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Risk of minimal access surgery in uterine leiomyosarcomas: a narrative review

: The aim of this paper is to review latest evidences concerning the risk of minimal access or minimally invasive surgery, with detail on incidence and impact of occult leiomyosarcoma (LMS) morcellation at treatment time for presumed benign conditions. Mini-invasive surgery includes techniques in which abdominal wall integrity is preserved (laparoscopy, robotic) and its advantages compared to laparotomy are well known (lower hospital stay, wound infection incidence, recovery time). Morcellation refers to the division of tissue into smaller pieces or fragments and is often used to facilitate the removal of specimens through small incisions. LMS is a rare tumour with aggressive behaviour, but morcellation seems to decrease patients’ prognosis further. Iatrogenic damages to other organs from power morcellation are also reported. In 2014 a Food and Drug Association (FDA)-warning banned the use of morcellation in peri- and post-menopause and “candidates for en bloc tissue removal”. After this ban, gynaecologists partially revised their surgical procedures. The real occult LMS incidence varies deeply in literature, with 0.08–1.2% range, mixing premalignant and malignant diseases, different histotypes and surgical techniques. Preoperative differential diagnosis between leiomyoma and LMS is challenging despite progresses in gynaecological imaging. Nevertheless, more efforts should be done to define an “high risk patient” based on anamnesis, symptoms, clinical and radiological information [both with magnetic resonance imaging (MRI) or an accurate ultrasound investigation by an expert sonographer], in order to avoid abdominal cells spread at the time of surgery. In bag morcellation could be a feasible and safe alternative to open surgery in selected cases. Every institution should review its surgical protocols in the diagnosis and treatment of myometrial masses, valuating pros and cons of laparoscopic/robotic approach for presumed fibroids. Risks and benefits should be widely discussed with the patient.