Original Investigation 1

The role of hysteroscopy with morcellator without

anesthesia in the management of abnormal uterine
bleeding
Francesco Giuseppe Martire1,2, Luca Labanca2, Matteo Giorgi3, Aikaterini Selntigia1, Consuelo Russo1,
Gabriele Centini3, Alessandro Ginetti3, Claudia D’Abate3, Stella Capriglione2, Caterina Exacoustos1,
Francesco Catania2, Errico Zupi3, Lucia Lazzeri3
1Department of Surgical Sciences, Obstetrics and Gynecology of Unit, University of Rome Tor Vergata, Rome, Italy
2Department of Surgical Sciences, Gynecological Unit, Valdarno Hospital, Montevarchi, Italy
3Department of Molecular and Developmental Medicine, Division of Obstetrics and Gynecology, University of Siena, Siena, Italy

Abstract
Objective: To evaluate the feasibility of hysteroscopy with morcellator without anesthesia and the diagnostic accuracy of 2D, 3D and power
Doppler transvaginal sonography (TVS) in patients with abnormal uterine bleeding (AUB).
Material and Methods: This was a retrospective study including women with AUB. All patients underwent 2D, 3D and power Doppler TVS
evaluation of the uterine cavity, and patients with suspicion on ultrasound (US) of endometrial pathology (EP) underwent hysteroscopy with
morcellator without anesthesia. The painful symptomatology was assessed during the procedure using a visual analogue scale (VAS). Additionally,
histological evaluation was performed.
Results: A total of 182 women underwent US imaging, of whom 131 (72%) had hysteroscopy. 130/131 patients completed the hysteroscopic
examination with good compliance (VAS <4). One patient (0.8%) was unable to complete the procedure due to nulliparity and cervical stenosis.
Of the 130 patients the US diagnosis was confirmed in 120 (92.3%), while in 10 patients (7.7%) the hysteroscopic diagnosis was different from the
US diagnosis. Histological examination confirmed benign endometrial polyps in 115/130 patients (88.5%), while premalignant conditions were
diagnosed in 3/130 patients (2.3%) and malignant conditions in 2/130 (1.5%). Of the 10 patients with endometrial thickening, two were diagnosed
with a malignant condition.
Conclusion: This study confirmed the feasibility of managing patients with AUB and suspicion of EP using “see-and-treat” hysteroscopy
with morcellator without anesthesia. This procedure has the potential to yield desired outcomes while minimizing pain and discomfort,
presenting a feasible outpatient approach for both treating and preventing endometrial carcinoma without requiring anesthesia.
(J Turk Ger Gynecol Assoc 2024; 25: 1-6)
Keywords: Abnormal uterine bleeding, endometrial polyp, hysteroscopy, morcellator

Received: 16 August, 2023 Accepted: 03 December, 2023

Introduction menopausal women (2). Transvaginal sonography (TVS) is

the primary modality for locating endometrial polyps and
Abnormal uterine bleeding (AUB) is a widespread identifying endometrial pathology (EP), in some cases using
gynecological problem, affecting up to 30% of women (1). contrast saline infusion or gel installation, while the gold
Endometrial polyps are one of the most common causes standard for diagnosis and treatment is hysteroscopy (3,4).
of uncontrolled uterine bleeding in both pre- and post-

Address for Correspondence: Errico Zupi

e.mail: [email protected] ORCID: orcid.org/0000-0003-0735-6301
DOI: 10.4274/jtgga.galenos.2023.2023-7-1

Copyright© 2024 The Author. Published by Galenos Publishing House on behalf of Turkish-German Gynecological Association. This is an open access
article under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 (CC BY-NC-ND) International License.
 Martire et al.
The possible advantages and disadvantages of office hysteroscopic morcellation J Turk Ger Gynecol Assoc 2024; 25: 1-6
2

Practice-based operative hysteroscopy is generally well subjectively evaluated for painful symptomatology during the
tolerated by patients (5), thus avoiding many traumatic procedure by means of completion of a visual analogue scale
uterine procedures and allowing a more direct strategy for (VAS). Hysteroscopic diagnosis was also made and histological
the assessment and treatment of a numerous intrauterine evaluation was performed in cases where samples were taken.
pathologies, at the same time that the diagnosis is made (6). Additionally, the accuracy of the TVS diagnosis was compared
Hysteroscopy may be suitable in women with AUB if there are with respect to the hysteroscopic diagnosis.
ultrasound (US) signs of EP (7), given the excellent diagnostic The criteria for inclusion in this study were: women with AUB
accuracy in the detection of uterine pathologies. and TVS suspicion of EP; who underwent hysteroscopy with
Endometrial polyps may be treated by uterine curettage and morcellator without anesthesia; and there was access to
grasping forceps, but this procedure is time-consuming, complete medical history, including symptoms and surgical
and may not yield satisfying results. Usually, small polyps reports. Exclusion criteria were; no suspicion of EP on TVS;
may be removed by hysteroscopic grasping instruments being pregnant; and unavailable accurate medical history.
or by electrosurgical resection. However, these strategies
are challenging when there are large or multiple polyps. In Clinical examination
these cases, hysteroscopic morcellation is faster, less painful, The complete medical, surgical, and obstetrical history of the
and more effective, allowing a more complete excision of patients including age, body mass index [(BMI), in kg/m2], age
endometrial polyps than electrosurgical resection (9,10). at menarche, gravidity, parity, and the mode of delivery were
Outpatient hysteroscopy provides significant advantages to recorded. Demographic data, menstrual information, indication
women who can tolerate it, as they can get safe and precise for hysteroscopy and imaging findings were collected.
detection and treatment of AUB, avoiding the potential
complications of general anesthesia and hospital admission Ultrasound examination
(11). For clinical management in the outpatient setting, the All TVS assessments and interpretations were performed
main objectives are to manage pain, improve efficiency, and by an experienced sonographer using a 4-9-MHz probe with
reduce the duration of procedures while maintaining adequate a 3D facility (Voluson E6 or E10, GE Medical Systems, Zipf,
accessibility standards for both diagnostic and therapeutic Austria). Routinely, 2D US with greyscale and power Doppler
outpatient hysteroscopy. for examination of the pelvis was carried out.
This retrospective study evaluated the feasibility of “see-and- The uterus, myometrium, and endometrium were analyzed.
treat” hysteroscopy with morcellator without anesthesia in The 2D examination was followed by the acquisition of the 3D
patients with AUB, and investigated the advantages that this volume of the uterus, with and without power Doppler, which
procedure may offer regarding alleviation of pain, levels of is important to assess the uterine cavity morphology. TVS scans
patient discomfort, and improving clinical efficiency without were performed using the International Endometrial Tumor
sacrificing treatment and prevention of endometrial carcinoma. Analysis (IETA) examination technique, and the US findings
were described in IETA terminology (12).
Material and Methods
Endometrial depth was measured in the sagittal plane including
This retrospective, observational study included women both endometrial layers. When intracavitary fluid was found,
with AUB referred to our hospital between November 2021 the two layers were measured separately, and the sum was
and December 2022, including patients with suspicion of EP recorded. Endometrial echogenicity was reported as uniform
such as polyps and endometrial thickening, and excluding or non-uniform. The color-Doppler score is a subjective
patients with suspected intracavitary myomas. AUB was evaluation of the amount of color, reflecting the vascularity, and
defined in childbearing age, as bleeding from the corpus is scored as 1 (no color), 2 (minimal color), 3 (moderate color)
of the uterus which was not controlled in duration, amount, or 4 (abundant color).
frequency and/or regularity, while postmenopausal bleeding All data was recorded as 2D still images, 2D video-clips, and 3D
was defined as either any bleeding after menopause in women volumes.
not on hormonal therapy or unexpected or heavy bleeding
in women on hormonal therapy. Subjects were divided into Hysteroscopy
premenopausal and menopausal groups. All patients underwent All patients underwent hysteroscopy with morcellator using
two-dimensional (2D), 3D and power Doppler TVS assessment an Integrated Bigatti Shaver (Karl Storz, Tuttlingen, Germany)
of the uterine cavity. Subsequently, patients with suspicion of without anesthesia using normal saline (NaCl: 0.9%) as
EP on TVS underwent hysteroscopy with morcellator without distention medium in an outpatient setting. The procedural
anesthesia, and were included in the study. All patients were time measurement began upon insertion of the instrument
 Martire et al.
J Turk Ger Gynecol Assoc 2024; 25: 1-6 The possible advantages and disadvantages of office hysteroscopic morcellation
3

using vaginoscopic access and continued until its removal. The mean ± SD age of the patients was 49.7±5.2 years. Most
Painful symptoms were assessed during the procedure using a patients (78.7%) had one or more pregnancies and 27.2% of
VAS, taking the mean score reported throughout the procedure. patients were affected by hypertension, diabetes, and/or
The hysteroscopic diagnoses of intracavitary pathologies were dyslipidemia. The majority (62.6%) were menopausal. None of
recorded for all patients. Removal of intrauterine pathologies the patients were undergoing hormone replacement therapy.
with histological examination was performed for all patients. The cohort was divided into two subgroups: pre-menopausal
patients (n=49) and menopausal (n=82) patients. There were
Ethical approval no differences in between the two groups in terms of BMI, age
All involved patients gave their informed consent before the at menarche, presence of metabolic diseases (hypertension,
TVS examination and the hysteroscopy to permit the use of diabetes, and dyslipidemia), or indication for hysteroscopy
their data. The study was submitted and approved by the board (Table 1). Thus, the two groups were considered together for
of the USL Toscana Sud Est (approval number: 0002959, date: further analysis.
22.11.2022). The characteristics of the hysteroscopic procedure used in the
study are shown in Table 2. The hysteroscopic procedure was
Statistical analysis completed in 99.2%. One patient was unable to complete the
Statistical analyses were performed using the SPSS v.15.0 procedure due to nulliparity and presence of cervical stenosis.
(SPSS, Inc., Chicago, IL, USA). Continuous variables are The mean duration of the procedure was 7.3 minutes, while the
reported as mean ± standard deviation (SD). Categorical mean VAS score reported was 2.5. The majority who completed
variables are reported as a frequency or percentage. The the hysteroscopy (n=128, 98.5%) reported satisfaction with the
statistical analyses initially assessed patient characteristics. procedure and setting. In two cases, complications involving
Then the characteristics of hysteroscopy procedure and US, fever and pelvic pain attributable to endometritis were reported
hysteroscopic and histological findings were evaluated in terms 2 days after the procedure.
of percentage. Intergroup comparisons were performed using The results of the sonographic, hysteroscopic and histological
chi-square tests for categorical variables and independent evaluations are shown in Table 3. In 120 cases (92.3%), the
sample t-tests for continuous data. Fisher’s exact test was used diagnosis was consistent with both TVS and hysteroscopy,
to compare prevalence. Results with p<0.05 were considered while in 10 patients (7.7%), hysteroscopy revealed the presence
statistically significant.
of an EP different from that suspected by the US. Histological
examination confirmed benign endometrial polyps in 115/130
Results
(88.5%), premalignant conditions (atypical endometrial
A total of 182 women underwent TVS and 131 (72%) patients hyperplasia) in 3/130 patients (2.3%) and malignant conditions
who matched the inclusion criteria were included. The (endometrial cancer) in 2/130 patients (1.5%). Among the 10
characteristics of the study cohort are shown in the Table 1. patients who received a diagnosis of endometrial thickening

Table 1. Patients characteristics in total study population, premenopausal group, and menopausal group
Total population, n (%)/ Premenopausal group, n Menopausal group, n
(mean ± SD) (%)/(mean ± SD) (%)/(mean ± SD)
Patients characteristics 131 49 (37.4) 82 (62.6)
Age (years) 49.7±5.2 43.5±4.6 51.1±4.2
BMI (kg/m2) 27.8±2.1 25.6±2.5 28.3±1.7
Menarche (years) 12.0±1.8 11.8±1.6 12.2±2.0
Gravidity 2.3±0.8 2.2±1.2 2.1±1.1
Parity 1.5±0.6 1.6±0.7 1.8±0.4
Nulliparity 29 (22.1) 11 (22.4) 18 (21.9)
Hypertension 23 (17.5) 7 (14.3) 16 (19.5)
Diabetes 5 (3.8) 1 (2.0) 4 (4.9)
Dyslipidemia 9 (6.9) 3 (6.1) 6 (7.3)
Previous uterine surgery 16 (12.2) 5 (10.2) 11 (13.4)
On hormonal therapy 12.2% (16) 32.6% (16) 0.0% (0)
Data shown as n (%) or mean ± standard deviation, BMI: Body mass index
 Martire et al.
The possible advantages and disadvantages of office hysteroscopic morcellation J Turk Ger Gynecol Assoc 2024; 25: 1-6
4

Table 2. The characteristics of hysteroscopic procedure, the evaluation of painful symptomatology and
patients’ satisfaction
Hysteroscopic procedure Total population
Completed (n)/total (%) 130/131 (99.2%)
Not completed, (n)/total (%) 1/131 (0.8%)
VAS (mean ± SD) 2.5±0.8
Duration of procedure, minutes (mean ± SD) 6.5±1.6
Patient satisfaction, (n)/total (%) 128/131 (97.7%)
Complications, (n)/total (%) 2/131 (1.5 %)
SD: Standard deviation, VAS: Visual analogue scale

Table 3. Sonographic, hysteroscopic and histological evaluation in total study population

Sonographic Hysteroscopic Histological

Uterine pathology (n %; pts/)
diagnosis diagnosis diagnosis

Benign endometrial polyp, (n)/total (%) 125/131 (95.2%) 120/130 (92.3%) 115 (88.5%)
Endometrial thickening, n/total (%) 6/131 (4.6%) 10/130 (7.7%) 8 (6.1%)
Atypical endometrial hyperplasia, n/total (%) 0 (0.0%) 0 (0.0%) 3 (2.3%)
Endometrial cancer, n/total (%) 0 (0.0%) 0 (0.0%) 4 (3.1%)

during hysteroscopy, two patients were diagnosed with hysteroscopy, however, unlike diagnostic hysteroscopy, which
endometrial cancer, and eight patients were diagnosed with is often not curative in terms of treatment, this surgical method
benign endometrial thickening. is both diagnostic and therapeutic. This technique is capable
of removing and aspirating polyp tissue, reducing the time
Discussion needed to reintroduce and to remove the hysteroscope to
extract material through the cervix (17).
AUB is one of the most frequent gynecological complaints.
Very often, AUB is the manifestation of a benign clinical This is an important consideration because the possibility
condition, but sometimes it can be the first sign of malignant of diagnosing and treating the cause of AUB during a single
uterine pathology (13). Therefore, evaluation of the cause of procedure is likely to make patients more compliant, reducing
AUB is important and should be performed promptly. Before the number of healthcare visits required to treat the condition.
obtaining the diagnosis and removing the organic EP causing Therefore, the role of US evaluation is fundamental. It can
AUB, the patient may be subjected to various procedures, guide towards diagnostic hysteroscopy, alleviating discomfort
such as diagnostic, and subsequently operative, hysteroscopy caused to the patient when there is suspicion of endometrial
(14). The purpose of our study was to estimate the feasibility thickening or a malignant myometrial pathology (18,19) or
of hysteroscopy with morcellator without anesthesia and all towards a “see-and-treat” hysteroscopy with morcellator when
outcomes regarding alleviating pain, discomfort, and improving endometrial polyps are identified. Diagnostic hysteroscopy
efficiency without sacrificing treatment and prevention of remains an important tool for direct endometrial sampling
endometrial carcinoma. and may be used as the first line treatment for the diagnosis
The hysteroscopic procedure was completed in 99.2% of the of endometrial cancer and hyperplasia. In line with this, the
patients and 98% of patients who completed the hysteroscopy results of the present study showed a high accuracy (92.3%) for
reported satisfaction with the procedure and setting, TVS in the evaluation of the endometrial cavity.
confirming that hysteroscopic morcellation was safe, effective Some authors have compared this surgical procedure with
and acceptable to patients, even in an outpatient setting (15). conventional operative hysteroscopy, with varying results. For
Pain might be a limitation for this procedure in an outpatient some, hysteroscopic morcellation is more accurate, effective
setting, but our results, in agreement with the literature, show and safe because it does not involve electrical equipment. This
that the technique is well tolerated patients (16). eliminates the risk of electrical damage to the patient, such
Certainly, given the size of the instrument, hysteroscopy with as tissue necrosis, uterine perforation or potential damage to
morcellation can be more troublesome than a simple diagnostic other organs that may occur due to alterations in the current
 Martire et al.
J Turk Ger Gynecol Assoc 2024; 25: 1-6 The possible advantages and disadvantages of office hysteroscopic morcellation
5

circuit. In addition, hysteroscopic morcellation does not evaluation plays a fundamental role. However, the tolerance
cause scars, the endometrium is better protected, and there for pain during practice-based operative hysteroscopy will vary
are fewer postoperative complications (20-22). For others, greatly among women and will also depend on the skill level
this new technology is no better than traditional resection in of the clinician performing the procedure, which may result in
terms of surgical success rate for treating endometrial lesions lower levels of patient acceptability.
(23). Certainly, operative hysteroscopy can have advantages
in certain types of intracavitary pathology, such as fibroids, Ethics Committee Approval: All involved patients gave
especially those that are calcified or measuring >40 mm (24), their informed consent before the TVS examination and the
or polyps located on the uterine fundus where it is more difficult hysteroscopy to permit the use of their data. The study was
to remove the entire lesion. In contrast, operative hysteroscopy submitted and approved by the board of the USL Toscana Sud
may be more difficult in the presence of large or numerous Est (approval number: 0002959, date: 22.11.2022).
polyps (25,26). This consideration once again highlights the
importance of pre-operative US diagnosis in order to select the Informed Consent: All involved patients gave their informed
consent before the TVS examination and the hysteroscopy to
most appropriate therapeutic approach for each patient (12).
permit the use of their data.
Another point of interest is the accuracy of the histological
diagnosis, which may be improved with this method. In the
Author Contributions: Surgical and Medical Practices: F.G.M.,
present study, 3.1% of patients were diagnosed with endometrial
L.Lab., F.C.; Concept: F.G.M., E.Z., C.E., S.C.; Design: F.G.M.,
malignancy. This may be attributed in part to the fact that one
L.L., S.C.; Data Collection or Processing: C.D.A., M.G., L.Lab.;
third of patients were affected by hypertension, diabetes, and
Analysis or Interpretation: C.R., A.S., G.C.; Literature Search:
dyslipidemia, all of which are contributing risk factors (27),
A.S., C.R., G.C., A.G.; Writing: F.G.M., E.Z., F.C., L.L.
and in part to the use of the technique that simultaneously
excises and aspirates polyp tissue, not only reducing the Conflict of Interest: No conflict of interest is declared by the
formation of bubbles and the accumulation of excision tissue authors.
fragments, but also facilitating subsequent histological analysis
(28). Within our cohort, no intraoperative complications were Financial Disclosure: The authors declared that this study
identified and only two postoperative complications were received no financial support.
reported. This evidence supports the published reports on this
technique, highlighting the role of hysteroscopic morcellation References
as a less complex surgery compared to conventional operative
1. Munro MG, Critchley HO, Broder MS, Fraser IS; FIGO Working Group
hysteroscopy (29). on Menstrual Disorders. FIGO classification system (PALM-COEIN)
However, hysteroscopic morcellation also has disadvantages, for causes of abnormal uterine bleeding in nongravid women of
reproductive age. Int J Gynaecol Obstet 2011; 113: 3-13.
for example the inability to coagulate bleeding vessels
2. American Association of Gynecologic Laparoscopists. AAGL
encountered during surgery (20). In addition, the expense
practice report: practice guidelines for the diagnosis and
incurred for disposable devices (blades, tubings, etc.) needed management of endometrial polyps. J Minim Invasive Gynecol
to perform hysteroscopic morcellation is higher compared 2012; 19: 3-10.
to the reusable instruments utilized for resectoscopy, but the 3. Di Guardo F, Incognito GG, Lello C, D’Urso G, Genovese F, Palumbo
M. Efficacy of sonohysterography and hysteroscopy for evaluation
possibility of performing a single procedure without the use of
of endometrial lesions in tamoxifen treated patients: a systematic
anesthesia and an operating room has been reported to more review. Eur J Gynaecol Oncol 2022; 43: 78-86.
than compensate for the higher operating costs (30). 4. Tanos V, Berry KE, Seikkula J, Abi Raad E, Stavroulis A, Sleiman Z,
et al. The management of polyps in female reproductive organs. Int
Conclusion J Surg 2017; 43: 7-16.
5. Clark TJ, Middleton LJ, Cooper NA, Diwakar L, Denny E, Smith P,
This study has provided additional evidence to support the et al. A randomised controlled trial of Outpatient versus inpatient
Polyp Treatment (OPT) for abnormal uterine bleeding. Health
opinion that “see-and-treat” hysteroscopy with morcellator
Technol Assess 2015; 19: 1-194.
without anesthesia is a safe and effective technique while 6. Saridogan E, Tilden D, Sykes D, Davis N, Subramanian D. Cost-
having high patient acceptability. This procedure exhibits the analysis comparison of outpatient see-and-treat hysteroscopy
potential to yield desired outcomes while minimizing pain and service with other hysteroscopy service models. J Minim Invasive
Gynecol 2010; 17: 518-25.
discomfort, presenting a feasible outpatient approach for both
7. Salim S, Won H, Nesbitt-Hawes E, Campbell N, Abbott J. Diagnosis
treating and preventing endometrial carcinoma. In deciding and management of endometrial polyps: a critical review of the
which technique should be used, a good pre-operative US literature. J Minim Invasive Gynecol 2011; 18: 569-81.
 Martire et al.
The possible advantages and disadvantages of office hysteroscopic morcellation J Turk Ger Gynecol Assoc 2024; 25: 1-6
6

8. Gebauer G, Hafner A, Siebzehnrübl E, Lang N. Role of hysteroscopy myomas (uterine smooth muscle tumors) and correlation with
in detection and extraction of endometrial polyps: results of a histopathology. Ultrasound Obstet Gynecol 2022; 60: 269-76.
prospective study. Am J Obstet Gynecol 2001; 184: 59-63. 20. Haber K, Hawkins E, Levie M, Chudnoff S. Hysteroscopic
9. McIlwaine P, McElhinney B, Karthigasu KA, Hart R. A prospective morcellation: review of the manufacturer and user facility device
study of the use of the Myosure resectoscope to manage experience (MAUDE) database. J Minim Invasive Gynecol 2015; 22:
endometrial polyps in an outpatient setting. Aust N Z J Obstet 110-4.
Gynaecol 2015; 55: 482-6. 21. Lukes A. Efficacy of the MyoSure® Procedure for Removal of Polyps
10. Smith PP, Middleton LJ, Connor M, Clark TJ. Hysteroscopic and Myomas: Impact on Health-Related Quality of Life at One Year.
morcellation compared with electrical resection of endometrial J Minim Invasive Gynecol 2013; 20: S77.
polyps: a randomized controlled trial. Obstet Gynecol 2014; 123: 22. McIlwaine P, McElhinney B, Karthigasu KA, Hart R. A prospective
745-51. study of the use of the Myosure resectoscope to manage
11. Vitale SG, Haimovich S, Riemma G, Ludwin A, Zizolfi B, De Angelis endometrial polyps in an outpatient setting. Aust N Z J Obstet
MC, et al. Innovations in hysteroscopic surgery: expanding the Gynaecol 2015; 55: 482-6.
meaning of “in-office”. Minim Invasive Ther Allied Technol 2021; 23. Li C, Dai Z, Gong Y, Xie B, Wang B. A systematic review and meta-
30: 125-32. analysis of randomized controlled trials comparing hysteroscopic
12. Leone FP, Timmerman D, Bourne T, Valentin L, Epstein E, Goldstein morcellation with resectoscopy for patients with endometrial
SR, et al. Terms, definitions and measurements to describe the lesions. Int J Gynaecol Obstet 2017; 136: 6-12.
sonographic features of the endometrium and intrauterine lesions: 24. Arnold A, Ketheeswaran A, Bhatti M, Nesbitt-Hawes E, Abbott
a consensus opinion from the International Endometrial Tumor J. A Prospective Analysis of Hysteroscopic Morcellation in the
Analysis (IETA) group. Ultrasound Obstet Gynecol 2010; 35: 103-12. Management of Intrauterine Pathologies. J Minim Invasive Gynecol
13. Jha S, Singh A, Sinha HH, Bhadani P, Anant M, Agarwal M. Rate 2016; 23: 435-41.
of premalignant and malignant endometrial lesion in “low- 25. Bigatti G, Ansari SH, Di W. The 19 Fr. Intrauterine Bigatti Shaver
risk” premenopausal women with abnormal uterine bleeding (IBS®): a clinical and technical update. Facts Views Vis Obgyn
undergoing endometrial biopsy. Obstet Gynecol Sci 2021; 64: 517- 2018; 10: 161-4.
23. 26. Bigatti G, Ferrario C, Rosales M, Baglioni A, Bianchi S. A 4-cm G2
14. Salazar CA, Isaacson KB. Office Operative Hysteroscopy: An cervical submucosal myoma removed with the IBS® Integrated
Update. J Minim Invasive Gynecol 2018; 25: 199-208. Bigatti Shaver. Gynecol Surg 2012; 9: 453-6.
15. Alkatout I, Mettler L, Günther V, Maass N, Eckmann-Scholz C, 27. Petersdorf K, Groettrup-Wolfers E, Overton PM, Seitz C, Schulze-
Elessawy M, et al. Safety and economical innovations regarding Rath R. Endometrial hyperplasia in pre-menopausal women: A
surgical treatment of fibroids. Minim Invasive Ther Allied Technol systematic review of incidence, prevalence, and risk factors. Eur J
2016; 25: 301-13. Obstet Gynecol Reprod Biol 2022; 271: 158-71.
16. De Silva PM, Stevenson H, Smith PP, Clark TJ. Pain and Operative 28. Hamerlynck TW, van Vliet HA, Beerens AS, Weyers S, Schoot BC.
Technologies Used in Office Hysteroscopy: A Systematic Review of Hysteroscopic Morcellation Versus Loop Resection for Removal of
Randomized Controlled Trials. J Minim Invasive Gynecol 2021; 28: Placental Remnants: A Randomized Trial. J Minim Invasive Gynecol
1699-711. 2016; 23: 1172-80.
17. Yin X, Cheng J, Ansari SH, Campo R, Di W, Li W, et al. Hysteroscopic 29. Ren F, Huang G, Wang X, Li X, Cai J. Comparison of Hysteroscopic
tissue removal systems for the treatment of intrauterine pathology: Morcellation Versus Resectoscopy in Treatment of Patients with
a systematic review and meta-analysis. Facts Views Vis Obgyn Endometrial Lesions: A Meta-Analysis. Med Sci Monit 2022; 28:
2018; 10: 207-13. e936771.
18. Ludovisi M, Moro F, Pasciuto T, Di Noi S, Giunchi S, Savelli L, et 30. Ahmad G, Saluja S, O’Flynn H, Sorrentino A, Leach D, Watson A.
al. Imaging in gynecological disease (15): clinical and ultrasound Pain relief for outpatient hysteroscopy. Cochrane Database Syst
characteristics of uterine sarcoma. Ultrasound Obstet Gynecol Rev. 2017; CD007710.
2019; 54: 676-87.
19. Russo C, Camilli S, Martire FG, Di Giovanni A, Lazzeri L, Malzoni
M, et al. Ultrasound features of highly vascularized uterine