Hysteroscopic Morcellation Better for Endometrial Polyp Removal

Veronica Hackethal, MD

March 21, 2014

Hysteroscopic morcellation may be a better method to remove endometrial polyps than conventional electrosurgical resection, according to a new randomized controlled trial (RCT) published online March 6 in Obstetrics & Gynecology.

"This RCT provides strong evidence to suggest that hysteroscopic morcellation is quicker to perform, more successful at completing polyp removal, less painful, and more acceptable to women than traditional electrosurgical resection for the removal of endometrial polyps," write Paul P. Smith, MBChB, from the Birmingham Women’s Hospital, Birmingham and Sheffield University Hospital, United Kingdom, and colleagues.

Morcellation is the process of fragmenting tissue for removal and has been used by gynecologic surgeons for laparoscopic or robot-assisted hysterectomies, myomectomies, and fibroidectomies. Hysteroscopic morcellation, used in the office setting, fragments tissue within the boundaries of the uterus.

The study was a single-blind RCT in which 121 women were recruited from 2 large, urban teaching hospitals in Birmingham or Sheffield. The women were randomly assigned in a 1:1 ratio to endometrial polyp removal with office-based hysteroscopic morcellation or electrosurgical resection between July 2012 and May 2013. Women were excluded if they had polyps expected to be malignant at diagnostic hysteroscopy. Self-reported data, collected immediately after the procedure, included acceptability (4-point scale) and pain (100-mm visual analog scale). Polypectomy was performed by 3 experienced surgeons, although they had more experience with conventional electrosurgery. Technical aspects were recorded by surgeons after the procedure.

Median time for procedure completion was 5 minutes and 28 seconds for morcellation vs 10 minutes and 12 seconds for electrosurgical resection (P < .001). Complete polyp removal was found in 61 (98%) of 62 women in the morcellation group vs 49 (83%) of 59 women in the electrosurgical resection group (odds ratio, 12.5; 95% confidence interval [CI], 1.5 - 100.6; P = .02). Pain scores averaged 16.1 points lower in the morcellation group, with a mean of 35.9 points compared with 52.0 points for electrosurgical resection (95% CI, −24.7 to −7.6; P < .001). Most (99%) of the women thought polypectomy was "acceptable."

Complications included vasovagal reactions in 1 (2%) of 62 women for morcellation vs 6 (10%) in 59 women for electrosurgical resection. One serious adverse event (endometritis) occurred after morcellation and was treated with antibiotics.

Limitations include an unequal distribution of potential confounders. Women who received hysteroscopic morcellation had more polyps than those in the electrosurgical resection group, and the morcellation group had more women from Sheffield as opposed to Birmingham. The nature of the study also precluded blinding surgeons from the procedure. Some participants may also have been aware of which procedure they received, as they were conscious at the time.

The authors mention several advantages of hysteroscopic morcellation over electrosurgical resection for endometrial polyp removal. These include less instrumentation, better visualization, less bubble formation, simultaneous cutting and extraction, reduced patient discomfort, and lower cost of office-based procedures. Contrary to concerns that morcellated tissue may not be provide good specimens for histological analysis, diagnoses were reached for all specimens in this study.

Intrauterine vs Intracorporeal Key

Recently, "morcellation" has become somewhat of a dirty word. During laparoscopic morcellation for fibroids (also called intracorporeal morcellation), there is a risk of disseminating ectopic leiomyoma, endometriosis, adenomyosis, and ovarian tissue, as well as occult malignancy into the abdominal and peritoneal cavity. The potential for seeding undetected malignancy is particularly concerning, as uterine malignancies carry poor prognoses and physicians lack a satisfactory means of differentiating between benign and malignant uterine masses preoperatively.

However, these concerns do not really translate to the new hysteroscopic morcellation technique for endometrial polyps presented in the new RCT, according to Dr. Smith.

"A hysteroscopic procedure avoids breaching the abdominal wall so there is less risk of disseminating ectopic tissue," Dr. Smith explained to Medscape Medical News. "And, more importantly, less risk of damaging other abdominal organs, which is more common [during laparoscopy]." Moreover, the indication for removal of polyps is different from fibroids, according to Dr. Smith.

"Although there is an extremely small risk of malignancy within fibroids, they are usually only removed for symptomatic reasons," Dr. Smith explained, "However, most gynecologists recommend removal of the polyps so that further histological analysis can be performed to rule out malignancy."

The techniques, instrumentation, and indications, as well as risks and benefits, for hysteroscopic compared with intracorporeal morcellation are different, according to Kimberly Kho, MD, MPH, assistant professor of obstetrics and gynecology, University of Texas Southwestern Medical Center, Dallas.

Dr. Kho recently coauthored an opinion piece in JAMA in which the authors described the potential problems associated with intracorporeal morcellation.

"Concerns about unenclosed intracorporeal morcellation involve organ damage from the exposed blade in the abdominal cavity and dissemination of malignant and benign tissue throughout the abdominal cavity," Dr. Kho told Medscape Medical News. "Hysteroscopic morcellation involves the fragmentation of intrauterine masses within the confines of the uterus."

"When performed by skilled surgeons, and using appropriate instrumentation, hysteroscopic polypectomy is a safe and useful minimally invasive option for the management of intrauterine pathology," she explained, "While there is the potential for complications like infection, perforation, damage to the uterus or surrounding organs, these risks appear to be small but require a larger sample size, as well as longer-term follow up, to better characterize and quantify associated risks."

The study was funded by Smith & Nephew, the makers of the hysteroscopic morcellator. One coauthor has reported receiving funding from Smith & Nephew for administrative costs associated with this study. He also reports honoraria from Smith & Nephew and Ethicon for conducting training workshops in office hysteroscopic techniques. Another coauthor reports receiving consultancy fees from Smith & Nephew for work performed after completion of this study. The other authors and Dr. Kho have disclosed no relevant financial relationships.

Obstet Gynecol. 2014;123:745-751. Full text

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