Edward C. Geehr, M.D.

Minimally invasive hysterectomies offer health benefits, but one type of this surgery may spread cancer.

More than 600,000 hysterectomies are performed in the U.S. each year, most commonly for the removal of large, uterine fibroids. Most of the surgeries use a traditional, open abdominal incision to remove the uterus.

A growing percentage of cases, though, use a minimally invasive laparoscopic approach associated with fewer infections, shorter hospital stay, reduced cost and faster recovery time than abdominal hysterectomy.

That's the good news.

The bad news: About 1of 368 women who undergo minimally invasive surgical hysterectomy that uses a high-speed cutting extraction device has a hidden cancer in the uterus, according to a recent study published in the Journal of the American Medical Association (JAMA). The concern is that fragmentation of the uterus before removal may result in the spread of undetected cancers.

In about 16% of more than 230,000 laparoscopic cases each year, the uterus is sliced apart using an electric-powered device called a morcellator. It uses a small, rapidly spinning blade that takes tiny bites out of the uterus and vacuum extracts the pieces through a tube. Sometimes they contain hidden cancer cells.

Earlier studies reported that undetected cancers in women undergoing morcellation occurred in 1 in 1,100 to 1 in 100 women. The Food and Drug Administration (FDA) had earlier estimated the risk at 1 in 352 women. Due to the potential risk of spreading cancer, it's important to know the true incidence of hidden cancer and the types of cancer in such women.

To determine the cancer risk, researchers at Columbia University examined a large database between 2006 and 2012, looking for the presence of underlying cancers in women undergoing laparoscopic hysterectomy with morcellation.

Of the more than 230,000 women who underwent minimally invasive hysterectomy, about 36,000 had morcellation performed. Among this group, 99 cases of uterine cancer were discovered, about 1 in 368 women undergoing the procedure – very close to the FDA's previous estimate.

Twenty-six other types of gynecologic cancers were found, along with 39 uterine tumors that could become cancerous.

The risk of underlying cancer increased with age, according to the JAMA article, with the greatest leap for women between ages 50 and 65. The highest risk group overall was women over age 65.

Experts at Brigham and Women's Hospital in Boston estimate that the spread of cancer from morcellation occurs in as many as 1 in 400 cases or as few as 1 in 1,000. If cancer is spread throughout the abdomen in this manner the odds of death within five years are tripled.

The risk of cancerous spread must be weighed against the benefits of laparoscopic surgery. Assuming there are 37,000 morcellation procedures annually, an additional 37-100 cancers could result, based on estimates from Brigham and Women's Hospital.

Brigham and Women's doctors recommend that higher-risk women – those older than 45 and who have a large uterine mass and heavy bleeding – avoid morcellation and choose open, abdominal hysterectomy or a vaginal hysterectomy. Other risk factors include being of African-American decent and a history of pelvic radiation therapy.

Patients should discuss with their physician the possible increased risk of cancer spread from minimally invasive uterine morcellation surgery and discuss the risks and benefits of alternative surgical approaches.