group. U.S. food and drug administration’s guidance regarding morcellation of leiomyomas: well-intentioned, but is it harmful for women? Obstet Gynecol 2016; 127(1): 18-22.
[http://dx.doi.org/10.1097/AOG.0000000000001157] [PMID: 26646134]
[10]
Wright JD, Tergas AI, Burke WM, et al. Uterine pathology in women undergoing minimally invasive hysterectomy using morcellation. JAMA 2014; 312(12): 1253-5.
[http://dx.doi.org/10.1001/jama.2014.9005] [PMID: 25051495]
[11]
Mahnert N, Morgan D, Campbell D, Johnston C, As-Sanie S. Unexpected gynecologic malignancy diagnosed after hysterectomy performed for benign indications. Obstet Gynecol 2015; 125(2): 397-405.
[http://dx.doi.org/10.1097/AOG.0000000000000642] [PMID: 25569001]
[12]
Ricci S, Angaritaa A, Cholakianb D, et al. Preoperative patient stratification results in low rates of occult uterine malignancy in women undergoing uterine surgery and morcellation. Gynecol Oncol 2015; 137(1): 11-2.
[http://dx.doi.org/10.1016/j.ygyno.2015.01.025]
[13]
Pritts EA, Vanness DJ, Berek JS, et al. The prevalence of occult leiomyosarcoma at surgery for presumed uterine fibroids: a meta-analysis. Gynecol Surg 2015; 12(3): 165-77.
[http://dx.doi.org/10.1007/s10397-015-0894-4] [PMID: 26283890]
[14]
Bojahr B, De Wilde RL, Tchartchian G. Malignancy rate of 10,731 uteri morcellated during laparoscopic supracervical hysterectomy (LASH). Arch Gynecol Obstet 2015; 292(3): 665-72.
[http://dx.doi.org/10.1007/s00404-015-3696-z] [PMID: 25820974]
[15]
Parker W, Pritts E, Olive D. Morcellation for gynecologic surgery. Clin Obstet Gynecol 2019; 62(4): 727-32.
[http://dx.doi.org/10.1097/GRF.0000000000000485] [PMID: 31498239]
[16]
Raine-Bennett T, Tucker LY, Zaritsky E, et al. Occult uterine sarcoma and leiomyosarcoma: incidence of and survival associated with morcellation. Obstet Gynecol 2016; 127(1): 29-39.
[http://dx.doi.org/10.1097/AOG.0000000000001187] [PMID: 26646120]
[17]
Lieng M, Berner E, Busund B. Risk of morcellation of uterine leiomyosarcomas in laparoscopic supracervical hysterectomy and laparoscopic myomectomy, a retrospective trial including 4791 women. J Minim Invasive Gynecol 2015; 22(3): 410-4.
[http://dx.doi.org/10.1016/j.jmig.2014.10.022] [PMID: 25460521]
[18]
Kho KA, Lin K, Hechanova M, Richardson DL. Risk of occult uterine sarcoma in women undergoing hysterectomy for benign indications. Obstet Gynecol 2016; 127(3): 468-73.
[http://dx.doi.org/10.1097/AOG.0000000000001242] [PMID: 26855091]
[19]
D’Angelo E, Prat J. Uterine sarcomas: a review. Gynecol Oncol 2010; 116(1): 131-9.
[http://dx.doi.org/10.1016/j.ygyno.2009.09.023] [PMID: 19853898]
[20]
Parker WH, Fu YS, Berek JS. Uterine sarcoma in patients operated on for presumed leiomyoma and rapidly growing leiomyoma. Obstet Gynecol 1994; 83(3): 414-8.
[PMID: 8127535]
[21]
Rosenbaum L. N-of-1 policymaking--tragedy, trade-offs, and the demise of morcellation. N Engl J Med 2016; 374(10): 986-90.
[http://dx.doi.org/10.1056/NEJMms1516161] [PMID: 26962735]
[22]
Garcia C, Kubat JS, Fulton RS, et al. Clinical outcomes and prognostic markers in uterine leiomyosarcoma: a population-based cohort. Int J Gynecol Cancer 2015; 25(4): 622-8.
[http://dx.doi.org/10.1097/IGC.0000000000000370] [PMID: 25675041]
[23]
Bansal N, Herzog TJ, Burke W, Cohen CJ, Wright JD. The utility of preoperative endometrial sampling for the detection of uterine sarcomas. Gynecol Oncol 2008; 110(1): 43-8.
[http://dx.doi.org/10.1016/j.ygyno.2008.02.026] [PMID: 18445505]
[24]
Cho HY, Kim K, Kim YB, No JH. Differential diagnosis between uterine sarcoma and leiomyoma using preoperative clinical characteristics. J Obstet Gynaecol Res 2016; 42(3): 313-8.
[http://dx.doi.org/10.1111/jog.12915] [PMID: 26695124]
[25]
Amant F, Coosemans A, Debiec-Rychter M, Timmerman D, Vergote I. Clinical management of uterine sarcomas. Lancet Oncol 2009; 10(12): 1188-98.
[http://dx.doi.org/10.1016/S1470-2045(09)70226-8] [PMID: 19959075]
[26]
Kitajima K, Murakami K, Kaji Y, Sugimura K. Spectrum of FDG PET/CT findings of uterine tumors. AJR Am J Roentgenol 2010; 195(3): 737-43.
[http://dx.doi.org/10.2214/AJR.09.4074] [PMID: 20729454]
[27]
Rha SE, Byun JY, Jung SE, et al. CT and MRI of uterine sarcomas and their mimickers. AJR Am J Roentgenol 2003; 181(5): 1369-74.
[http://dx.doi.org/10.2214/ajr.181.5.1811369] [PMID: 14573436]
[28]
Goto A, Takeuchi S, Sugimura K, Maruo T. Usefulness of Gd-DTPA contrast-enhanced dynamic MRI and serum determination of LDH and its isozymes in the differential diagnosis of leiomyosarcoma from degenerated leiomyoma of the uterus. Int J Gynecol Cancer 2002; 12(4): 354-61.
[http://dx.doi.org/10.1046/j.1525-1438.2002.01086.x] [PMID: 2144683]
[29]
Sizzi O, Manganaro L, Rossetti A, et al. Assessing the risk of laparoscopic morcellation of occult uterine sarcomas during hysterectomy and myomectomy: literature review and the ISGE recommendations. Eur J Obstet Gynecol Reprod Biol 2018; 220: 30-8.
[http://dx.doi.org/10.1016/j.ejogrb.2017.10.030] [PMID: 29149644]
[30]
Tanaka YO, Nishida M, Tsunoda H, Okamoto Y, Yoshikawa H. Smooth muscle tumors of uncertain malignant potential and leiomyosarcomas of the uterus: MR findings. J Magn Reson Imaging 2004; 20(6): 998-1007.
[http://dx.doi.org/10.1002/jmri.20207] [PMID: 15558559]
[31]
Leibsohn S, d’Ablaing G, Mishell DR Jr, Schlaerth JB. Leiomyosarcoma in a series of hysterectomies performed for presumed uterine leiomyomas. Am J Obstet Gynecol 1990; 162(4): 968-74.
[http://dx.doi.org/10.1016/0002-9378(90)91298-Q] [PMID: 2327466]
[32]
Schwartz LB, Diamond MP, Schwartz PE. Leiomyosarcomas: clinical presentation. Am J Obstet Gynecol 1993; 168(1 Pt 1): 180-3.
[http://dx.doi.org/10.1016/S0002-9378(12)90910-2] [PMID: 8420323]
[33]
Tulandi T, Ferenczy A. Biopsy of uterine leiomyomata and frozen sections before laparoscopic morcellation. J Minim Invasive Gynecol 2014; 21(5): 963-6.
[http://dx.doi.org/10.1016/j.jmig.2014.06.010] [PMID: 24993657]
[34]
AAGL Advancing Minimally Invasive Gynecology Worldwide.. AAGL position statement: route of hysterectomy to treat benign uterine disease. J Minim Invasive Gynecol 2011; 18(1): 1-3.
[http://dx.doi.org/10.1016/j.jmig.2010.10.001] [PMID: 21059487]
[35]
Odejinmi F, Agarwal N, Maclaran K, Oliver R. Should we abandon all conservative treatments for uterine fibroids? The problem with leiomyosarcomas. Womens Health (Lond) 2015; 11(2): 151-9.
[http://dx.doi.org/10.2217/WHE.14.71] [PMID: 25776289]
[36]
Kainsbak J, Hansen ES, Dueholm M. Literature review of outcomes and prevalence and case report of leiomyosarcomas and non-typical uterine smooth muscle leiomyoma tumors treated with uterine artery embolization. Eur J Obstet Gynecol Reprod Biol 2015; 191: 130-7.
[http://dx.doi.org/10.1016/j.ejogrb.2015.05.018] [PMID: 26117442]
[37]
Siedhoff MT, Kim KH. Morcellation and myomas: balancing decisions around minimally invasive treatments for fibroids. J Surg Oncol 2015; 112(7): 769-71.
[http://dx.doi.org/10.1002/jso.24010] [PMID: 26768314]
[38]
Hagemann IS, Hagemann AR. LiVolsi VA, Montone KT, Chu CS. Risk of occult malignancy in morcellated hysterectomy: a case series. Int J Gynecol Pathol 2011; 30(5): 476-83.
[http://dx.doi.org/10.1097/PGP.0b013e3182107ecf] [PMID: 21804400]
[39]
Hodges KR, Davis BR, Swaim LS. Prevention and management of hysterectomy complications. Clin Obstet Gynecol 2014; 57(1): 43-57.
[http://dx.doi.org/10.1097/GRF.0000000000000004] [PMID: 24488052]
[40]
Aarts JW, Nieboer TE, Johnson N, et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev 2015; 8(8) CD003677
[http://dx.doi.org/10.1002/14651858.CD003677.pub5] [PMID: 26264829]
[42]
Venturella R, Rocca ML, Lico D, et al. In-bag manual versus uncontained power morcellation for laparoscopic myomectomy: randomized controlled trial. Fertil Steril 2016; 105(5): 1369-76.
[http://dx.doi.org/10.1016/j.fertnstert.2015.12.133] [PMID: 26801067]
[43]
Leal MA, Piñera A, De Santiago J, Zapardiel I. Novel technique for contained power morcellation through umbilicus with insufflated bag. Gynecol Obstet Invest 2017; 82(2): 205-7.
[http://dx.doi.org/10.1159/000449157] [PMID: 27595411]
[44]
Srouji SS, Kaser DJ, Gargiulo AR. Techniques for contained morcellation in gynecologic surgery. Fertil Steril 2015; 103(4) e34
[http://dx.doi.org/10.1016/j.fertnstert.2015.01.022] [PMID: 25712576]
[45]
Anapolski M, Panayotopoulos D, Alkatout I, Soltesz S, Schiermeier S, Noé G. Preclinical safety testing for morcellation and extraction for an endobag with sealable ports: in vitro pilot study. Surg Endosc 2017; 31(1): 494-500.
[http://dx.doi.org/10.1007/s00464-016-4969-8] [PMID: 27194256]
[46]
Trivedi PH, Patil SS, Parekh NA, Gandhi AC, Trivedi SP, Abreo MO. Laparoscopic morcellation of fibroid and uterus in-bag. J Obstet Gynaecol India 2015; 65(6): 396-400.
[http://dx.doi.org/10.1007/s13224-015-0795-5] [PMID: 26663999]
[47]
Winner B, Porter A, Velloze S, Biest S. Uncontained compared with contained power morcellation in total laparoscopic hysterectomy. Obstet Gynecol 2015; 126(4): 834-8.
[http://dx.doi.org/10.1097/AOG.0000000000001039] [PMID: 26348168]
[48]
Rimbach S, Holzknecht A, Nemes C, Offner F, Craina M. A new in-bag system to reduce the risk of tissue morcellation: development and experimental evaluation during laparoscopic hysterectomy. Arch Gynecol Obstet 2015; 292(6): 1311-20.
[http://dx.doi.org/10.1007/s00404-015-3788-9] [PMID: 26093523]
[49]
Brölmann H, Tanos V, Grimbizis G, et al. European Society of Gynaecological Endoscopy (ESGE) steering committee on fibroid morcellation. Options on fibroid morcellation: a literature review. Gynecol Surg 2015; 12(1): 3-15.
[http://dx.doi.org/10.1007/s10397-015-0878-4] [PMID: 25774118]
[50]
Park JY, Park SK, Kim DY, et al. The impact of tumor morcellation during surgery on the prognosis of patients with apparently early uterine leiomyosarcoma. Gynecol Oncol 2011; 122(2): 255-9.
[http://dx.doi.org/10.1016/j.ygyno.2011.04.021] [PMID: 21565389]
[51]
Nagai T, Takai Y, Akahori T, et al. Novel uterine sarcoma preoperative diagnosis score predicts the need for surgery in patients presenting with a uterine mass. Springerplus 2014; 3: 678.
[http://dx.doi.org/10.1186/2193-1801-3-678] [PMID: 25520907]
[52]
Papadia A, Salom EM, Fulcheri E, Ragni N. Uterine sarcoma occurring in a premenopausal patient after uterine artery embolization: a case report and review of the literature 2007; 104(1): 260-3.
[http://dx.doi.org/10.1016/j.ygyno.2006.08.051]
[53]
George S, Barysauskas C, Serrano C, et al. Retrospective cohort study evaluating the impact of intraperitoneal morcellation on outcomes of localized uterine leiomyosarcoma. Cancer 2014; 120(20): 3154-8.
[http://dx.doi.org/10.1002/cncr.28844] [PMID: 24923260]
[54]
Resta L. Uterine myomas and histopathologyuterine myoma, myomectomy and minimally invasive treatments. Springer Publisher 2015; pp. 27-38.
[55]
Ricci S, Stone RL, Fader AN. Uterine leiomyosarcoma: epidemiology, contemporary treatment strategies and the impact of uterine morcellation. Gynecol Oncol 2017; 145(1): 208-16.
[http://dx.doi.org/10.1016/j.ygyno.2017.02.019] [PMID: 28209496]
[56]
Sandberg EM, van den Haak L, Bosse T, Jansen FW. Disseminated leiomyoma cells can be identified following conventional myomectomy. BJOG 2016; 123(13): 2183-7.
[http://dx.doi.org/10.1111/1471-0528.14265] [PMID: 27533508]
[57]
Cohen SL, Greenberg JA, Wang KC, et al. Risk of leakage and tissue dissemination with various contained tissue extraction (CTE) techniques: an in vitro pilot study. J Minim Invasive Gynecol 2014; 21(5): 935-9.
[http://dx.doi.org/10.1016/j.jmig.2014.06.004] [PMID: 24928740]
[58]
Harris JA, Swenson CW, Uppal S, et al. Practice patterns and postoperative complications before and after US Food and Drug Administration safety communication on power morcellation. Am J Obstet Gynecol 2016; 214(1): 98.e1-98.e13.
[http://dx.doi.org/10.1016/j.ajog.2015.08.047] [PMID: 26314519]
[59]
Cui RR, Wright JD, Hou JY. Uterine leiomyosarcoma: a review of recent advances in molecular biology, clinical management and outcome. BJOG 2017; 124(7): 1028-37.
[http://dx.doi.org/10.1111/1471-0528.14579] [PMID: 28128524]
[60]
Yin Y, Tian X. Survival after laparoscopic vs abdominal hysterectomy. JAMA 2017; 318(6): 574.
[http://dx.doi.org/10.1001/jama.2017.8161] [PMID: 28787498]
[61]
Multinu F, Casarin J, Hanson KT, et al. Practice patterns and complications of benign hysterectomy following the FDA statement warning against the use of power morcellation. JAMA Surg 2018; 153(6) e180141
[http://dx.doi.org/10.1001/jamasurg.2018.0141] [PMID: 29641835]
[62]
Chalas E. Morcellation in gynecologic oncology. Curr Opin Obstet Gynecol 2018; 30(1): 96-8.
[http://dx.doi.org/10.1097/GCO.0000000000000429] [PMID: 29251679]
[63]
Takeda A, Tsuge S, Shibata M, Shinone S, Nakamura H, Watanabe K. Identification of leiomyoma cell sheets in peritoneal washings retrieved by an intraoperative red blood cell salvage device during laparoscopic-assisted myomectomy with in-bag manual tissue extraction: a pilot study. J Minim Invasive Gynecol 2018; 25(7): 1266-73.
[http://dx.doi.org/10.1016/j.jmig.2018.03.026] [PMID: 29631012]
[64]
Ala-Nissilä S, Laurikainen E, Mäkinen J, Jokimaa V. Vaginal cuff dehiscence is observed in a higher rate after total laparoscopic hysterectomy compared with other types of hysterectomy. Acta Obstet Gynecol Scand 2019; 98(1): 44-50.
[http://dx.doi.org/10.1111/aogs.13459] [PMID: 30199573]
[65]
White paper (December 2017): FDA updated assessment of morcellation for uterine fibroids:. https://www.fda.gov/ downloads/ MedicalDevices/ProductsandMedicalProcedures/Surgeryand LifeSupport/UCM584539.pdf
[66]
Haber K, Hawkins E, Levie M, Chudnoff S. Hysteroscopic morcellation: review of the manufacturer and user facility device experience (MAUDE) database. J Minim Invasive Gynecol 2015; 22(1): 110-4.
[http://dx.doi.org/10.1016/j.jmig.2014.08.008] [PMID: 25128851]
[67]
Vitale SG, Sapia F, Rapisarda AMC, et al. Hysteroscopic morcellation of submucous myomas: a systematic review. BioMed Res Int 2017; 2017 6848250
[http://dx.doi.org/10.1155/2017/6848250] [PMID: 28948169]
[68]
Di Tommaso S, Cavallotti C, Malvasi A, et al. A qualitative and quantitative study of the innervation of the human non pregnant uterus. Curr Protein Pept Sci 2017; 18(2): 140-8.
[http://dx.doi.org/10.2174/1389203717666160330105341] [PMID: 27063643]
[69]
Brauer MM. Plasticity in uterine innervation: state of the art. Curr Protein Pept Sci 2017; 18(2): 108-19.
[http://dx.doi.org/10.2174/1389203717666160322145411] [PMID: 27001066]
[70]
Solima E, Scagnelli G, Austoni V, et al. Vaginal uterine morcellation within a specimen containment system: a study of bag integrity. J Minim Invasive Gynecol 2015; 22(7): 1244-6.
[http://dx.doi.org/10.1016/j.jmig.2015.07.007] [PMID: 26205578]
[71]
ACOG Committee Opinion No. ACOG Committee Opinion No. 770: Uterine Morcellation for Presumed Leiomyomas. Obstet Gynecol 2019; 133(3): e238-48.
[http://dx.doi.org/10.1097/AOG.0000000000003126] [PMID: 30801477]
[72]
Clark NM, Schembri M, Jacoby VL. Change in surgical practice for women with leiomyomas after the U.S. food and drug administration morcellator safety communication. Obstet Gynecol 2017; 130(5): 1057-63.
[http://dx.doi.org/10.1097/AOG.0000000000002309] [PMID: 29016511]
[73]
Tinelli A, Tsin DA, Forgione A, et al. Exploring the umbilical and vaginal port during minimally invasive surgery. J Turk Ger Gynecol Assoc 2017; 18(3): 143-7.
[PMID: 28890429]
[74]
Ghezzi F, Casarin J, De Francesco G, et al. Transvaginal contained tissue extraction after laparoscopic myomectomy: a cohort study. BJOG 2018; 125(3): 367-73.
[http://dx.doi.org/10.1111/1471-0528.14720] [PMID: 28467660]
[75]
Bogani G, Uccella S, Cromi A, et al. Electric motorized morcellator versus transvaginal extraction for myoma retrieval after laparoscopic myomectomy: a propensity-matched analysis. J Minim Invasive Gynecol 2014; 21(5): 928-34.
[http://dx.doi.org/10.1016/j.jmig.2014.04.012] [PMID: 24780382]
[76]
Miller CE. Morcellation equipment: past, present, and future. Curr Opin Obstet Gynecol 2018; 30(1): 69-74.
[http://dx.doi.org/10.1097/GCO.0000000000000435] [PMID: 29194076]
[77]
Glaser LM, Friedman J, Tsai S, Chaudhari A, Milad M. Laparoscopic myomectomy and morcellation: a review of techniques, outcomes, and practice guidelines. Best Pract Res Clin Obstet Gynaecol 2018; 46: 99-112.
[http://dx.doi.org/10.1016/j.bpobgyn.2017.09.012] [PMID: 29078975]
[78]
Bortoletto P, Friedman J, Milad MP. Economics of gynecologic morcellation. Curr Opin Obstet Gynecol 2018; 30(1): 89-95.
[http://dx.doi.org/10.1097/GCO.0000000000000422] [PMID: 29232257]
[79]
Tinelli A, Farghaly SA. Morcellation of occulted sarcomas during laparoscopic myomectomy and hysterectomy for patients with large fibroid uterus. Minerva Ginecol 2018; 70(1): 84-8.
[PMID: 28975775]
[80]
Vilos GA, Allaire C, Laberge PY, Leyland N. SPECIAL CONTRIBUTORS. The management of uterine leiomyomas. J Obstet Gynaecol Can 2015; 37(2): 157-78.
[http://dx.doi.org/10.1016/S1701-2163(15)30338-8] [PMID: 25767949]

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