Temple restricts controversial gynecological procedure

PHILADELPHIA — Taking a bold stand on a growing medical controversy, Temple University Hospital this week issued new guidelines restricting use of a minimally invasive gynecological surgical procedure called morcellation.

Electric morcellation devices are used in the body to pulverize the uterus or benign fibroids so the tissue can be removed through tiny skin incisions.

In rare cases, the procedure spreads cancer that was hidden in the uterus, turning a treatable tumor into advanced disease with a grim prognosis.

That tragic scenario played out for two Philadelphia-trained physicians, prompting them to launch a national campaign to ban morcellation in gynecologic surgery.

Anesthesiologist Amy Reed, 40, a mother of six, had a hysterectomy by morcellation in October and now has metastatic cancer. She and her husband, surgeon Hooman Noorchashm, work at Brigham and Women's Hospital in Boston, where her hysterectomy was done.

Temple's new policy, issued Monday, says not to use morcellation unless an "isolation bag" surrounds the tissue to prevent spillage. It also says fibroids larger than 18 centimeters (seven inches) should be removed through a large incision, not minimally invasively.

The policy allows morcellation without bags in certain situations, but requires diagnostic tests and precautions. Also, the patient must be told of risks and benefits, including that morcellated tissue is hard to analyze for the presence of cancer.

Enrique Hernandez, Temple's chair of obstetrics and gynecology, credited Noorchashm's activism. "He reached out to our leadership at Temple," Hernandez said. "He has reached out to everyone, including the FDA and Congress. We decided it's the right thing to do."

Larry Kaiser, chief executive of Temple University Health System, was chief of surgery at the University of Pennsylvania when Noorchashm did his surgical residency there.

Noorchashm praised Temple's response as "the strongest and most cogent thus far."

"I don't personally think the bag is a solution. Morcellators can break the bag. But Dr. Hernandez and Dr. Kaiser have said this is the wrong practice. Brigham and Women's hasn't been willing to come out and say it's wrong."

Of nearly 500,000 hysterectomies each year in the U.S., a third are done using minimally invasive techniques, and 11 percent involve morcellation, according to the American College of Obstetrics and Gynecology (ACOG).

Minimally invasive operations lessen blood loss, infection risk, and recovery time compared with surgery that cuts open the abdomen.

ACOG, like other groups, says decisions on a hysterectomy must be based on the patient's history, health, and diagnostic tests.

ACOG also says, "Even the best medical evaluation, however, does not always reveal the presence of underlying disease before surgery, such as a hidden cancer."

The malignancy hidden in Reed and other women is leiomyosarcoma - cancerous uterine fibroids. Biopsies may not reveal its presence.

Leiomyosarcoma was believed to be very rare before Reed and her husband launched their campaign, which includes a change.org petition.

But a recent review found that as many one in 415 women who choose fibroid surgery have sarcoma. "I think [Noorchashm] has a valid point," Hernandez said. "He's saying there's a way to achieve what needs to be achieved without hurting anyone."

215-854-2720 @repopter