Surgical Methods for the Treatment of Uterine Fibroids – Risk of Uterine Sarcoma and Problems of Morcellation: Position Paper of the DGGG

 

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Abstract

The appropriate surgical technique to treat patients with uterine fibroids is still a matter of debate as is the potential risk of incorrect treatment if histological examination detects a uterine sarcoma instead of uterine fibroids. The published epidemiology for uterine sarcoma is set against the incidence of accidental findings during surgery for uterine fibroids. International comments on this topic are discussed and are incorporated into the assessment by the German Society for Gynecology and Obstetrics (DGGG). The ICD-O-3 version of 2003 was used for the anatomical and topographical coding of uterine sarcomas, and the “Operations- und Prozedurenschlüssel” (OPS) 2014, the German standard for process codes and interventions, was used to determine surgical extirpation methods. Categorical qualifiers were defined to analyze the data provided by the Robert Koch Institute (RKI), the German Federal Bureau of Statistics (DESTATIS; Hospital and Causes of Death Statistics), the population-based Cancer Register of Bavaria. A systematic search was done of the MEDLINE database and the Cochrane collaboration, covering the period from 1966 until November 2014. The incidence of uterine sarcoma and uterine fibroids in uterine surgery was compared to the literature and with the different registries. The incidence of uterine sarcoma in 2010, standardized for age, was 1.53 for Bavaria, or 1.30 for every 100 000 women, respectively, averaged for the years 2002–2011, and 1.30 for every 100 000 women in Germany. The mean incidence collated from various surveys was 2.02 for every 100 000 women (0.35–7.02; standard deviation 2.01). The numbers of inpatient surgical procedures such as myoma enucleation, morcellation, hysterectomy or cervical stump removal to treat the indication “uterine myoma” have steadily declined in Germany across all age groups (an absolute decrease of 17 % in 2012 compared to 2007). There has been a shift in the preferred method of surgical access from an abdominal/vaginal approach to endoscopic or endoscopically assisted procedures to treat uterine fibroids, with the use of morcellation increasing by almost 11 000 coded procedures in 2012. Based on international statements (AAGL, ACOG, ESGE, FDA, SGO) on the risk of uterine sarcoma as an coincidental finding during uterine fibroid surgery and the associated risk of a deterioration of prognosis (in the case of morcellation procedures), this overview presents the opinion of the DGGG in the form of four Statements, five Recommendation and four Demands.

Zusammenfassung

In der Behandlung der Patientin mit Uterus myomatosus gibt es Diskussionen über die Art der Operationstechnik und das damit verbundene Risiko der eventuellen falschen Behandlung, wenn sich in der histologischen Aufarbeitung keine Uterusmyome, sondern ein Uterussarkom herausstellt. Die publizierte Epidemiologie von Uterussarkomen wird hier ins Verhältnis zu Zufallsbefunden bei Operationen zur Behandlung von Uterusmyomen gesetzt. Die internationalen Stellungnahmen zu diesem Thema werden diskutiert, um eine Bewertung seitens der Deutschen Gesellschaft für Gynäkologie und Geburtshilfe (DGGG) abzugeben. Zur anatomischen und topografischen Codierung der Uterussarkome wurde der ICD-O-3 in der Ausgabe von 2003 und für die Operations- und Prozedurenschlüssel der exstirpierenden Verfahren der OPS 2014 benutzt. Um die übermittelten Daten des Robert Koch-Instituts (RKI), des Statistischen Bundesamts (DESTATIS; Abteilung Krankenhausstatistik und Todesursachenstatistik), des bevölkerungsbezogenen Krebsregisters Bayern auswerten zu können, wurden eindeutige Abfragekriterien definiert. Zusätzlich wurde eine systematische Literaturrecherche in MEDLINE von 1966 bis November 2014 und bei der Cochrane Collaboration durchgeführt. Die Inzidenz von Uterussarkomen und Uterusmyomen bei Operationen der Gebärmutter wurden in den verschiedenen Registern und in der Literatur verglichen. Die altersstandardisierte Inzidenz im Jahr 2010 für Uterussarkome war für Bayern 1,53, respektive 1,30 auf 100 000 Frauen gemittelt über die Jahre 2002–2011, in Deutschland bei 1,30 auf 100 000 Frauen. Die mittlere Inzidenz aus verschiedenen Erhebungen beträgt 2,02 auf 100 000 Frauen (0,35–7,02; Standardabweichung 2,01). Stationär durchgeführte Operationen wie Myomenukleation, Morcellation, Hysterektomie oder Zervixstumpfresektion sind bei der Indikation Uterusmyom in Deutschland gleichbleibend über alle Altersgruppen hinweg zurückgegangen (absoluter Rückgang von 17 % im Jahr 2012 zum Jahr 2007). Es zeigt sich eine Verschiebung des operativen Zugangswegs von abdominal/vaginal zu endoskopisch bzw. endoskopisch assistierten zur Behandlung von Uterusmyomen mit einer ansteigenden Benutzung der Morcellation von fast 11 000 codierten Prozeduren im Jahr 2012. Nach den Veröffentlichungen von internationalen Stellungnahmen (AAGL, ACOG, ESGE, FDA, SGO) zum Risiko Uterussarkom als Zufallsbefund im Rahmen einer Myomoperation und dem damit verbundenen Risiko einer Prognoseverschlechterung (im Falle einer Morcellation) wird in dieser Übersichtsarbeit die DGGG-Stellungnahme in Form von 4 Statements, 5 Empfehlungen und 4 Forderungen dargestellt.

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