Full length article| Volume 259, P32-37, April 2021

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Hysteroscopic morcellation versus bipolar resection for removal of type 0 and 1 submucous myomas: A randomized trial

Published:January 29, 2021DOI:


      • Type 0 and 1 submucous myomas are removed the fastest using hysteroscopic morcellation.
      • Overall, the procedure time of hysteroscopic morcellation and resection are the same.
      • Calcified myomas are challenging for both procedures.
      • Fluid deficit remains a limiting factor.
      • Optimal preoperative assessment of the myoma is key to select the best technique.



      To compare hysteroscopic morcellation with bipolar resection for the removal of submucous type 0 and 1 myomas, in terms of procedure time (primary outcome), adverse events, tissue availability, short term effectiveness and postoperative adhesion formation (secondary outcomes).

      Study design

      The study was performed from May 2011 to May 2018 in the Catharina hospital (Eindhoven, the Netherlands) and the Ghent University hospital (Ghent, Belgium). Women with type 0 and 1 submucous myomas up to 3 cm were randomized to hysteroscopic morcellation with the T r u C l e a r T M 8.0 Tissue Removal System or to bipolar resection with a rigid 8.5-mm resectoscope. Skewed time variables were log-transformed and analyzed with the Student t-test. Multiple linear regression analysis was performed to assess the effect of myoma diameter on operating time.


      Forty-five and 38 women were included in the hysteroscopic morcellation and resection group, respectively. The median operating time was significantly shorter for hysteroscopic morcellation compared with resection (9.2 min [interquartile range 5.6–14.4] versus 13.4 min [interquartile range 8.6–17.5], P = .04). In the morcellation group, operating time, corrected for the myoma diameter, was reduced by 26 % (95 % CI 5–43%; P = .02). The median setup time was significantly longer in the morcellation group (5.2 min [interquartile range 4.2–6.9] versus 3.8 min [interquartile range 3.3–5.3], P = .006). The median total procedure time was not significantly different between the two techniques (14.4 min [interquartile range 11.4–19.2] versus 17.3 [interquartile range 12.7–23.8], P = .18). Two procedures of the morcellation group were converted to bipolar resection because of the myoma hardness. Complete resection was found in 89 % of the morcellation group and 95 % of the resection group. Adverse events occurred in 3 patients of the morcellation group, namely a fluid deficit > 2500 mL with the need of potassium suppletion, an asystolic vasovagal response after conversion to resection and postoperative fever requiring antibiotics. Tissue was available for pathology analysis in all cases. Routine second-look hysteroscopy performed in one center showed no intrauterine adhesions.


      Overall, there is no difference in total procedure time between hysteroscopic morcellation using the T r u C l e a r T M system compared to bipolar resection for the removal of smaller type 0 and 1 submucous myomas. Although hysteroscopic morcellation is faster, its setup time is longer. Calcified myomas can be challenging and fluid deficit remains a limiting factor.


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        • Tammam A.E.
        • Ahmed H.H.
        • Abdella A.H.
        • Taha S.A.M.
        Comparative study between monopolar electrodes and bipolar electrodes in hysteroscopic surgery.
        J Clin Diagn Res. 2015; 9: QC11-3
        • Emanuel M.H.
        Hysteroscopy and the treatment of uterine fibroids.
        Best Pract Res Clin Obstet Gynaecol. 2015; 29: 920-929
        • Di Spiezio Sardo A.
        • Mazzon I.
        • Bramante S.
        • Bettocchi S.
        • Bifulco G.
        • Guida M.
        • et al.
        Hysteroscopic myomectomy: a comprehensive review of surgical techniques.
        Hum Reprod Update. 2008; 14: 101-119
        • Hamerlynck T.W.O.
        • Van Vliet H.A.A.M.
        • Beerens A.-S.
        • Weyers S.
        • Schoot B.C.
        Hysteroscopic morcellation versus loop resection for removal of placental remnants: a randomized trial.
        J Minim Invasive Gynecol. 2016; 23: 1172-1180
        • Hamerlynck T.W.O.
        • Schoot B.C.
        • Van Vliet H.A.A.M.
        • Weyers S.
        Removal of endometrial polyps: hysteroscopic morcellation versus bipolar resectoscopy, a randomized trial.
        J Minim Invasive Gynecol. 2015; 22: 1237-1243
        • Mazzon I.
        • Favilli A.
        • Grasso M.
        • Horvath S.
        • Bini V.
        • Di Renzo G.C.
        • et al.
        Predicting success of single step hysteroscopic myomectomy: a single centre large cohort study of single myomas.
        Int J Surg [Internet]. 2015; 22: 10-14
        • Deans R.
        • Abbott J.
        Review of intrauterine adhesions.
        J Minim Invasive Gynecol. 2010; 17: 555-569
        • van Dongen H.
        • Emanuel M.H.
        • Wolterbeek R.
        • Trimbos J.B.
        • Jansen F.W.
        Hysteroscopic morcellator for removal of intrauterine polyps and myomas: a randomized controlled pilot study among residents in training.
        J Minim Invasive Gynecol. 2008; 15: 466-471
        • Emanuel M.H.
        • Wamsteker K.
        The Intra Uterine Morcellator: a new hysteroscopic operating technique to remove intrauterine polyps and myomas.
        J Minim Invasive Gynecol. 2005; 12: 62-66
        • Smith P.P.
        • Middleton L.J.
        • Connor M.
        • Clark T.J.
        Hysteroscopic morcellation compared with electrical resection of endometrial polyps: a randomized controlled trial.
        Obstet Gynecol. 2014; 123: 745-751
        • Rubino R.J.
        • Lukes A.S.
        Twelve-month outcomes for patients undergoing hysteroscopic morcellation of uterine polyps and myomas in an office or ambulatory surgical center.
        J Minim Invasive Gynecol. 2015; 22: 285-290
        • Keltz M.D.
        • Greene A.D.
        • Morrissey M.B.
        • Vega M.
        • Moshier E.
        Sonohysterographic predictors of successful hysteroscopic myomectomies.
        J Soc Laparoendosc Surg. 2015; 19
        • Mavrelos D.
        • Naftalin J.
        • Hoo W.
        • Ben-Nagi J.
        • Holland T.
        • Jurkovic D.
        Preoperative assessment of submucous fibroids by three-dimensional saline contrast sonohysterography.
        Ultrasound Obstet Gynecol. 2011; 38: 350-354
        • Lasmar R.B.
        • Lasmar B.P.
        • Celeste R.K.
        • da Rosa D.B.
        • de B.Depes D.
        • et al.
        A new system to classify submucous myomas: a brazilian multicenter study.
        J Minim Invasive Gynecol. 2012; 19: 575-580
        • Dueholm M.
        • Forman A.
        • Ingerslev J.
        Regression of residual tissue after incomplete resection of submucous myomas.
        Gynaecol Endosc. 1998; 7: 309-314
        • Van Dongen H.
        • Hans Emanuel M.
        • Smeets M.J.
        • Trimbos B.
        • Willem Jansen F.
        Follow-up after incomplete hysteroscopic removal of uterine fibroids.
        Acta Obstet Gynecol Scand. 2006; 85: 1463-1467
        • 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 [Internet]. 2015; 22: 110-114