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Background: In recent years, due to the increase in medical mal-practice complaints, the Sicilian Regional Health System has adopted procedures for the direct management of claims by each health facility with the aim of reducing the costs of insurance premiums and related taxes. Mandatory sentinel event monitoring is a crucial part of this strategy to improve patient safety and quality of care. The reported case relates to a laparoscopic myomectomy surgery performed by means of morcellation, a controversial technique. After the FDA's intervention in 2014, it is believed that morcellation may worsen the staging of the disease by spreading malignancies such as leiomyosarcoma into the abdomen., Case Report: A 28-year-old woman, underwent laparoscopic surgery for uterine fibroids and an ovarian cyst removal in August 2018. Post-surgery, she was diagnosed with Leiomyoma. She returned to the hospital due to metrorrhagia and was discharged after a week. Persistent symptoms led to her readmission and subsequent exploratory laparoscopic surgery at another hospital. This resulted in a total hysterectomy and the discovery of uterine leiomyosarcoma, with FIGO STAGE IIIB staging. Despite chemotherapy, she passed away six months later., Discussion and Conclusions: This case highlights medical-legal issues. Informed consent for morcellation and its risks was not obtained. The morcellation technique was used, increasing cancer spread risk. The histopathological process was inadequate, with three biopsies leading to misdiagnosis. This could be medical malpractice, making providers legally responsible for the patient's deteriorating condition and the anticipation of possible death.

Purpose: This systematic review aims to comprehensively assess the safety and efficacy of transvaginal morcellation within an enclosed bag in gynecological surgeries, with a focus on its benefits, potential risks, and recommendations for its use., Methods: We conducted a comprehensive search of Epistemonikos, Web of Science, Medline (PubMed), Scopus, and Cochrane databases for studies on transvaginal contained morcellation in adult patients undergoing gynecological surgeries. The review included 22 studies that met the inclusion criteria, encompassing diverse surgical procedures, patient profiles, and outcomes. These studies were thoroughly reviewed and analyzed to assess the safety and efficacy of the morcellation technique., Results: Key findings from the selected studies indicate that transvaginal morcellation within an enclosed bag offers several advantages in gynecological surgeries, including reduced invasiveness, shorter operative times, and minimal blood loss when compared to conventional methods. The risk of tumor recurrence or dissemination appears to be low when appropriate precautions are taken, emphasizing the technique's safety, especially when performed by experienced surgical teams. While some studies reported complications, these were generally not directly associated with the morcellation technique., Conclusion: Transvaginal morcellation within an enclosed bag demonstrates potential as a safe and effective option for gynecological surgeries. The technique offers the benefits of minimally invasive procedures, including reduced bleeding, shorter recovery times, and improved cosmetic outcomes. This review also highlights the need for standardization in study methodologies and reporting, as the heterogeneity in outcomes across the selected studies poses challenges in drawing definitive conclusions., (© 2024. The Author(s).)

Objective: To compare contained and free manual vaginal morcellation of large uteruses after total laparoscopic hysterectomy (TLH) in women at low risk of uterine malignancy in terms of feasibility and safety., Methods: A single-center, observational, retrospective, cohort study was carried out including all patients undergoing TLH requiring manual vaginal morcellation for specimen extraction of large uteruses from January 2015 to August 2021 at the Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria of Bologna, Bologna, Italy. Patients were divided into two groups according to the type of manual vaginal morcellation (contained or free), and compared in terms of demographic, clinical, and perioperative data., Results: In all, 271 patients were included: 186 (68.6%) in the contained morcellation group and 85 (31.4%) in the free morcellation group. The mean operative time was significantly lower in the contained morcellation group compared with the free morcellation group (median [interquartile range] 130 [45] vs. 155 [60] min; P < 0.001). No significant difference was found in complications related to the morcellation step, overall, intraoperative and postoperative complications, estimated blood loss, length of hospital stays, uterine weight, and rate of occult malignancy between the two groups., Conclusion: Contained vaginal manual morcellation of the uterus after total laparoscopic hysterectomy using a specimen retrieval bag appears to be a safe procedure with significantly lower operative time than free vaginal manual morcellation., (© 2023 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.)

Objective: This study aimed to comprehensively evaluate the complications associated with morcellation in Total Laparoscopic Hysterectomy (TLH) procedures, providing evidence-based insights to enhance patient safety and surgical efficacy., Data Sources: A comprehensive literature search was conducted using multiple databases, including PubMed, EMBASE, Google Scholar, and Cochrane Central Register of Controlled Trials. The inclusion criteria were Studies that focused on morcellation and morcellation-related complications were included. The risk of bias in the included studies was assessed using established evaluation scales., Methods of Study Selection: Thirteen studies investigating complications associated with morcellation in TLH (Total Laparoscopic Hysterectomy) were included in this review.This review covers intraoperative blood loss, length of hospital stay, loss of bag integrity, mean uterine specimen and weight, morcellation time, operation time, and TLH morcellation complications., Tabulation, Integration, and Results: The selected studies covered different approaches and aspects related to this procedure, providing valuable insights into the factors associated with complications and efficacy of the technique in various clinical settings.This review highlights the importance of evaluating and considering complications associated with morcellation in TLH., Conclusion: The findings of this review provide valuable insights into complications associated with morcellation in TLH. Clinicians could use this information to make informed decisions, implement safe protocols, and improve patient care. Addressing these complications will enhance the safety and efficacy of morcellation for TLH. Ethical Compliance: All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and the 1964 Helsinki Declaration and its later amendments or comparable ethical standards., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: In polypectomy with mechanical hysteroscopic morcellators, the tissue removal procedure continues until no polyp tissue remains. The decision that the polypoid tissues were removed completely is made based on visual evaluation. In a situation where the polyp tissue was visually completely removed and no doubt that the polyp has been completely removed, short spindle-like tissue fragments on the polyp floor continue in most patients. There are no studies in the literature on whether visual evaluation provides adequate information at the cellular level in many patients in whom polypoid tissues have been determined to be completely removed. The aim of the present study was to analyze the pathological results of the curettage procedure, which was applied following the completion of polyp removal with operative hysteroscopy, and to evaluate whether there was residual polyp tissue in the short spindle-like tissue fragments that the mechanical hysteroscopic morcellator could not remove. The secondary aims of this study were to compare conventional loop resection hysteroscopy with hysteroscopic morcellation for the removal of endometrial polyps in terms of hemoglobin/hematocrit changes, polypectomy time and the amount of medium deficit., Methods: A total of 70 patients with a single pedunculate polypoid image of 1.5-2 cm, which was primarily visualized by office hysteroscopy, were included in the study. Patients who had undergone hysteroscopic polypectomy were divided into two groups according to the surgical device used: the morcellator group (n = 35, Group M) and the resectoscope group (n = 35, Group R). The histopathological results of hysteroscopic specimens and curettage materials of patients who had undergone curettage at the end of operative hysteroscopy were evaluated. In addition, the postoperative 24th hour Hb/HCT decrease amounts in percentage, the polypectomy time which was measured from the start of morcellation, and deficit differences were compared between groups., Results: In total, 7 patients in the morcellator group had residual polyp tissue detected in the full curettage material. The blood loss was lower in the morcellator group than in the resectoscope group (M, R; (-0.07 ± 0.08), (-0,11 ± 0.06), (p < 0.05), respectively). The deficit value of the morcellator group were higher (M, R; (500 ml), (300 ml), (p < 0.05), respectively). The polypectomy time was shorter in the morcellator group (M, R; mean (2.30 min), (4.6 min), (p < 0.05))., Conclusions: Even if the lesion is completely visibly removed during hysteroscopic morcellation, extra caution should be taken regarding the possibility of residual tissue. There is a need for new studies investigating the presence of residual polyp tissue., (© 2024. The Author(s).)

Objective: To study the comparison between hysteroscopic morcellation (HM) of retained products of conception (RPOC) with ultrasound (US)-guided electric vacuum aspiration in terms of intrauterine adhesion (IUA) formation, efficacy, and complications., Design: A randomized controlled, nonblinded trial., Setting: Three teaching hospitals and one university hospital from April 2015 to June 2022., Patients: A total of 133 women with RPOC on US, ranging from 1-4 cm, were randomized to receive either HM or electric vacuum aspiration., Intervention: Hysteroscopic morcellation was performed with the TruClear System (Medtronic, Minneapolis, MN, USA). Electric vacuum aspiration was performed using an 8- or 10-mm flexible plastic Karman cannula under US guidance. Women allocated to vacuum aspiration underwent the procedure as soon as possible., Main Outcome Measures: In the HM group, an office diagnostic hysteroscopy was planned a minimum of 6 weeks after the end of pregnancy, followed by retained product of conception removal at least 8 weeks after the end of the pregnancy. Postoperatively, an office second-look hysteroscopy was scheduled to assess the primary outcome of IUAs., Results: Postoperative IUAs were seen in 14.3% (9/63) of patients in the HM group and 20.6% (13/64) of patients in the vacuum aspiration group (-6% [-19.1% to 7.1%]). Significantly more RPOC were removed completely by HM compared with vacuum aspiration (95.2% vs. 82.5% (-14% [-24.9% to -3.1%]), and additional operative hysteroscopy was less frequently necessary in the HM group (12.5%) compared with the vacuum aspiration group (31.3%) (-20.1% [-34.3% to -6%]). The median operating time was shorter for vacuum aspiration compared with HM (5.80 minutes vs. 7.15 minutes). No differences were observed between HM and vacuum aspiration for the occurrence of intraoperative or postoperative complications (5.5% vs. 5.0% and 2.7% vs. 1.3%, respectively)., Conclusion: In our randomized controlled trial, no significant differences were found in the occurrence of IUAs and complications. However, the RPOC were more often completely removed by HM than vacuum aspiration, and the HM group required fewer additional hysteroscopic treatments., Clinical Trial Registration Number: NTR4923 (https://trialsearch.who.int/Trial2.aspx?TrialID=NTR4923). Date of registration: November 23, 2014, date of initial participant enrollment: January 1, 2015., Competing Interests: Declaration of interests L.P.W. has nothing to disclose. T.W.H. (the Ghent University Hospital) has received compensation from Medtronic for a lecture on RPOC. C.M.R. has nothing to disclose. L.W.P. has nothing to disclose. S.W. has nothing to disclose. B.C.S. has received compensation from Medtronic on an hourly basis for lectures on HM and donated all the compensation to a foundation that promotes research in obstetrics and gynecology. H.A.v.V. has received compensation from Medtronic on an hourly basis for lectures on HM and donated all the compensation to a foundation that promotes research in obstetrics and gynecology., (Copyright © 2023 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction and Hypothesis: Robotics-assisted laparoscopic supracervical hysterectomy (RALSH) with concomitant apical robotics-assisted POP repair provides advantages of minimally invasive procedures; however specimen removal without intraperitoneal spillage of potential pathology remains challenging. The primary aim of our study is to determine the factors affecting contained manual morcellation (CMM) of specimens during RALSH for POP surgery. The secondary aim of the study is to report complications associated with CMM and on specimen pathology., Methods: A total of 67 sequential patients underwent RALSH with concomitant robotics-assisted sacrocolpopexy or uterosacral vaginal suspension. Factors analyzed to affect CMM were specimen weight, length of skin and fascia incisions, patient age, body mass index (BMI), and estimated blood loss (EBL)., Results: Median CMM time was 11 min (1 to 46) and specimen weight 62 g (19 to 711). Median patient age was 56 years (36 to 83), and patient BMI was 28 (18 to 44). Median EBL was 50 ml (10 to 150). Median skin and fascial incision lengths were 3 cm (1.5 to 7), and 3.5 cm (1.5 to 8). CMM time was significantly dependent on specimen weight (p < 0.0001) and length of rectus fascia incision (p < 0.0126). There was no gross tissue spillage or bag ruptures. Uterine pathology revealed normal tissue (26%), leiomyoma (47%), adenomyosis (49%), and endometriosis (14%). 4.5% of specimens had evidence of microscopic neoplasm, and 5 years after surgery patients were cancer free., Conclusion: Contained manual extraction of the uterus and/or adnexae at the time of RALSH for POP surgery is a viable, safe, and efficient method of specimen removal., (© 2023. The International Urogynecological Association.)

Objectives: Our objective was to identify predictors of morcellation during a total laparoscopic hysterectomy (TLH)., Methods: A retrospective cohort study (Canadian Task Force classification II-2) taking place in a university hospital center in Quebec, Canada. Participants were women undergoing a TLH for a benign gynaecologic pathology from January 1, 2017, to January 31, 2019. All women underwent a TLH. If the uterus was too voluminous to be removed vaginally, surgeons favoured in-bag morcellation by laparoscopy. Uterine weight and characteristics were assessed before surgery by ultrasound or magnetic resonance imaging to predict morcellation., Results: A total of 252 women underwent a TLH and the mean age was 46 ± 7 (30-71) years old. The main indications for surgery were abnormal uterine bleeding (77%), chronic pelvic pain (36%) and bulk symptoms (25%). Mean uterine weight was 325 (17-1572) ± 272 grams, with 11/252 (4%) uterus being >1000 grams and 71% of women had at least 1 leiomyoma. Among women with a uterine weight <250 grams, 120 (95%) did not require morcellation. On the opposite, among women with a uterine weight >500 grams, 49 (100%) required morcellation. In addition to the estimated uterine weight (≥250 vs. <250 grams; OR 3.7 [CI 1.8 to 7.7, P < 0.01]), having ≥ 1 leiomyoma (OR 4.1, CI 1.0 to 16.0, P = 0.01) and leiomyoma of ≥5 cm (OR 8.6, CI 4.1 to 17.9, P < 0.01) were other significant predictors morcellation in multivariate logistic regression analysis., Conclusions: Uterine weight estimated by preoperative imaging as well as the size and number of leiomyomas are useful predictors of the need for morcellation., (Crown Copyright © 2023. Published by Elsevier Inc. All rights reserved.)

Uterus-like mass is a rare form of endometriosis, which shows striking structural similarity to the normal uterus. Formation of a mass lesion raises clinical concern for malignancy, and pathologic examination is necessary for accurate diagnosis. We describe herein, a middle aged woman who presented with a mesenteric mass six years post hysterectomy, which was initially suspected to be a gastrointestinal stromal tumor. The resected was specimen was grossly pear shaped with microscopy showing a central endometrial glands and stroma lined cavity, surrounded by a thick muscular wall reminiscent of uterine myometrium. Histogenesis of this entity is unclear, and several theories are proposed regarding the etiology, including congenital anomaly theory, metaplasia and heterotopia theories. Our clinical scenario developed a few years after uterine morcellation, indicating a possibility of another "iatrogenic implantation" theory behind the pathogenesis of this rare lesion.

Background: Laparoscopic surgery has been a milestone for minimally invasive surgeries. But safe removal of large uterine tissue is a challenge for minimally invasive procedures, and there still exists concern about the dissemination of benign or occult malignant uterine tissue during the use of the morcellator. Different tissue containment systems have been used in laparoscopic power morcellation. However, a risk of leakage still exists in clinical practice. In this study, we aimed to evaluate leakage and tissue dissemination associated with a new detachable multi-hard-port containment system for tissue removal during laparoscopic myomectomy morcellation., Methods: Beef tongue specimens were stained with methylene blue solution and morcellated in a plastic trainer box under laparoscopic guidance. The morcellation test in vitro conditions comprised two different containment systems to simulate laparoscopic power morcellation, specifically a polyurethane bag with two pipes (control group) and a detachable multi-hard-port containment system (experimental group). Insufflation pressure was set at 14 mmHg. Three methods are used to detect the leakage The procedure times were recorded. Thirty trials were performed using a multi-port approach and the two tissue containment systems., Results: The leakage rate was 0.03% (n = 30) for the experimental group and 26.6% (n = 30) for the control group (p < 0.005). Morcellation time was significantly shorter in the experimental group than in the control group (p < 0.001). Median bag introduction time was shorter in the experimental group than in the control group; however, removal time differences were not significant., Conclusions: This study quantified the low leakage rate during morcellation and the improved convenience of operation provided by a new tissue containment system., (© 2023. The Author(s).)

Purpose: To determine the factors affecting morcellation efficiency in holmium laser enucleation of the prostate (HoLEP) surgery., Materials and Methods: Patients who underwent HoLEP surgery by a single surgeon between 2018 and 2022 were included in the study. Our primary outcome of interest in this study was morcellation efficiency. The effect of preoperative and perioperative variables on morcellation efficiency was evaluated with linear regression analysis., Results: A total of 410 patients were included in the study. The mean morcellation efficiency was 6.95±1.70 g/min. Univariable and multivariable linear regression analysis was performed to identify factors affecting morcellation efficiency. Presence of the "beach ball" effect (small, round prostatic tissue fragments that are fibrotic and difficult to morcellate), the learning curve, resectoscope sheath type, prostate-specific antigen (PSA) density, morcellated tissue weight, and the presence of prostate calcification were found to be independent predictive factors (β=-1.107, 95% CI: -1.59 to -0.55, p<0.001; β=-0.514, 95% CI: -0.85 to -0.17, p=0.003; β=-0.394, 95% CI: -0.65 to -0.13, p=0.003; β=-0.302, 95% CI: -0.59 to -0.09, p=0.043; β=0.062, 95% CI: 0.05 to 0.06, p<0.001; β=-0.329, 95% CI: -0.55 to -0.10, p=0.004; respectively)., Conclusions: This study reports that presence of the beach ball effect, the learning curve, small resectoscope sheath, PSA density, and presence of prostate calcification negatively affect morcellation efficiency. On the contrary, morcellated tissue weight has a linear relationship with morcellation efficiency., Competing Interests: The authors have nothing to disclose., (© The Korean Urological Association.)

Objective: Uterine size is one of the essential factors determining the feasibility of a minimally invasive gynecologic surgery approach. A traditional electromechanical morcellator is a well-known tool but not without flaws. We aim to assess feasibility and safety of a novel intrauterine power morcellation device for uterine size reduction to overcome these limitations during hysterectomy., Methods: This single-arm, observational study was conducted in a single tertiary care medical center from April 2022 to July 2022. Feasibility and safety of a novel intrauterine morcellation device for uterine size reduction was tested in ten post-hysterectomy uteri (Ex-vivo)., Measurements and Main Results: Ten uteri were examined in this trial. No major complications occurred during the procedure. All ten (10) uteri were successfully reduced in size (size reduction range was between 9% to 54%). The average resection time using the Heracure Device was 4.3 minutes (range: 1min- 10min). Mean uterus weight reduction was 21%, with a mean circumference reduction of 25%. No leakage was observed from the outer surface of the uterus/serosa after the saline injection post-procedure examination., Conclusion: In this novel experiment, we verified the feasibility and safety of the Heracure device for vaginal intra-uterine morcellation for uterine size reduction. This technique could enable rapid and easy removal of the uterus through the vaginal orifice., Clinical Trial Registration: Name of the registry: ClinicalTrials.gov; Number Identifier: NCT05332132., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Pomeranz et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objectives: Laparoscopic subtotal hysterectomy (LSH) is a possible treatment for patients with benign uterine disease. Once the hysterectomy has been completed, morcellation and extraction of the corpus uteri is a crucial step of the procedure. We here present a case series to evaluate the feasibility of the in-bag transvaginal specimen retrieval following LSH., Study Design: We report a case series of consecutive patients who underwent LSH followed by in-bag transvaginal specimen retrieval. LSH was accomplished in a standard fashion. Once the uterus was detached from the cervix, a 2 cm posterior colpotomy was performed laparoscopically with a monopolar hook under direct view to insert a specimen retrieval bag into the abdomen. The corpus uteri was placed into the bag and transvaginal contained manual morcellation was performed. The colpotomy was then sutured transvaginally. Baseline patients' characteristics and surgical data were collected. Postoperative complications, same-hospital readmissions, and reoperations were registered if occurred within 30 days from surgery., Results: Patients' median age and BMI were 45,5 and 22,7, respectively. Median operative time was 71.5 min (range 34-143) and uterus weight ranged from 60 g to 470 g (median 210 g). The estimated blood loss was 100 mL (median) and no blood transfusion was required. No conversions to open surgery, nor intraoperative complications occurred. Median hospital stay was 2 days (1-3) and no postoperative complications within 30 days from surgery were recorded., Conclusions: LSH followed by in-bag transvaginal specimen extraction is a promising technique and might be considered a reliable and safe option to further reduce the invasiveness of the procedure., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Aim: This study aimed to compare the laparoscopic-enclosed electromechanical morcellation (LEM) with vaginal-enclosed scalpel morcellation (VSM) in laparoscopic myomectomy procedures., Methods: One hundred eighteen patients who underwent laparoscopic myomectomy were enrolled the prospective randomized interventional clinical study in tertiary university hospital. After myomectomy, tissue removal was accomplished via either LEM using the in-glove morcellation technique or VSM., Results: The median tissue removal time was longer in the LEM group (25 min [range: 14-55]) than the VSM group (20 min [range: 6-38] [p = 0.001]). Rescue analgesia requirement was significantly higher in the LEM group than the VSM group (mean rank: 56.92 vs. 40.92 doses, respectively; p < 0.001). There was no significant difference between preoperative and postoperative third month total scores of female sexual function index (FSFI) and subdomains in the LEM group. Conversely, all subdomains and total scores of FSFI (26.5 [16.7-34.8] vs. 22.7 [15.2-28.7]) except pain significantly worsened 3 months after operation in the VSM group., Conclusions: LEM was associated with a longer tissue removal time and increased postoperative analgesic requirement. On the other hand, VSM was associated with worsened postoperative sexual function from baseline., (© 2022 Japan Society of Obstetrics and Gynecology.)

Aims: To evaluate morcellation practices among Fellows of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)., Materials and Methods: RANZCOG Fellows were invited to complete an online survey. This anonymous, cross-sectional survey consisted of 29 questions regarding demographics and morcellation practices., Results: Four hundred and thirty eight (19.04%) of 2300 RANZCOG Fellows responded, and of these 258 (11.22%) completed the entire survey; analysis was undertaken on data from the latter respondents. Respondents were broadly representative of all RANZCOG Fellows regarding gender, age, and location. Of the respondents, 53.10% considered themselves advanced laparoscopic surgeons. Of respondents who had worked as gynaecology consultants prior to 2014, 39.39% used uncontained power morcellation prior to 2014, compared to 17.58% since (a decrease of 44.63%). The most common reasons for utilising uncontained power morcellation less often were the 2014 Food and Drug Administration warnings (40.31%), risk of adverse outcomes (33.72%), and recommendations from colleges such as RANZCOG (27.13%). When undertaking an operation that required specimen extraction, the most common methods used were: employing an open approach from the get-go (utilised by respondents in 31.01% of such cases); contained manual morcellation (28.90%); and conversion to intra-operative laparotomy (10.10%)., Conclusions: There has been a strong trend away from uncontained power morcellation since 2014, with a 36.00% increase in clinicians who never use uncontained power morcellation, and an 80.65% decrease in clinicians who always use this method of specimen extraction. The most common reason cited for employing uncontained power morcellation less often was the 2014 Food and Drug Administration's warnings., (© 2022 The Authors. Australian and New Zealand Journal of Obstetrics and Gynaecology published by John Wiley & Sons Australia, Ltd on behalf of Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Purpose: Holmium laser enucleation of the prostate (HoLEP) is reported to be widely used in the surgical treatment of benign prostatic hyperplasia (BPH), which consists of two procedures: enucleation and morcellation. This study is to examine the efficiency and safety of two different morcellator systems within a cohort of men undergoing HoLEP for BPH., Methods: A total of 210 consecutive patients undergoing HoLEP and morcellation procedures were enrolled. Individuals were randomly divided into 2 separated groups: the first group (105 patients) was performed with a nephroscope using a mechanical Versacut morcellator and the second (105 patients) was performed with the new morcellation system, nephroscopes and Piranha morcellator. Perioperative characteristics were studied and analyzed., Results: The morcellation time and the morcellation rate was similar when the prostate volume (PV) ≤ 60 mL while the morcellation time was significantly shorter and the morcellation rate was higher in the Piranha group with PV > 60 mL. No significant difference was observed according to the bladder irrigation time, indwelling catheter time, and discharge time., Conclusion: Piranha morcellator presents a higher efficiency for the prostate over 60 mL., (© 2022. The Author(s), under exclusive licence to Springer Nature B.V.)

The laparoscopic approach for the treatment of uterine leiomyoma is increasingly practiced. The necessity to remove large specimens from the small laparoscopic incision has always been one of the main limits of this procedure. The unrestricted use of morcellation, to overtake this weak point of minimally invasive surgery, has opened in recent years a broad debate, especially on the risk of unintended dissemination of cells that could in some cases lead to extremely negative repercussions. This review analyzes these aspects and the principal recommendations from the major gynecological society on this topic surveying their effects. Furthermore, the purpose of this article is to provide an overview of the different morcellation techniques and how they are performed, evaluating their advantages and disadvantages. Contained morcellation seems to overcome many limits; however, based on recent data, an appropriate evaluation and selection of patients, as well as complete counseling before the surgery, are mandatory.

Competing Interests: Financial Disclosure The authors did not report any potential conflicts of interest.

Objective: To estimate trends in use of laparoscopic power morcellators in women undergoing minimally invasive hysterectomy and to examine use of containment systems in these patients in relation to safety guidance from the U.S. Food and Drug Administration (FDA)., Methods: We examined data that were recorded in the Premier Healthcare Database from patients who underwent laparoscopic supracervical hysterectomy from 2010 to 2018. Patients were stratified based on use of laparoscopic power morcellators. The cohort was further stratified as either pre-FDA guidance (2010 quarter 1-2014 quarter 1) or post-FDA guidance (2014 quarter 2-2018 quarter 2). Interrupted time series analyses were performed to determine the effect of FDA guidance on the use of laparoscopic power morcellators and containment bags., Results: Among 67,115 patients, laparoscopic power morcellator use decreased from 66.7% in 2013 quarter 4 to 13.3% by 2018 quarter 2. The likelihood of laparoscopic power morcellator use decreased by 9.5% for each quarter elapsed in the post-FDA warning period (risk ratio [RR] 0.91, 95% CI 0.90-0.91). Containment bag use rose from 5.2% in 2013 quarter 4 to 15.2% by 2018 quarter 2. The likelihood of containment bag use increased by 3% for each quarter elapsed in the post-FDA warning period (RR 1.03, 95% CI 1.02-1.05). Among women who had laparoscopic power morcellator use, uterine cancers or sarcomas were identified in 54 (0.17%) before the FDA guidance compared with seven (0.12%) after the guidance ( P =.45). Containment bags were used in 11.1% of women with uterine cancers or sarcomas before the FDA guidance compared with 14.3% after the guidance ( P =.12). The perioperative complication rate was 3.3% among women who had laparoscopic power morcellator use without a containment bag compared with 4.5% ( P =.001) in those with a containment bag (aRR 1.35, 95% CI 1.12-1.64)., Conclusion: Use of laparoscopic power morcellators has decreased over time. Containment bag use increased after the FDA's 2014 guidance; however, most procedures employing laparoscopic power morcellators are still performed without a containment bag., Competing Interests: Financial Disclosure Dr. Wright has received royalties from UpToDate and received research support from Merck. Dr. Hou has served as a consultant for Foundation Medicine and Natera. The other authors did not report any potential conflicts of interest., (Copyright © 2022 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Uterine fibroids are difficult to distinguish from malignant masses using standard ultrasonography; and morcellation carries the risk of disseminating occult cancer in a small but relevant group of women with an undetected uterine malignancy. In this context, we follow the progress of a woman diagnosed with uterine leiomyosarcoma after suboptimal initial surgery for an assumed fibroid. Evidence is reviewed that guided multidisciplinary tumor board decisions about optimal management approaches after local seeding and development of distant metastases, and informed treatment selection at each line of therapy. As the case study illustrates, choice of treatment for advanced soft tissue sarcomas frequently involves finding an appropriate balance between the efficacy and toxicity of available options, aiming to allow patients to maintain their normal lives.

Competing Interests: The authors declare that they have no conflict of interest.

Context: Although several studies have compared different morcellators and enucleation techniques for the management of benign prostatic hyperplasia (BPH), there is sparse literature on morcellation, so further experimental and clinical research is required for its optimization., Objective: To critically appraise the contemporary literature on prostate morcellation and to evaluate the safety and efficiency of currently available morcellators for endoscopic enucleation of the prostate (EEP) in the context of BPH., Evidence Acquisition: A comprehensive review of the English and French literature relevant to prostate morcellation was performed using the PubMed-MEDLINE, Cochrane Library, Web of Science, and Wiley Online Library database from 1998 to 2020 using PICOS (patient population, intervention, comparison, outcome, and study design) criteria., Evidence Synthesis: We retrieved 26 studies involving 5652 patients treated with a morcellator that were eligible for data extraction and analysis. The mean patient age was 67.4 (range 61.4-72.8) yr. The weighted mean efficiency of Piranha, VersaCut, and DrillCut morcellators was 5.29, 3.95, and 5.3 g/min, respectively. Several approaches, such as en bloc, two-lobe, inverse, and improved techniques, may increase morcellation efficiency and safety. The lowest weighted mean rate of bladder wall injury was 1.24% for Piranha, followed by 1.98% for DrillCut, and 5.23% for VersaCut, while the VersaCut morcellator had the lowest weighted mean rate of device malfunction at 0.74%, compared to 2.07% for Piranha and 7.86% for DrillCut., Conclusions: All three morcellators are efficient and safe for prostatic morcellation after EEP. Further development of devices and techniques may improve the efficiency and safety profile of morcellation. To increase safety, surgeon expertise, technical equipment, and patient characteristics should be considered. Therefore, interdisciplinary exchange of knowledge and further technological innovations are strongly encouraged., Patient Summary: We reviewed the safety and efficacy of devices called morcellators. These devices cut tissue into small pieces that are easier to remove from the body, and are used during laser surgery for benign enlargement of the prostate. Three morcellators are currently available on the market and are comparable in safety and efficacy., (Copyright © 2021 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Introduction: Despite the significant advantages of morcellation, it may be associated with severe complications. We aimed to determine both direct and indirect complication rates of morcellation at gynecological laparoscopy., Material and Methods: This multicenter retrospective study included patients traced from 2008 to 2017. We identified women who underwent an operation with the use of electromechanical power morcellation (EMM) or vaginal manual morcellation during laparoscopy. Clinical records, intraoperative-postoperative outcomes were reviewed., Results: We analyzed 1795 patients who underwent laparoscopic supracervical hysterectomy (LASH), total hysterectomy (TLH), or myomectomy (45.5%, 14.2%, and 40.3%, respectively). No severe intraoperative complications associated with morcellation or parasitic leiomyoma were observed. Patients with unexpected sarcoma were detected in five cases (0.28%). Four of them were detected after LASH and one after vaginal manual morcellation following TLH, who had an intraabdominal recurrence and died after 18 months. The patients after LASH underwent secondary laparotomy for staging; no histological dissemination of sarcoma was observed, however two had a recurrence. The five-year survival rate was 80%., Conclusions: There is a small risk of intraoperative complications or unexpected malignancy following morcellation, provided the surgeon adheres to regular surgical standards. In patients with a normal size uterus, TLH could be preferred over LASH to avoid morcellation.

Objectives: Morcellation is an integral part of laparoscopic procedures related to uterine fibroids, which consist of the mechanical fragmentation of the tumor and its extraction outside the abdominal cavity. To avoid the risk of tissue dissemination, special extraction systems have been developed, which allow morcellation of the specimen under visual control and its removal without contact with the abdominal organs. The aim of the paper is to compare the two systems for laparoscopic morcellation., Material and Methods: The study included 33 premenopausal women with symptomatic leiomyomas or adenomyosis, who were qualified for laparoscopic surgery with contained power morcellation. Patients were allocated alternately to a different tissue extraction system's group. According to the study protocol, selected operative parameters were prospectively recorded. Finally, an assessment of bag use was performed. The data was statistically analyzed., Results: There were significant differences between the two tested systems in terms of introducing and positioning the bag, its removal from the peritoneal cavity, as well as optic trocar insertion and establishing the pseudo-peritoneum., Conclusions: Despite the minor design differences and some ergonomic aspects, both presented systems proved to be safe and feasible tools for laparoscopic contained morcellation. This technique both reduces the risk of tissue dissemination and preserves the advantages of minimal invasiveness.

Objective: To summarize recent data and knowledge of laparoscopic power morcellation., Methods: Review of articles., Results: Laparoscopic morcellation has been introduced to gynecologic surgery in 90s. In 2014, Food and Drug Administration announced negative statement about the morcellation use due to the risk of potential spreading of malignant tumor cells. This statement reduced utilization of morcellation, especially in the United States. Since that, many health institutions and organizations started new researches focused on the safety of this surgical technique. After a couple of years, the morcellation is considered as a useful tool if certain rules are followed., Conclusion: Morcellation has a place in laparoscopic operative procedures even in 2022, in condition of correct selection of patients and possible utilization of contained in-bag morcellation.

Objectives: Open power morcellation during a laparoscopic myomectomy (LM) can result in the dissemination of benign or occult malignant tumor cells in the abdominopelvic cavity. The development of a new contained collection bag for power morcellation is now favored by gynecologic surgeons worldwide., Material and Methods: This study was a single-arm trial comprising 20 women who consecutively underwent an LM involving the use of a newly designed contained collection bag for power morcellation between November 3rd 2017 and April 31st 2018. There was also a historical control group consisting of 30 women who underwent open power morcellation during an LM between May 1st 2017 and October 31st 2017. All the essential information concerning the patients and surgically related data, including the myoma size, the operation duration, and the cell count of the intraperitoneal irrigating fluid, were collected and analyzed., Results: The uterus size and the maximum diameters of the uterus and the myoma of the two groups were not significantly different (p = 0.65, p = 0.71, and p = 0.31, respectively). Pseudopneumoperitoneum was established and clear visualization was guaranteed in all 20 cases in the experimental group. The remaining fragment tissue amount (mean ± SD) and weight (mean ± SD) in the collection bag after morcellation in the experimental group were 5.00 ± 1.48 and 3.87 ± 1.31 (g). All the collection bags were routinely examined after the LM using normal saline, and no leaks or lesions were found. The cell counts of the intraperitoneal irrigating fluid both before and after morcellation were less than 105-106/L. The pathology of all the tissues confirmed that there were no malignant tumors. The operation of the experimental group was 18 mins longer than that of the historical control group (p = 0.00)., Conclusions: This newly designed collection bag system for LM morcellation is effective, feasible, and safe.

Purpose: Holmium laser enucleation of the prostate (HoLEP) entails both enucleation and morcellation. Only three popular prostate morcellation devices are available for this procedure. In this study, a retrospective review was done to compare the Wolf ® and Storz ® morcellators. Materials and Methods: After Institutional Review Board approval, a multi-institutional retrospective chart review of prospectively collected data was performed at two institutions with a single surgeon at each center performing HoLEP. Thunder Bay Regional Health Sciences Center employed the Storz morcellator while Baylor Scott and White Medical Center used the Wolf. Preoperative, perioperative, postoperative, and demographic data for both sets of patients were analyzed and compared retrospectively. Results: A total of 506 patients in the Wolf cohort and 60 patients in the Storz cohort were analyzed. Morcellated pathologic weight was 52.3 g in the Wolf arm and 101.7 g on the Storz arm ( p  < 0.0001). Overall, average morcellation rates were faster in the Storz arm; morcellation rate was 5.8 g/min for Wolf, and 6.7 g/min in the Storz ( p  = 0.0015). Morcellator malfunction was significantly lower in Wolf cohort 0% vs 6.6% in the Storz ( p  = 0.0001), but this did not significantly slow morcellator efficiency times. The total number of mucosal bladder injuries was comparable with rates of 1.4% and 1.6% in the Wolf and Storz groups, respectively ( p  = 0.59). The duration of hospital stay and catheterization were <24 hours in both groups. Conclusions: In this retrospective study, the Storz DrillCut had higher efficacy in morcellation when compared with Wolf Piranha. However, it was associated with more malfunctions. Both morcellators have comparable rates of complications and perioperative outcomes.

Electromechanical morcellation-so called power morcellation-is a minimally invasive approach to remove bulky lesions such as uterine fibroids. The spread of benign and malignant tissue due to morcellation is a major concern that might limit the use of laparoscopic interventions. We present an in vitro evaluation of the safety characteristics of a four-port endobag with closable trocar sleeves, and describe physical properties of the bag that may or may not allow passage through the hole. In addition, we report our preliminary experience of this tool when used for laparoscopic supracervical hysterectomies. The behavior of the endobag during the extraction process was analyzed by extracting opened and re-sealed bags filled with 20 ml blue dye solution through a wooden template, with incisions measuring 10 to 24 mm. The endobag was used in 50 subtotal hysterectomies during the morcellation procedure. In the in vitro test, no dye loss was recorded for incisions measuring 11-24 mm. The mean force required to pull the bag through the template was inversely proportional to incision size. No bag rupture occurred during the surgical procedures. The mean time taken to prepare the bag for morcellation was 7.1 min (range, 4-14 min), the mean duration of subtotal hysterectomy was 53.4 min (range, 20-194 min). The mean weight of the removed body of the uterus was 113.8 g (range, 13-896 g), the mean weight of tissue and fluid remaining in the bag after morcellation 7.9 g (range, 0-39 g). In the in vitro setting, the improved endobag signifies greater patient safety during bag extraction, along with less tissue traumatization due to a smaller incision in the abdominal wall. The improved ergonomic features of the bag permit the insertion of three trocars in the lower abdomen and avoid closure of unused access ports. Our preliminary experience has shown that the device can be used under routine conditions. Failure rates will be evaluated in future studies., (© 2021. The Author(s).)

Introduction: The risk of unknowingly disseminating leiomyosarcoma by morcellation in women undergoing laparoscopic hysterectomy has massively impacted gynaecological practice. Here, we present the results of an in vitro assessment of a novel protection system developed to mitigate this hazard., Methods: The Tissue Containment System for Manual Morcellation (Guardenia™, Advanced Surgical Concepts, Wicklow, Ireland) is an evolved wound protection/specimen extraction guarded bag system compatible with any 12mm trocar. Device use was assessed by device-naïve gynaecological and general surgeon volunteers (providing expert and inexpert morcellation cohorts, respectively) on a bench model consisting of biological tissue in a custom-built moulded rig with camera control after the operators were instructed in its use., Results: Twenty surgeons (10 gynaecologists/10 general surgeons, median duration of practice experience: 8 years, median annual number of laparoscopic operative procedures: 150 and 80, respectively) completed the user assessment. All subjects understood and correctly performed each step; i.e., (i) placement of the bag through the trocar, (ii) specimen bagging, (iii) incision extension (range 25-60 mm) after tethering the bag through the port, (iv) insertion of the device guard through the mouth of the bag after trocar removal, and (v) sufficient tissue morcellation within the bag to enable complete specimen removal (mean specimen weight 390g, range 201-1800g). There was 100% bag integrity by water-leak testing following use, despite scalpel contact with the guard in 14/20 cases (70%)., Conclusion: Among first-time clinical users, this novel device enabled complete containment of morcellation debris and removal of a laparoscopic specimen, which would support further submission for regulatory approval.

Background: Hysterectomy is the most commonly performed benign gynaecological surgery. Recently, the rates of minimally invasive hysterectomy have fallen due to the banning of mechanical morcellation techniques that rendered minimal invasive gynaecology surgeons unable to extract large uteri from the relatively small colpotomy incisions., Aims: This study aims to share our experience in utilising Colpo-V incision to remove large uterine specimens transvaginally and report its success and complication rates to promote a minimal invasive approach in patients with large uteri without the need to perform large abdominal incisions or transabdominal morcellation., Methods: This is a prospective case series study in which women with large uteri and|or narrow vaginal canal underwent total laparoscopic hysterectomy and a subsequent posterior vaginal wall incision (Colpo-V) to facilitate the intact extraction of the uterus through the vagina. Patients were seen in the clinic six weeks after the surgery for post-operative assessment and documentation of late complications., Results: Seventeen women underwent the procedure, and the intact extraction of the specimen was successful in 16 out of the 17 cases (94%). No major complications were encountered during or after the procedure., Conclusion: Colpo-V incision is a simple and effective technique for the intact extraction of larger uterine specimens at hysterectomy., (© 2021 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Objectives: To evaluate the hysteroscopic morcellation service in office-setting in everyday practice outside the context of clinical trials. The primary objectives were to assess level of acceptability and factors affecting women satisfaction. The secondary objectives included assessment of complete resection rate, complications rate, pain score during the procedure and on discharge, and the correlation between the lesion size as subjectively estimated by the hysteroscopists versus the volume of morcellated tissues as semi-quantitively measured by the laboratory., Method: The clinical data was compiled for 287 consecutive women undergoing hysteroscopic morcellation in office-setting from 1 January 2017 to 31 March 2021 in a teaching hospital in the UK. A questionnaire, formulated on the Visual Analogue Scale (VAS), was completed immediately after the procedure by the last 110 women undergoing the procedure., Results: The mean age of the cohort (n = 278) was 54.5 years (SD ± 12.5). Only 7 (2.4%) women required two-stage procedure because of size (fibroid ≥ 4 cm), vascularity or multiplicity of lesions. No complications were encountered. The majority of women completing the questionnaire (n = 110) found office procedure acceptable (105, 95.5%, VAS ≥ 7), were willing to have it again if indicated (102, 92.7%, VAS ≥ 7), would recommend it to family and friends (105, 95.5%, VAS ≥ 7) and confirmed receiving adequate preoperative information by doctors and nurses (107, 97.3%, VAS ≥ 7). The level of preoperative explanation and information-giving showed significant (p < 0.01) positive correlation with the level of acceptability and recommendation to others and significant (p = .007) negative correlation with the pain experienced on discharge. The median (IQR) estimated size at hysteroscopy was 2 cm (1-6 cm) for polyps and 2.5 cm (1-4 cm) for fibroid. The median (IQR) volume of the morcellated specimens as estimated by laboratory was 2000 mm 3 (1100-3800 mm 3 ). The estimated size at hysteroscopy was positively correlated with the specimen's volume (Spearman's rho (r) = 0.31, 95% = CI, 0.14-0.45, p < 0.01)., Conclusion: Office hysteroscopic morcellation is associated with high satisfaction rate and low pain score on discharge. Good preoperative explanation and information-giving was the crucial factor that increased women satisfaction. Subjective estimation of lesion size by hysteroscopists may be an accurate and simple method of measurement., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Study Objective: Operative hysteroscopy requires elevated intrauterine pressures, which could lead to the spread of malignant cells into the peritoneal cavity. Currently, there is a paucity of data analyzing clinical outcomes in endometrial cancer after hysteroscopic morcellation with newer equipment. In this study, we sought to determine whether there are increased rates of positive peritoneal cytology, lymphovascular space invasion, or surgical upstaging in patients undergoing hysteroscopic morcellation compared with alternative endometrial biopsy methods., Design: A retrospective chart review of patients from 2013-2018 was performed. The exclusion criteria included biopsy at outside institution, stage IV endometrial cancer known before biopsy, and missing data regarding biopsy method and histology. Peritoneal cytology results, lymphovascular space invasion, and surgical staging were compared by method of biopsy and histology using chi-square and Kruskal-Wallis tests., Setting: The patients included in this study were accrued from the Karmanos Cancer Insittute in Detroit, Michigan., Patients: A total of 289 patients met the inclusion criteria: 184 patients were classified as low-grade (Fédération Internationale de Gynécologie et d'Obstétrique grades 1 and 2) and 105 as high-grade (Fédération Internationale de Gynécologie et d'Obstétrique grade 3, serous, clear cell, and carcinosarcoma) endometrial cancer., Interventions: Fifty-three patients (18%) underwent hysteroscopy with morcellation. Alternative biopsy methods included hysteroscopy without morcellation, n = 81 (28%); endometrial biopsy, n = 112 (38.7%); and dilation and curettage, n = 43 (15%)., Measurements and Main Results: Positive peritoneal cytology was noted in 34 cases (12%) and negative cytology in 165 (57%). Cytology was not performed in 90 cases (31%). When comparing outcomes by histologic subtypes, no difference was seen in peritoneal cytology (p = .704 and .727 for low grade and high grade, respectively), stage (p = .773 and .053 for low grade and high grade, respectively) or lymphovascular space invasion (p = .400 and .142 for low grade and high grade, respectively)., Conclusion: Our study demonstrates that hysteroscopy with morcellation is a safe diagnostic method for low- and high-grade endometrial pathologic conditions and does not lead to increased dissemination of malignant cells, lymphovascular space invasion, or upstaging of patients., (Copyright © 2021. Published by Elsevier Inc.)

Study Objective: To show 3 different techniques for achieving an endobag morcellation without adding extra time and cost to the surgery., Design: Stepwise demonstration of the 3 techniques with narrated video footage., Setting: Morcellation is a useful procedure for fragmenting and extracting specimens during laparoscopic surgery without the need to perform a laparotomy. Patients who otherwise would not be eligible for minimally invasive surgery (i.e., those with a large uterus or myomas) could benefit from laparoscopic advantages. However, morcellation has a major limitation: the risk of dissemination of unsuspected malignancies. In 2017, the Food and Drug Administration released an updated assessment of the use of laparoscopic power morcellators for treatment of leiomyomas. A total of 23 studies were included in the analysis, and 20 studies (90 910 women) contributed to the estimated prevalence of leiomyosarcoma at the time of surgery for presumed leiomyomas. Depending on the modeling methodology used, the estimated prevalence of uterine sarcoma was 1 in 305 to 1 in 360 women, and for leiomyosarcoma, the estimated prevalence was 1 in 570 to 1 in 750 women [1]. Currently available evidence has suggested that if an undiagnosed uterine malignancy is intra-abdominally morcellated, there is a risk of intraperitoneal dissemination of the disease [2]. Therefore, the European Society of Gynecological Oncology emitted a statement in 2016 recommending avoiding morcellation if there is any suspicion of sarcoma and using endobag containers for morcellation of the surgically removed uterine myomas [3]. In addition, in the United States, the Food and Drug Administration recommends performing laparoscopic power morcellation for myomectomy or hysterectomy only with a tissue containment system, legally marketed in the United States [4]., Interventions: There are several techniques described in the literature for contained uterine myomas morcellation [5]. In this video, we present 3 of them: First, an indirect-view morcellation is described. In this technique, we placed the myoma in the bag and exteriorize it through one of the trocars. Once outside the abdomen, we placed the morcellator through the bag opening and did the morcellation inside the bag while checking through the umbilicus camera. Special attention must be paid to avoid any damage to the bag because the visualization is limited in this technique. Second, a direct-view technique is described, in which we exteriorized the opening of a 15-mm bag through the suprapubic trocar and a closed end of the bag through the umbilicus. We made a hole in the umbilicus end of the bag and introduced the camera trocar through it. Once done, we introduced the morcellator through the opening and the camera in the umbilicus port. Third, a single-port-contained morcellation is explained. The bag was exteriorized through the umbilicus, and a skin retractor was placed. A glove was placed outside the retractor to isolate the bag. Once placed, 2 of the fingers were opened and used as trocars (one for the morcellator and the other for a 30° camera). After using this technique, the scope should be replaced to minimize the risk of contamination. The following are possible limitations of each technique: in the indirect-view technique, owing to the limited visualization, the surgeon must pay special attention to avoid tearing the bag while morcellating the specimen. In the direct-view technique method, the surgeon needs to ensure the proper closure of the bag before removing it from the abdomen to avoid possible dissemination risk. Finally, in the single-port technique, the surgeon must have previous experience in this type of approach, minimizing the risk of contamination by changing the scope after the morcellation process., Conclusion: Laparoscopic power morcellation may provide several benefits for our patients, when performing a hysterectomy or a multiple myomectomy. We presented 3 different and feasible techniques for laparoscopic power morcellation using an endobag container., (Copyright © 2020 AAGL. Published by Elsevier Inc. All rights reserved.)

Background: An adenomyoma is a well circumscribed form of adenomyosis and can be located within the myometrium, in the endometrium as a polyp, or extrauterine with the last being the rarest presentation amongst the three. With the ongoing advancement in gynecological surgery, the use of electromechanical morcellators have made the removal of large and dense specimens possible with minimally invasive techniques. However, it has also caused an increase in complications which were previously rare. Whilst the tissue is being grinded within the abdominal cavity, residual tissue can spread and remain inside, allowing for implantation to occur and thereby giving rise to recurrence of uterine tissue as a new late postoperative complication. Case presentation A 45-year-old woman presented with worsening constipation and right iliac fossa pain. Her past surgical history consists of laparoscopic supra-cervical hysterectomy that was indicated due to uterine fibroids. Computerized tomography and magnetic resonance imaging were done, which showed an irregular lobulated heterogeneous mass seen in the presacral space to the right, located on the right lateral aspect of the recto-sigmoid, measuring 4.5 × 4.3 × 4.3 cm in size. A transvaginal ultrasound revealed a cyst in the left ovary. The patient had a treatment course over several months that included Dienogest (progestin) and Goserelin (GnRH analogue) with add-back therapy. In line with the declining response to medications, the patient was advised for a laparoscopic ovarian cystectomy. During the surgery, an additional lesion was found as a suspected fibroid and the left ovarian cyst was identified as pockets of peritoneal fluid which was sent for cytology. The surgical pathology report confirmed adenomyosis in both specimens, namely the right mass and the initially suspected fibroid., Conclusion: In this case report, we showcase a rare occurrence of an extrauterine adenomyoma presenting two years post laparoscopic morcellation at hysterectomy. This poses questions regarding the benefits versus risks of power morcellation in laparoscopic hysterectomy.

Study Objective: This study evaluated peritoneal washings for the detection of spindle cells (SCs) in laparoscopic and open myomectomies., Design: Prospective, nonrandomized clinical trial., Setting: An academic tertiary referral center., Patients: Women suspected of having benign uterine myoma undergoing laparoscopic or open myomectomy from October 2016 to April 2018., Interventions: Washing of the peritoneal cavity to detect SCs was performed twice during the laparoscopic myomectomy. The first washing was after the closure of the myometrial incision and before morcellation. The second one was performed after morcellation. The procedure was also performed once during the open myomectomy, after the completion of the myomectomy and the closure of the incision. After a peritoneal washing with 200 mL normal saline, 30 mL liquid was collected and sent to the laboratory for SC detection. Surgical parameters such as operating time, mean change in serum hemoglobin level, complications, length of hospital stay, and readmission were compared between the 2 groups., Measurements and Main Results: A total of 150 participants were included in the analysis: 78 in the laparoscopic group and 72 in the open myomectomy group. After morcellation, the incidence of SCs was 2.6% (n = 2) and 6.9% (n = 5) in the laparoscopic and open myomectomy groups, respectively (p = .204)., Conclusion: SCs were observed in both the laparoscopic and open myomectomy groups. Thus, morcellation alone could not be the cause for SC dissemination, which might also be triggered by the manipulation of myoma(s)., (Copyright © 2020 AAGL. All rights reserved.)

Background: Safety warnings about power morcellation in 2014 considerably changed hysterectomy practice, especially for laparoscopic supracervical hysterectomy that typically requires morcellation to remove the corpus uteri while preserving the cervix. Hospitals might vary in how they respond to safety warnings and altered hysterectomy procedures to avoid use of power morcellation. However, there has been little data on how hospitals differ in their practice changes., Objective: This study aimed to examine whether hospitals varied in their use of laparoscopic supracervical hysterectomy after safety warnings about power morcellation and compare the risk of surgical complications at hospitals that had different response trajectories in use of laparoscopic supracervical hysterectomy., Study Design: This was a retrospective analysis of data from the New York Statewide Planning and Research Cooperative System and the State Inpatient Databases and State Ambulatory Surgery and Services Databases from 14 other states. We identified women aged ≥18 years undergoing hysterectomy for benign indications in the hospital inpatient and outpatient settings from October 1, 2013 to September 30, 2015. We calculated a risk-adjusted utilization rate of laparoscopic supracervical hysterectomy for each hospital in each calendar quarter after accounting for patient clinical risk factors. Applying a growth mixture modeling approach, we identified distinct groups of hospitals that exhibited different trajectories of using laparoscopic supracervical hysterectomy over time. Within each trajectory group, we compared patients' risk of surgical complications in the prewarning (2013Q4-2014Q1), transition (2014Q2-2014Q4), and postwarning (2015Q1-2015Q3) period using multivariable regressions., Results: Among 212,146 women undergoing benign hysterectomy at 511 hospitals, the use of laparoscopic supracervical hysterectomy decreased from 15.1% in 2013Q4 to 6.2% in 2015Q3. The use of laparoscopic supracervical hysterectomy at these 511 hospitals exhibited 4 distinct trajectory patterns: persistent low use (mean risk-adjusted utilization rate of laparoscopic supracervical hysterectomy changed from 2.8% in 2013Q4 to 0.6% in 2015Q3), decreased medium use (17.0% to 6.9%), decreased high use (51.4% to 24.2%), and rapid abandonment (30.5% to 0.8%). In the meantime, use of open abdominal hysterectomy increased by 2.1, 4.1, 7.8, and 11.8 percentage points between the prewarning and postwarning periods in these 4 trajectory groups, respectively. Compared with the prewarning period, the risk of major complications in the postwarning period decreased among patients at "persistent low use" hospitals (adjusted odds ratio, 0.88; 95% confidence interval, 0.81-0.94). In contrast, the risk of major complications increased among patients at "rapid abandonment" hospitals (adjusted odds ratio, 1.48; 95% confidence interval, 1.11-1.98), and the risk of minor complications increased among patients at "decreased high use" hospitals (adjusted odds ratio, 1.31; 95% confidence interval, 1.01-1.72)., Conclusion: Hospitals varied in their use of laparoscopic supracervical hysterectomy after safety warnings about power morcellation. Complication risk increased at hospitals that shifted considerably toward open abdominal hysterectomy., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: To evaluate the efficacy and safety of an endoscopic bag during laparoscopic morcellation of leiomyoma or myomatous uterus., Materials and Methods: A total of 48 patients with symptomatic leiomyoma were randomized for laparoscopic morcellation in two groups: group A with a specific endoscopic bag or group B without any bag. The primary outcome measure was the detection of smooth muscle cells from washing after power morcellation determined by peritoneal cytology and immunohistochemistry (IHC)., Results: Cytology and IHC from group A did not revealed any smooth muscle cells, while 29% of cases (7/24) from group B were positive ( p = .009). The duration of the surgical procedure was the same in both groups. The duration of positioning the bag did not change significantly during the study. Only in one case the use of the bag was difficult due to a low pneumoperitoneum., Conclusions: The use of a morcellation bag is efficient to prevent the spread of smooth muscle cells during the morcellation of leiomyoma or myomatous uterus. This study confirms the feasibility and the safety of the laparoscopic inbag morcellation versus open morcellation., Competing Interests: The authors declare that they have no competing interest., (Copyright © 2021 Chloe Bensouda-Miguet et al.)

Study Objective: The objective of this study was to determine the incidence of occult uterine malignancy at the time of sacrocolpopexy with concurrent hysterectomy, in the context of practice pattern changes as a result of the 2014 Food and Drug Administration (FDA) power morcellation safety communication., Design: Retrospective chart review., Setting: Tertiary care referral center in the United States., Patients: A total of 839 patients who underwent sacrocolpopexy from January 2004 to December 2018., Interventions: All patients received a concurrent hysterectomy without a diagnosis of suspected or confirmed gynecologic malignancy before surgery. Trends of surgeries were compared before and after the 2014 FDA power morcellation safety communication., Measurements and Main Results: Demographic and perioperative data were collected from the system-wide electronic medical record. Operative and pathology reports were reviewed to determine the method of specimen retrieval and specimen pathology results. A total of 238 patients (28.4%) had a hysterectomy at the time of sacrocolpopexy. There were no cases of occult uterine malignancy (0%, 95% CI 0%-1.6%). There was 1 case of borderline tumor of the ovary. The most common mode of hysterectomy over the 15-year period was laparoscopic hysterectomy (n = 84, 35.3%), followed by vaginal hysterectomy (n = 63, 26.5%). After the FDA communication, the most common form of hysterectomy changed significantly to vaginal hysterectomy (n = 35, 55.6%; p <.001). When comparing the first 2 years after the announcement (2014-2016) to the subsequent 2 years (2017-2018), there was again a significant increase in the use of laparoscopic hysterectomy in the latter time period (7.3% vs 40.9%; p <.001)., Conclusion: In this cohort of patients undergoing sacrocolpopexy with concurrent hysterectomy, the incidence of occult uterine malignancy was low. After the FDA safety communication, practice patterns with regard to the mode of hysterectomy changed, but the magnitude of these changes were transient., (Copyright © 2020 AAGL. Published by Elsevier Inc. All rights reserved.)

Objectives: 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 TruClear TM 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., Results: 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., Conclusion: Overall, there is no difference in total procedure time between hysteroscopic morcellation using the TruClear TM 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., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Abstract: Morcellation is a surgical technique used to reduce the size of the uterus or myomas by creating smaller pieces to allow the tissue to be removed through small incisions or with laparoscopic instruments. Open (uncontained) morcellation of the uterus and myomas has been scrutinized because of the possible spread of an unsuspected leiomyosarcoma while using a power morcellator during a hysterectomy or myomectomy for presumed symptomatic uterine leiomyomas. Before considering morcellation of the uterus, a woman should be evaluated to determine if she is at increased risk of malignancy of the uterine corpus. Morcellation of a malignancy is contraindicated and women should be evaluated preoperatively to identify malignancy. However, leiomyosarcoma cannot be reliably diagnosed preoperatively; thus, there is a risk that a woman with a presumed leiomyoma may have a malignancy that may be spread through morcellation, leading to a potentially worsened prognosis. Although an abdominal hysterectomy or myomectomy may reduce the chance of spreading cancer cells in women with undiagnosed leiomyosarcoma, it is associated with increased morbidity when compared with minimally invasive approaches. The obstetrician-gynecologist and patient should engage in shared decision making, including informed consent, explaining the risks and benefits of each approach to surgery for presumed leiomyomas, the risks and benefits of morcellation, and alternatives to morcellation., Competing Interests: All ACOG committee members and authors have submitted a conflict of interest disclosure statement related to this published product. Any potential conflicts have been considered and managed in accordance with ACOG’s Conflict of Interest Disclosure Policy. The ACOG policies can be found on acog.org. For products jointly developed with other organizations, conflict of interest disclosures by representatives of the other organizations are addressed by those organizations. The American College of Obstetricians and Gynecologists has neither solicited nor accepted any commercial involvement in the development of the content of this published product., (Copyright © 2021 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Rationale: Leiomyomatosis peritonealis disseminata (LPD) is a rare benign lesion primarily consisting of smooth muscle cells, which mostly affects premenopausal females. Here, we reported 3 females with LPD (age, 40-48 years) admitted for pelvic masses., Patient Concerns: All 3 LPD cases received laparoscopic uterine fibroid morcellation at 3, 8, and 14 years ago, respectively. Two cases were admitted for pelvic masses. One case was admitted for recurrent fibroids with pollakiuria., Diagnoses: LPD was considered in 2 cases preoperation according to imaging examination, and one of them received ultrasound-guided biopsy of the lesion in the right lobe of the liver. One case was considered as recurrent fibroids preoperation. After surgery, all cases were pathologically diagnosed as LPD consisting of benign smooth muscle cells., Interventions: A total abdominal hysterectomy, salpingo-oophorectomy, and debulking was performed for all 3 cases. Intraoperative exploration revealed that the fibroids distributed in the mesentery (3 cases), broad ligament (1 case), omentum (1 case), liver (1 case), and rectus abdominis (1 case)., Outcomes: No recurrence was found during postoperative following-up (5-12 months)., Lesions: Preoperative diagnosis of LPD is presented as a challenge due to unspecific clinical manifestations. Its diagnosis mainly depends on histopathologic evaluation. Surgery still is the primary treatment for LPD. For patients without reproductive desire, total abdominal hysterectomy, salpingo-oophorectomy, and debulking can be performed, and the affected tissue should be removed as much as possible based on the risk assessment.

Introduction: Electromechanical power morcellation is a widely used technique to extract uterine fibroids during laparoscopic hysterectomy. Although the complication rate of morcellators is low, ectopic leiomyoma can appear several years after their use. Patients and methods: We present a case of an ectopic leiomyoma and a literature review of power morcellation-induced complications and ectopic leiomyoma. Results: A 49-year-old female presented with epigastric pain 12 years after laparoscopic subtotal hysterectomy with morcellation of the specimen. Radiological examinations revealed an epigastric mass of 45 mm that was laparoscopically removed. Histological examination confirmed the diagnosis of an ectopic leiomyoma. Complications of power morcellation are rarely reported and include perioperative injuries to bowel, vascular and urinary tract, spreading of ectopic leiomyoma and occult malignancy. Conclusions: Ectopic leiomyoma are a late and rare complication of a laparoscopic hysterectomy with power morcellation of the uterus.