Figure 4 MyoSure? Tissue Removal System (Hologic, Bedford, MA). (A) MyoSure system hysteroscope, hand piece, and motor drive. (B) MyoSure system blade inserted through hysteroscope. free copy Note beveling on the outer surface of the blade. Photos courtesy of Hologic. … Table 1 Comparison of Device Characteristics of TRUCLEAR? Hysteroscopic Morcellator and MyoSure? Tissue Removal System Hysteroscopic Morcellation Technique Regardless of the methodology used to resect intrauterine pathology, it is important to remember that resected tissue must be thought of in terms of three-dimensional rather than two-dimensional measurements. Thus, increasing pathology diameter yields a exponential rather than linear increase in volume following the equation �� = ��d3/6 (see Figure 5).

This mathematical consideration becomes important as one plans a surgical approach for submucous myomas in which the resection rate and procedure time will be a function of the volume, density, and type of myoma tissue. With loop resectoscopy, the amount of tissue removed per minute will depend on (1) how quickly the surgeon deploys each pass of the loop, (2) how much tissue each bite with the loop resects, and (3) how quickly the tissue chips can be removed from the uterine cavity. On the other hand, with hysteroscopic morcellation, the amount of tissue removed per minute will only be a function of (1) how much contact the cutting window maintains with the myoma and (2) how quickly the device can cut tissue and aspirate it out.

Because the devices�� cutting speeds are relatively fixed by their design characteristics, minimizing procedure time mostly depends on maintaining tissue contact between the cutting window and the pathology. Learning the correct resection technique, although not difficult, is of prime importance with hysteroscopic morcellation. Figure 5 Volume as a function of diameter (�� = ��d3/6).23 Morcellation Versus Resectoscopy For polyps and Type I and Type II submucous myomas, hysteroscopic morcellation has been demonstrated to be both faster and easier to learn than traditional resectoscopy. The earliest published trial with a hysteroscopic morcellation device by Emanuel and colleagues showed a significant reduction in operating room time when removing polyps and Type I and Type II submucous myomas. In that study, polyps were removed with a 72% reduction in operating room time with a morcellator as compared with a resectoscope (8.

7 min vs 30.9 AV-951 min), whereas Type 0 and Type I myomas were removed in 61% less time, respectively (16.4 min vs 42.2 min).19 Similarly, in a 2008 trial by van Dongen and associates, 60 patients with intrauterine pathology consisting of either a polyp or a Type 0 myoma or Type I myoma smaller than 30 mm were randomized to either hysteroscopic morcellation or loop-electrode resection. All the procedures were performed by residents in training under the direct guidance of an attending physician.