Comparative Outcomes of Commonly Used Morcellator Devices in Endoscopic Laser Enucleation of the Prostate: A Systematic Review and Meta-Analysis

Abstract

Introduction:

Holmium laser enucleation of the prostate (HoLEP) has now emerged as a new, prostate-size-independent gold standard, largely because of its favorable side-effect profile compared with the previous surgical methods. In this minimally invasive procedure, tissue morcellator devices are used as an important part. This systematic review and meta-analysis compares the outcomes of the different commercial tissue morcellators used in HoLEP procedures.

Methods:

Three electronic databases were searched (PubMed, Web of Science, and EMBASE) without date restrictions to find the studies evaluating morcellator device performance during HoLEP. After screening 1145 studies, 34 English, human-subject studies were included. Devices evaluated included Wolf Piranha, CyberBlade, Lumenis VersaCut, Hawk, DrillCut, and MultiCut morcellators. Two reviewers performed the study selection individually to reduce the probable bias. Extracted outcomes included perioperative parameters and complications among different commercial morcellator devices. The review was conducted with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

Results:

A total of 7211 patients were analyzed. Meta-analysis showed no statistically significant differences between morcellator systems in morcellation time (mean difference [MD] 1.02 minutes, 95% confidence interval [CI] –1.37 to 3.41), morcellation efficiency (MD 0.75 g/min, 95% CI: –0.46 to 1.97), or catheterization duration (MD 3.22 hours, 95% CI: –1.09 to 7.52). The intraoperative complication rate was low in all studies. Device malfunction (risk ratio [RR] 1.16, 95% CI: 0.23 to 5.70), bladder mucosal injury (RR: 0.85, 95% CI: 0.46 to 1.57), and bladder perforation (RR: 0.35, 95% CI: 0.10 to 1.25) did not differ significantly between devices. Cost data were limited to two studies and there was no significant cost advantage for any device.

Conclusion:

Available evidence shows that commonly used morcellators have comparable operative performance, and safety during HoLEP. No device showed a consistent advantage compared with the others, suggesting that the morcellator choice might be done by surgeon’s preference, resource considerations, the health center’s policy, and the availability rather than performance differences.

Keywords

morcellators HoLEP EEP surgical outcomes

Introduction

Transurethral resection of the prostate (TURP) has historically been the gold standard treatment for benign prostatic hyperplasia (BPH).¹ However, the development of efficient soft tissue morcellators has been a key enabling technology for holmium laser enucleation of the prostate (HoLEP), a type of endoscopic enucleation of the prostate (EEP). HoLEP has now emerged as a new, prostate-size-independent gold standard, largely because of its favorable side-effect profile compared with TURP.²

EEP, which includes HoLEP, demonstrates advantages over TURP in various metrics. A meta-analysis of randomized controlled trials (RCTs) suggests benefits of EEP over TURP in hemoglobin loss, blood transfusion rate, hospital stay, serum sodium decrease, and fewer complications.³

The concept of tissue morcellation was developed in the late 20th century and was primarily used in surgical specialties dealing with the abdominal cavity, such as gynecology.⁴ A few years later, the first major mention of laser enucleation of the prostate with mechanical morcellation was in 1998. The earliest systems widely adopted were reciprocating blade morcellators, which use back-and-forth blade motion. These were subsequently joined by oscillating blade systems that use rotational cutting mechanisms. Furthermore, since manufacturers release updated versions of morcellators over time, study era and device generation may influence reported outcomes (because of factors such as workflow maturity, learning curve, device design changes).⁵

With the increasing use of EEP to treat BPH, and its accompanying increase in the use of mechanical morcellators, several commercial morcellators have been developed. Current stand-alone morcellators for the treatment of BPH include the Piranha (Richard Wolf, Knittlingen, Germany), the DrillCut (Karl Storz, Tuttlingen, Germany), VersaCut (Lumenis, Santa Clara, CA, USA), Cyberblade (Olympus, Tokyo, Japan), MultiCut (Karl Storz SE & Co. KG, Tuttlingen, Germany), and Hawk (Olympus, Tokyo, Japan).⁶ With the advent of different morcellation devices, several studies have evaluated the efficiency of certain commercially available morcellators.^6–8

There are two main morcellation mechanisms currently in use: Oscillation and reciprocation. Oscillating morcellators, such as the Wolf Piranha and the Storz DrillCut, use a rotating oscillating blade mechanism that moves in a circular cutting pattern.⁹ Reciprocating morcellators, such as the Lumenis VersaCut, use a back-and-forth reciprocating blade motion rather than rotational movement.⁹ The mechanism of morcellation appears to play a role in outcome parameters such as morcellation efficiency, operative time, and complication rates. Some studies show improved outcomes with one over the other, but these studies tend to have small sample sizes, and findings have not been consistent across studies.^10,11 This systematic review of available morcellator devices provides a much-needed synthesis of available data to see how morcellators compare at the aggregate level.

Another difference in the use of morcellators is the use of disposable vs reusable morcellator blades. In preliminary studies, disposable blades have been shown to demonstrate better morcellation efficiency at higher speeds.⁷ The type of blade used, which can be based on surgeon or institutional preference, may play a role in morcellator performance.

Despite the increasing number of different commercially available morcellators, the choice of device used during EEP is often based on surgeon familiarity or institutional availability rather than comparative evidence. Clinicians and hospital systems must decide which morcellator technology to use, considering factors such as morcellation efficiency, operative time, complication rates, and device characteristics.

However, the literature directly comparing different parameters of the types of commercially available morcellators to treat BPH is limited. With evidence suggesting that there may be differences in outcomes, efficiency, and other clinically relevant parameters based on the morcellator brand used to treat BPH,^6–8 it is imperative to explore the differences between using the different brands. Synthesizing information comparing different commercially available mechanical morcellators for BPH can help guide surgeons, administrators, and hospitals in making instrument decisions in BPH treatment. This review provides a detailed analysis of clinically relevant parameters comparing different mechanical morcellators to treat BPH.

Methods

We conducted this systematic review and meta-analysis according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses¹² and is an evidence-based minimum set of items for reporting systematic reviews and meta-analyses that can be used as a basis for reporting reviews of different types of research. The review protocol was registered in the PROSPERO, International Prospective Register of Systematic Reviews (Registration No. CRD420261335370). Regarding the nature of this systematic review and meta-analysis, the study did not require ethics approval or the consent of participants.

Search strategy

We comprehensively searched the PubMed, EMBASE, and Web of Science databases for articles published before August 26, 2025, that reported or compared different morcellators. The search was performed with the following medical subject headings (Mesh):

PubMed: 290(“Morcellation”[Mesh] OR morcellat*) AND (“Prostate”[Mesh] OR prostate)

EMBASE: 985(‘morcellation’/exp OR morcellat*) AND (‘prostate’/exp OR prostate)

Web of Science: 528 morcellat* AND prostate

A detailed search strategy is presented in Figure 1.

FIG. 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram of study selection.

Inclusion and exclusion criteria

Studies were included if they met all the following criteria: •

Adult patients undergoing EEP.

•

Use of a mechanical morcellation device for prostate tissue retrieval.

•

Direct evaluation or comparison of morcellator devices.

•

Provided sufficient quantitative data to calculate effect estimates.

•

Reported at least one of the following outcomes: ◦

morcellation time

◦

morcellation efficiency (g/min)

◦

device malfunction

◦

bladder mucosal injury

◦

bladder perforation

◦

catheterization duration

◦

device-related cost

•

Published in peer-reviewed journals.

•

Articles published in English.

Studies were excluded if they met any of the following criteria: •

Lack of extractable outcome data or reporting outcomes in a noncomparable format.

•

Duplicate publications or overlapping patient populations; in such cases, the most complete or most recent dataset was included.

•

Animal studies, bench testing, or cadaveric studies.

•

Conference abstracts, editorials, commentaries, and non–peer-reviewed reports, because of limited methodological detail and incomplete outcome reporting.

Data extraction

Two reviewers independently screened the identified publications according to the titles and abstracts and selected relevant studies that met the eligibility criteria. Data were extracted and collated independently by the same two reviewers, with any disagreement settled by a third reviewer.

The following items were extracted: •

Basic information: Name of the first author, publication date, and sample size.

•

Perioperative results: Morcellation time, morcellation efficiency, morcellation malfunction, catheterization length (hours), bladder mucosal injury, bladder perforation, and cost.

The number of included studies for each variable is summarized in Table 1.

Table 1.

Summary of Included Studies by Comparison Parameter

Outcome	Number of included studies
Morcellation efficiency	15
Morcellation time	12
Device malfunction	9
Bladder mucosal injury	17
Bladder perforation	6
Catheterization length	8
Cost	2

Bias assessment

Risk of bias was assessed independently according to the study design. RCTs were evaluated using the Cochrane Risk of Bias 2 (RoB 2) tool, while prospective and retrospective nonrandomized studies were assessed using the ROBINS-I tool. Each domain was rated as low, moderate/some concerns, serious, or critical risk of bias. Disagreements were resolved by consensus, and results were presented using traffic-light plots (Figs. 2 and 3).

FIG. 2.

Risk-of-bias assessment using ROBINS 1 tool for nonrandomized studies.

FIG. 3.

Risk-of-bias assessment using ROB 2 for randomized studies.

Outcomes

The primary outcomes of interest were morcellation efficiency and morcellation time, as these most directly reflect operative performance of the device.

Secondary outcomes included the following: •

Catheterization duration

•

Device malfunction

•

Bladder mucosal injury

•

Bladder perforation

•

Device-related cost

Statistical analyses

After applying outcome-specific eligibility criteria, the number of studies included in each meta-analysis varied by endpoint based on data availability. All data processing and statistical analyses were performed using R (version 4.1), primarily utilizing the meta and metafor packages.

Study-level characteristics were summarized using appropriate descriptive statistics, including frequencies and percentages for categorial outcomes and means with standard deviations for continuous outcomes when reported by the original studies. When continuous outcomes were reported using medians with ranges or interquartile ranges, established conversion methods described by Wan et al.¹³ were applied to estimate the corresponding means and standard deviations when sufficient information was available.

Meta-analyses were conducted using random-effects models to account for anticipated clinical and methodological heterogeneity across studies. Continuous outcomes, including morcellation time, morcellation efficiency, morcellation weight, catheterization length, and cost, were pooled using mean differences (MDs) with inverse-variance weighting. Binary outcomes, including device malfunction, bladder mucosal injury, and bladder perforation, were analyzed using risk ratios (RRs) estimated via random-effects Mantel–Haenszel models.

For binary outcome with rare events or zero-cell counts, a continuity correction of 0.5 was applied uniformly, and studies with zero events in both arms were retained in the analysis. Heterogeneity was assessed using the Cochran’s Q test, the I² statistic, and between-study variance estimates (tau²). Forest plots were generated for all outcomes to display individual study effects, pooled estimates, and measures of heterogeneity.

Outcomes with sparse or inconsistently reported data, particularly cost, were interpreted with caution because of limited study counts and substantial between-study variability.

Results

We retrieved a total of 1803 articles; of these, 1122 remained after excluding duplicate articles. After reading the title and abstract, 1084 articles were eliminated. Finally, 34 studies^{9–11,14–44} met the inclusion criteria (Fig. 2). The characteristics of the 34 studies involving 7212 participants are summarized in Table 2. Most studies directly compared two morcellation devices, most commonly Piranha, VersaCut, DrillCut, MultiCut, CyberBlade, and Hawk systems.

Table 2.

Raw Results

Study	Device	MCx time	MCx efficiency	Malfunction	Mucosal injury	Bladder perforation	Catheter time	Cost
McAdams 9	Piranha (oscillating): 41 VersaCut (reciprocating): 41	Piranha (oscillating): 8 (2–35) VersaCut (reciprocating): 13 (5–168)	Piranha (oscillating): 8.6 (3–20.5) VersaCut (reciprocating): 3.8 (0.9–10.1)	Piranha (oscillating): 0 VersaCut (reciprocating): 0	Piranha (oscillating): 0 VersaCut (reciprocating): 0	Piranha (oscillating): 0 VersaCut (reciprocating): 0
Dowd 10	Piranha: 506DrillCut: 60	Piranha: 8 (1–90)DrillCut: 13 (4–58)	Piranha: 5.12 (0.5–21)DrillCut: 6.47 (2.89–15)	Piranha: 0DrillCut: 4	Piranha: 7DrillCut: 1
El Tayeb 11	Piranha: 37Versacut: 37	Piranha: 13 (2–24)VersaCut: 11 (3–100)	Piranha: 5.6 (1.4–18)VersaCut: 4.8 (1.3–9.5)	Piranha: 1VersaCut: 0	Piranha: 0VersaCut: 1		Piranha: 15 (9–19.3)VersaCut: 14.5(8.5–33.8)	Piranha: 471VersaCut: 241
García 14	MultiCut solo: 232DrillCut: 41		MultiCut solo: 14.5 ± 7.6		N/A	MultiCut solo: 3
Schwartzmann 15	MultiCut: 68Piranha: 69	MultiCut: 14.4 ± 13.3Piranha: 11.1 ± 9.17	MultiCut: 7.34 ± 4.33Piranha: 9.34 ± 4.84	MultiCut: 1Piranha: 7	MultiCut: 3Piranha:0	MultiCut: 0Piranha: 0
Perri 16	Piranha: 100CyberBlade: 105	Piranha: 11.8 ± 2.7CyberBlade: 10.1 ± 3.1			Piranha: 3Cyberblade: 2		Piranha: 43.2 ± 21.6CyberBlade: 40.8 ± 19.2
Stevens 17	MultiCut: 38Piranha: 100	MultiCut: 9.88 ± 7.87Piranha: 15.04 ± 14.25	MultiCut: 10.56 ± 4.05Piranha: 6.72 ± 2.78		N/A		MultiCut: 48 ± 53.04Piranha: 77.52 ± 126
Sun 18	DrillCut: 23Hawk: 18	DrillCut: 16.3 ± 4.87Hawk: 15.01 ± 5.08	DrillCut: 3.32 ± 0.62Hawk: 4.76 ± 0.79		DrillCut: 1Hawk: 1
Berti 19	Piranha: 100VersaCut: 105			Piranha: 8VersaCut: 0	Piranha: 3VersaCut: 2	Piranha: 0VersaCut: 3
Chen 20	Piranha: 100VersaCut: 105	Piranha: 13 ± 4VersaCut: 15 ± 6.5	Piranha: 3.5 ± 1.2VersaCut: 3 ± 1.2		Piranha: 2VersaCut: 4	Piranha: 0VersaCut: 0	Piranha: 73.3 ± 24.8VersaCut: 70.5 ± 24	Piranha: 164.2 ± 20.7VersaCut: 165.7 ± 19.2
Yalçın 21	VersaCut: 600	VersaCut: 17	VersaCut: 4	VersaCut: 1	VersaCut: 8		VersaCut: 21.5
Kaya 22	Versa Cut (Group1): 100VersaCut (Group 2): 114	VersaCut (Group1): 7.22 ± 5.46VersaCut (Group 2): 11.27 ± 8.57	VersaCut (Group1): 9.81 ± 5.61VersaCut (Group 2): 7.45 ± 4.14		Group1: 0Group2: 6
Enikeev 23	Piranha (en bloc): 406 Piranha (two lobe): 709	Piranha (en bloc): 28.4 ± 11.4 Piranha (two lobe): 28.3 ± 12.1	Piranha (en bloc): 2.7 ± 1.3 Piranha (two lobe): 2.8 ± 1.8	Piranha (en bloc): 5 Piranha (two lobe): 12	Piranha (en bloc): 2Piranha (two lobe): 3		Piranha (en bloc): 40.8 ± 19.2 Piranha (two lobe): 38.4 ± 16.8
Ibrahim 24	DrillCut: 41VersaCut: 41	DrillCut: 22.6 ± 11.7VersaCut: 17.3 ± 12.1	DrillCut: 3.9 ± 0.9VersaCut: 4.9 ± 1.1	DrillCut: 4VersaCut: 2	DrillCut: 1VersaCut: 2			DrillCut: 247.5VersaCut: 169.9
Hodhod 25	DrillCut: 60	DrillCut: 12.5	DrillCut: 6.46	DrillCut: 4	DrillCut: 1
Aydoğan 26	VersaCut (with MS): 40VersaCut (without MS): 80	VersaCut (with MS): 9 ± 6.24VersaCut (without MS): 7 ± 6.72	VersaCut (with MS): 5.09 ± 2.37VersaCut (without MS): 4.08 ± 3.09		N/A		VersaCut (with MS): 31 ± 19.63VersaCut(without MS):28 ± 21.08
Elmansy 27	DrillCut: 40	DrillCut: 15 (4–58)	DrillCut: 5.6 (2.9–14.2)	DrillCut: 3	DrillCut: 0	DrillCut: 0
Pirola 28	Piranha (HoLEP): 117Piranha (ThuLEP): 117	Piranha (HoLEP): 11.5Piranha (ThuLEP): 12	Piranha (HoLEP): 3.6Piranha (ThuLEP): 3.52		N/A		Piranha (HoLEP): 24
Maheshwari 29	Piranha: 140VersaCut: 82	Piranha: 14.5VersaCut: 9.8	Piranha: 4.7VersaCut: 8.4	Piranha: 8VersaCut: 0	Piranha: 11VersaCut: 23	Piranha: 0VersaCut: 3
Rivera 30	VersaCut: 142Piranha: 142	VersaCut: 20.1 ± 18.6Piranha: 14 ± 16.8	VersaCut: 4.4 ± 2.4Piranha: 7 ± 3		VersaCut :1Piranha: 0			VersaCut: 1637.5 ± 1313.52Piranha: 1338.81 ± 1185.12
Piesche 31	MultiCut: 41Piranha: 36	MultiCut: 11Piranha: 15	MultiCut: 5.3Piranha: 4		MultiCut: 0Piranha: 0
Rijo 32	Piranha: 436	Piranha: 5	Piranha: 11		Piranha: 2
Becker 33	Single-use Piranha: 24Reusable Piranha: 24	Single-use Piranha: 5.5Reusable Piranha: 7	Single-use Piranha: 7.67Reusable Piranha: 4.8		Single-use Piranha:1Reusable Piranha: 0
Abdul-Muhsin 34	Older VersaCut: 40New VersaCut+: 20	Older VersaCut: 14.6 ± 11.6New VersaCut+: 19.9 ± 13.7	Older VersaCut: 4.44 ± 2.45New VersaCut+: 3.33 ± 1.82		N/A
Elshal 35	Piranha: 67VersaCut: 55	Piranha: 20 (5–30)VersaCut: 25 (5–70)	Piranha: 6.2 (2.8–12)VersaCut: 2.13 (0.46–7)	Piranha: 7VersaCut: 2	Piranha: 0VersaCut:5	Piranha: 0VersaCut: 0	Piranha: 24 (24–120)VersaCut: 24(24–72)
Netsch 36	Piranha (200 W)-A: 28Piranha (120 W): 28	Piranha (200 W)-A: 16.52Piranha (120 W): 20.48			N/A
Iacono 37	Piranha: 148	Piranha: 18.23 ± 13.34	Piranha: 5.23 ± 1.04		N/A		Piranha: 48.96 ± 10.8
Bach 38	Piranha: 90	Piranha: 28.16 ± 20.31	Piranha: 3.48 ± 1.85		Piranha: 0
Bae 39	VersaCut: 309	VersaCut: 11.3 ± 9.5	VersaCut: 2.06		VersaCut: 28	VersaCut: 18	VersaCut: 45.6
Hwang 40	VersaCut (upward technique): 84VersaCut (inverse technique): 80	VersaCut (upward technique): 14.3 ± 8.6VersaCut (inverse technique): 6.1 ± 7.4	VersaCut (upward technique): 1.93 ± 1.14VersaCut (inverse technique): 4.06 ± 7.4		VersaCut (upward technique): 11VersaCut (inverse technique): 2		VersaCut (upward technique): 62.4 ± 40.8VersaCut(inverse technique):48 ± 28.8
Placer 41	VersaCut: 125	VersaCut: 17.6 ± 9.7	VersaCut: 2.81 ± 1.52		VersaCut: 5	VersaCut: 13	VersaCut: 44
Vavassori 42	VersaCut: 330	VersaCut: 17.3 ± 14.5	VersaCut: 2.3 ± 1.5		VersaCut: 19		VersaCut: 23 ± 14.7
Seki 43	VersaCut: 70	VersaCut: 10.9 ± 5.9	VersaCut: 2.9 ± 1.2		VersaCut: 2	VersaCut: 1

HoLEP = holmium laser enucleation of the prostate; ThuLEP = thulium laser enucleation of the prostate; W = watts.

For meta-analysis, devices were analyzed according to the pairwise comparisons reported in the original studies (e.g., Piranha vs VersaCut or Piranha vs DrillCut). When studies reported multiple arms, comparisons were treated as independent pairwise contrasts to avoid double-counting participants.

The primary outcomes of interest were morcellation time and morcellation efficiency, reflecting the operative performance of the devices. Secondary outcomes included device malfunction, bladder mucosal injury, bladder perforation, catheterization duration, and device-related cost.

The number of studies contributing to each outcome varied depending on data availability (Table 1).

Because the majority of included studies directly compared two devices, analyses were conducted as pairwise random-effects meta-analyses based on the device contrasts reported in the original studies.

Morcellation time

Twelve studies, including 2765 patients, compared morcellation time between two device groups. Across individual studies, results varied, with some favoring one device and the others showing no difference. When pooled using a random-effects model, there was no significant difference in morcellation time between the device categories (MD 1.02 minutes, 95% confidence interval [CI] −1.37 to 3.41; p = 0.40). Substantial heterogeneity was observed (I² = 89.5%) (Fig. 4).

FIG. 4.

Forest plot of mean differences in morcellation time (generated from Code Snippet 2).

Morcellation efficiency

Fifteen studies, including 3404 patients, compared morcellation efficiency between two device categories. Individual study effects varied widely, ranging from −2.60 g/min to +5.53 g/min. Pooled analysis using a random-effects model showed no significant difference in morcellation efficiency between devices (MD 0.75 g/min, 95% CI: −0.46 to 1.97; p = 0.23). Heterogeneity was extremely high (I² = 96.3%) (Fig. 5).

FIG. 5.

Forest plot of mean differences in morcellation efficiency (generated from Code Snippet 4).

Morcellation malfunction

Nine studies, including 2605 patients, reported morcellator malfunction events. Malfunctions were rare, with most study arms reporting rates between 0% and 3%. Individual study RRs varied widely, ranging from 0.01 to 17.85, reflecting low event counts and frequent zero-event studies. As a result, CIs were wide and estimates imprecise.

Catheterization length (hours)

Eight studies, including 2143 patients, compared catheterization duration between two device groups. Individual study effects ranged from −29.5 to +14.4 hours. Pooled random-effects analysis showed no significant difference in catheterization length between devices (MD 3.22 hours, 95% CI: −1.09 to 7.52; p = 0.14). Substantial heterogeneity was present (I² = 81%), indicating considerable variation across studies.

Bladder mucosal injury

Seventeen studies, including 3843 patients, reported bladder mucosal injury events. Injuries were uncommon, with 98 events overall. Individual study RRs varied widely in both directions, largely because of low event counts and frequent zero-event studies. Pooled random-effects analysis showed no significant difference in mucosal injury risk between device groups (RR: 0.85, 95% CI: 0.46 to 1.57; p = 0.57).

Bladder perforation

Six studies, including 973 patients, reported bladder perforation events. Perforations were extremely rare, with only six events overall and several studies reporting zero events in both groups. Individual study RRs varied because of sparse data, but most estimates reflected no meaningful difference. Pooled random-effects analysis showed no statistically significant difference in perforation risk between devices (RR: 0.35, 95% CI: 0.10 to 1.25; p = 0.087). Heterogeneity was minimal, consistent with the extremely low event rates.

Cost

Two studies, including 489 patients, compared device-related costs. One study found no significant cost difference between devices, while the other reported higher costs with Device 2. When pooled using a random-effects model, there was no statistically significant difference in cost between device groups (MD USD 111.90, 95% CI: −173.36 to 397.15; p = 0.44). The CI: was wide, indicating substantial imprecision. Heterogeneity was considerable (I² = 75.5%). Given the limited number of studies and variability in cost definitions and reporting methods, these findings should be interpreted cautiously.

The forest plot for the above variables can be found in the Supplementary Figures.

Discussion

In this systematic review and meta-analysis, we assessed the comparative performance of morcellation devices applied during EEP by synthesizing data from 34 studies involving over 7000 patients. Despite heterogeneity in device design, study populations, reporting quality, and operative technique, the pooled evidence shows no statistically significant differences in morcellation time, morcellation efficiency, complication rates, catheterization duration, or device malfunction among currently available morcellators. These findings suggest that modern morcellation systems—oscillating, reciprocating, or guillotine-based—offer broadly comparable clinical outcomes and support their continued use across diverse surgical settings.

Studies comparing individual systems, such as El-Shal et al., who evaluated Piranha vs VersaCut, reported device-level differences in specific parameters but ultimately showed overall equivalence in safety and acceptable performance across systems.³⁵ Schwartzmann et al. similarly reported differences in morcellation efficiency between MultiCut and Piranha systems, while noting no clinically significant differences in complication rates.¹⁵ Our meta-analysis extends these findings by incorporating a larger set of direct comparisons, applying standardized analytic methods, and pooling data across a broader array of device generations and clinical settings.

Whereas many individual studies favored one morcellator over another, these effects did not hold up when compiled. For instance, several single-center studies described faster morcellation with oscillating systems, while others demonstrated more efficient cutting with guillotine-based blades or with newer generation reciprocating devices.^10,11,15,35 For example, El Tayeb et al. and Dowd et al. reported higher morcellation efficiency with oscillating systems in select cohorts, whereas Ibrahim et al. and Rivera et al. observed superior performance with alternative devices under different operative conditions.^10,11,24 However, our combined results demonstrate that such differences were not consistent across studies, reflecting marked context dependence. Surgeon experience, institutional familiarity with specific devices, device maintenance status, prostate size distributions, and technique variables (e.g., upward vs inverse morcellation, use of enhanced visualization strategies) have all been shown to influence efficiency and safety outcomes.^1,2,8 These factors likely contributed to the high heterogeneity observed in morcellation time (I² = 89.5%) and efficiency analyses, despite the absence of statistically significant pooled differences.

Of note, safety outcomes in terms of bladder mucosal injury, perforation, bleeding, and device malfunction were uniformly low across devices. This finding is consistent with prior comparative trials and reviews, which have reported low rates of morcellation-related complications regardless of device type.^10,11,15,35 Together, these outcomes reaffirm the overall safety of intravesical morcellation as the standard method for tissue retrieval following HoLEP. Although a few studies reported slightly higher mucosal injury rates with individual devices, most notably VersaCut in certain series, this did not extend to significant differences in the overall aggregated analysis nor appear to influence postoperative recovery metrics such as duration of catheterization.^15,35,36 In relation to growing prostate sizes treated with EEP and rising procedural volumes, the lack of a significant difference in safety profiles between systems represents an important reassurance to both surgeons and institutions.

Our findings also have implications for procurement, cost-containment, and surgeon autonomy. Manufacturers often market morcellators based on superior performance related to blade geometry, oscillation frequency, or suction design. Yet, the aggregated clinical data do not support a consistent advantage of any single device.^10,15,35 This implies that institutional decisions can reasonably prioritize factors beyond clinical performance, such as availability, cost, staff familiarity, and serviceability, without compromising patient outcomes. The fact that a number of morcellators in this analysis are not available in the United States also underscores that limited market penetration reflects regulatory and distribution factors rather than inferiority in clinical functionality.¹⁵

Several areas for future research emerge from this analysis. First, most studies lacked standardized definitions for morcellation time, efficiency, or complications, limiting cross-study comparability.^15,35 Second, contextual factors such as surgeon learning curve, operating room staff familiarity, maintenance protocols, and device age were rarely quantified despite their likely influence on outcomes.⁴⁰ Third, new single-use blade technologies and hybrid systems were underrepresented, and thus an opportunity exists for higher quality prospective trials. Finally, cost data were sparse and inconsistently reported, even though significant financial considerations may exist with disposable vs reusable components.¹⁰

The strengths of this study include a comprehensive literature coverage, including both randomized and observational designs, adherence to rigorous meta-analytic methods, and access to detailed raw data that enabled standardized conversions and combined analyses. Limitations include substantial heterogeneity across studies, variability in the quality of reporting, and the inability to account for key contextual variables such as prostate size, surgeon experience, and intraoperative visibility. In addition, several studies reported medians with limited dispersion metrics, necessitating estimation of means and standard deviations. These limitations reflect the current state of the literature and further highlight the need for consistent reporting in future trials.

Overall, morcellators currently used during HoLEP demonstrate comparable safety and efficiency, with no device showing consistent superiority across polled clinical outcomes. While individual studies may favor one system over another under specific conditions, the aggregated evidence supports the conclusion that modern morcellators are reliable and effective tools whose performance is more influenced by contextual factors than by inherent design differences. Future standardized studies are warranted to further assess user-centered outcomes, cost considerations, and performance for large prostates and complex anatomies.

Conclusion

Available evidence suggests that commonly used morcellators in a prostate endoscopic procedure, including Wolf Piranha, DrillCut, VersaCut, CyberBlade, MultiCut, and Hawk systems, do not have consistent differences in operative performance or safety. Among the analyzed outcomes, including morcellation time, morcellation efficiency, bladder mucosal injury, bladder perforation, catheterization duration, device malfunction, and cost, no individual device consistently showed a clear advantage over others.

These findings suggest that morcellator selection may reasonably be guided by various factors such as surgeon preference, institutional resources, equipment availability, and service considerations rather than consistent differences in clinical performance.

Footnotes

Acknowledgments

The authors acknowledge Carole A. Gruhn and Stephanie D. Fondy for their support in providing relevant studies.

Authors' Contributions

P.M.: Writing—Original Draft, Validation, Methodology. A.G.: Data Curation, Writing—Review and Editing. V.V.: Data Curation, Writing—Review and Editing. A.E.: Writing—Review and Editing, Formal Analysis. M.E.: Project Administration, Resources, Writing—Review and Editing, Supervision.

Author Disclosure Statement

The authors declare no conflicts of interest.

Funding Information

This research received no external funding.

Supplemental Material

Abbreviations Used

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