Small Diameter Hysteroscopy: Is it a Real Opportunity?

The hysteroscopy is the gold standard for treatment of uterine intracavitary diseases. It is effective and safe with low rate of recurrence and complications. The features of intrauterine lesions are factors influencing the instrument choice. The larger are generally treated by resectoscope but this technique is associated with potential serious complications mainly due to the need of cervical dilatation. To overcome this limitation, technological improvements have led to the introduction of small-diameter hysteroscopes not exceeding 5mm in diameter equipped with bipolar electrodes that work in saline solution. The vaginoscopic approach avoids the use of speculum and tenaculum, and the small caliber of the instruments avoids cervical dilatation; therefore small-diameter hysteroscopes are more suitable. However, the major challenge in the use of small diameter hysteroscopy is the extraction of tissue fragments through a narrow cervical canal. Therefore, hysteroscopic morcellation is introduced.It provides a fast, effective and safe alternative to bipolar resectoscopy in the hysteroscopic treatment of endometrial polyps, but future trials are required for assess cost-effectiveness and cost-benefit ratio. To date, there are no guidelines defining the limits of the size, location and number beyond which small diameter hysteroscopy should be preferred to the resectoscopy. However, the indications for smalldiameter operative hysteroscopy are expanding and not yet completely defined; in experienced hands a small-diameter hysteroscopy is a safe and effective approach for benign endometrial disease up to 4cm, especially in patients with unfavourable cervical canal at risk of cervical injury.