A Hybrid Strategy Using Uterine Artery Embolization Followed by Hysteroscopic Morcellation for Vascular Retained...

Background/Objectives: Retained products of conception (RPOC) are typically managed using dilation, curettage, or hysteroscopic resection. However, when the retained tissue is hypervascular, there is a significant risk of hemorrhage, particularly in cases of spontaneous miscarriage, in which vascular RPOC is rarely reported. Uterine artery embolization (UAE) is an established method for controlling acute bleeding. However, using mechanical hysteroscopic morcellation after UAE has not been fully explored. Methods: We report two cases of reproductive-aged women who developed vascular RPOC after spontaneous miscarriage, one following natural conception and the other following assisted reproduction. Both patients initially underwent expectant management but developed either acute or persistent vaginal bleeding. Imaging revealed hypervascular intrauterine lesions. UAE was performed using absorbable gelatin sponge particles targeting the ascending uterine artery branches. Following devascularization, hysteroscopic morcellation using the IBS or TruClear system was performed under direct visualization. Results: Intraoperatively, reddish vascular and whitish avascular degenerative tissues were noted. All retained tissues were completely resected with minimal bleeding. Both patients resumed menstruation shortly thereafter and expressed a desire for future pregnancy. Conclusions: This case series demonstrated the feasibility and effectiveness of a staged approach combining UAE and hysteroscopic morcellation for vascular RPOC management after spontaneous miscarriage. UAE improves surgical visibility and reduces bleeding risk, whereas mechanical morcellation ensures complete removal under direct vision with minimal trauma to the endometrium. This hybrid strategy may be a valuable fertility-preserving option, particularly in complex or hemodynamically unstable cases. Further prospective studies are needed to validate its safety, cost-effectiveness, and impact.