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Advanced Hysteroscopic Technology for Gynecological Disease

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A Special Issue of Journal of Clinical Medicine (ISSN 2077-0383) belonging to the section "Obstetrics & Gynecology".

Deadline for manuscript submissions: closed (20 August 2026) | Viewed by 7957

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Editors

Dr. Guglielmo Stabile

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Guest Editor

Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, 71121 Foggia, Italy
Interests: hysteroscopy; laparoscopy; endometriosis; oncology; leiomyomas
Special Issues, Collections and Topics in MDPI journals

Prof. Dr. Luigi Nappi

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Guest Editor

Dr. Felice Sorrentino

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Guest Editor

Institute of Obstetrics and Gynecology, Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, FG, Italy
Interests: gynecological surgery; hysteroscopy; laparoscopy; endometriosis; gynecological oncology; urogynecology
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Special Issue Information

Dear Colleagues,

The progress seen in hysteroscopy in the gynecology field is remarkable. More and more pathologies can be diagnosed and treated with the use of hysteroscopy. Furthermore, the instrumental advancement and the improvement of its effectiveness have made hysteroscopy a fundamental tool for treating the majority of endometrial and uterine pathologies.

For this reason, with this Special Issue, we want to focus on the recent development of hysteroscopy in the technological fields and also in the diagnostics and therapeutic management of different uterine pathologies (endometrial pathologies, leiomyomas, isthmocele, uterine septum, ectopic pregnancies, oncological pathologies, endocervical pathologies).

Invited topics are:

New technologies in hysteroscopy.
Advances in the diagnosis of uterine pathologies.
Advances in the treatment of uterine pathologies.
Outcomes after hysteroscopic surgery.
New preoperative therapies.
New methods for pain reduction during outpatient hysteroscopy.
New diagnostic and prognostic biomarkers following endometrial biopsy.

Dr. Guglielmo Stabile
Prof. Dr. Luigi Nappi
Dr. Felice Sorrentino
Guest Editors

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Keywords

hysteroscopy
new technology
therapy
mini-invasive approach
laser
diagnosis
outcomes

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Published Papers (6 papers)

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15 pages, 455 KB

Open AccessArticle

Clinical Factors Associated with Pain During Outpatient Hysteroscopy in a Standardized Vaginoscopic Setting: A Prospective Observational Study

by Francesco Pio Toscano, Maria D’Angelo, Luigi Riello, Mario Ardovino and Antonio Mollo

J. Clin. Med. 2026, 15(16), 6335; https://doi.org/10.3390/jcm15166335 - 16 Aug 2026

Viewed by 350

Abstract

Background: Outpatient hysteroscopy is the reference standard for the diagnosis and treatment of benign intrauterine pathology. Although several pharmacological and non-pharmacological strategies have been proposed to reduce procedural pain, the clinical and procedural factors primarily determining patient tolerability in a standardized vaginoscopic setting remain incompletely understood. This prospective study aimed to identify the main predictors of pain, procedural tolerability, successful completion, and patient acceptance during outpatient hysteroscopy. Methods: A prospective observational study was conducted between February and June 2026 at a second-level referral hospital. Consecutive women undergoing outpatient hysteroscopy were enrolled. All procedures were performed according to a standardized vaginoscopic “no-touch” protocol using a 15-Fr Bettocchi hysteroscope. Patients completed structured questionnaires before and after the procedure, while physicians recorded procedural findings immediately afterward. Clinical characteristics, psychological variables, procedural factors, pain scores, procedural tolerability, successful completion, and future patient preference were prospectively analyzed. Results: A total of 105 women were included. Diagnostic hysteroscopy was successfully completed in 94 patients (89.5%), and a see-and-treat procedure was performed in 57 (54.3%). Difficult cervical access occurred in 37 cases (35.2%) and emerged as the strongest determinant of poor procedural tolerability. These patients experienced significantly higher maximum pain scores (7.35 ± 2.81 vs. 4.04 ± 2.51; p < 0.001), a higher prevalence of severe pain (67.6% vs. 20.6%; p < 0.001), poorer procedural tolerability, greater preference for future hysteroscopy under anesthesia, and a higher risk of incomplete diagnostic examination. All incomplete hysteroscopies occurred in patients with difficult cervical access. Expected procedural pain was significantly associated with maximum pain (p = 0.0016), whereas pre-procedural anxiety was not. More than half of the patients identified cervical passage as the most painful procedural step. Patients undergoing successful see-and-treat procedures reported the lowest pain scores, suggesting that the operative phase itself was not the principal determinant of procedural discomfort. Conclusions: In a standardized vaginoscopic setting, procedural tolerability during outpatient hysteroscopy appears to depend primarily on difficult cervical access rather than on the operative intervention itself. Pain expectation may influence the hysteroscopic experience more than pre-procedural anxiety, whereas successful see-and-treat procedures remain well tolerated once uncomplicated access to the uterine cavity has been achieved. Early identification of patients at increased risk of difficult cervical access may improve patient counseling, optimize procedural completion, and preserve the benefits of outpatient hysteroscopy. Full article

(This article belongs to the Special Issue Advanced Hysteroscopic Technology for Gynecological Disease)

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11 pages, 517 KB

Open AccessArticle

Asherman Syndrome in Mexican Women: Clinical Characteristics, Management, and Outcomes at a Tertiary Hospital

by Andrea Olguín-Ortega, Jessica Aidee Mora-Galván, Fernando Escobar-Ponce, Fernanda Villalobos-Mendoza, Alejandro Rendón-Molina, Oliver Cruz-Orozco and Enrique Reyes-Muñoz

J. Clin. Med. 2026, 15(10), 3672; https://doi.org/10.3390/jcm15103672 - 10 May 2026

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Abstract

Background/Objective: Asherman syndrome is an acquired intrauterine adhesive disorder associated with menstrual abnormalities, infertility, recurrent pregnancy loss, and adverse reproductive outcomes. Data from Latin American tertiary referral centers remain limited. To characterize clinical history, classification, hysteroscopic management strategies, and anatomical and reproductive outcomes in a single cohort of Mexican women with Asherman syndrome. Methods: This retrospective cohort study included women identified through institutional electronic records between July 2016 and December 2023 with a diagnosis of Asherman syndrome and analyzable hysteroscopic records. Women were followed for twelve months. Recurrence was defined as hysteroscopic evidence of intrauterine adhesions during follow-up. Among women with follow-up hysteroscopy, two-sided Fisher’s exact tests were used to calculate odds ratios and 95% confidence intervals. Results: Fifty-four women were analyzed. A prior uterine procedure was documented in 44 women (81.5%), with sharp curettage in 35 (64.8%). The most common reasons for consultation were secondary infertility (29.6%), abnormal uterine bleeding (27.8%), primary infertility (20.4%), and recurrent pregnancy loss (13.0%). Disease severity was classified as mild in 30 women (55.6%), moderate in 11 (20.4%), and severe in 7 (13.0%). Hysteroscopic intervention was predominantly performed with cold knife adhesiolysis (83.3%). Twelve-month follow-up hysteroscopy was performed in 38 women (70.4%); recurrence was identified in 30 (55.6%). Among the 34 women with reproductive intent, 12 achieved a live birth, corresponding to a live birth rate of 35.3%. Conclusions: Prior uterine instrumentation, particularly sharp curettage, was the most frequent antecedent. Recurrence remained common despite surgical management, highlighting the need for standardized postoperative surveillance and preventive strategies. Full article

(This article belongs to the Special Issue Advanced Hysteroscopic Technology for Gynecological Disease)

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18 pages, 523 KB

Open AccessArticle

Application of the Analgesia Nociception Index and Visual Analog Scale to Assess Pain During Hysteroscopy Under Local Anesthesia

by Adrian Nowak, Karolina Chmaj-Wierzchowska, Adam Malinger and Maciej Wilczak

J. Clin. Med. 2025, 14(23), 8386; https://doi.org/10.3390/jcm14238386 - 26 Nov 2025

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Abstract

Background/Objectives: Pain assessment during hysteroscopy facilitates rapid operator intervention (e.g., repeated anesthesia, administration of additional analgesics, or termination of the procedure), thereby improving patient comfort. Traditionally, pain intensity has been evaluated based on the patient’s subjective reporting; however, the introduction of an objective indicator in combination with subjective measures can considerably improve pain assessment. In this context, the present study aimed to evaluate pain intensity in patients undergoing hysteroscopy under local anesthesia (GUBBINI Mini Hystero-Resectoscope; Tontarra Medizintechnik, Tuttlingen, Germany), with simultaneous assessment using the Visual Analog Scale (VAS) and the Analgesia Nociception Index (ANI). Determining the relationship between ANI and VAS could contribute to improving patient comfort during hysteroscopic procedures performed under local anesthesia. Methods: The study included a total of 221 patients between the ages of 22 and 82 years, divided into two groups: 125 patients underwent diagnostic hysteroscopy (HD) and 96 patients underwent operative hysteroscopy (HO). After the procedure, patients were asked to assess pain intensity by using the VAS. The ANI was also monitored during the procedure. Measurements were conducted immediately before the procedure (T0), at the 1st minute (T1), mid-procedure (T1/2), and at the end of the procedure (T2). Results: The mean pain score in the study group was 3 points (3.04 ± 2.29), with a mean post-procedure score of 2.79 ± 2.19 and 3.36 ± 2.38 in the DH and OH groups, respectively. At Tmean, the ANI values ranged from 42 to 97 points, with a mean value of 70 points (70.37 ± 10.99). All correlations between the ANI values and VAS pain scores were statistically nonsignificant (p > 0.05), with correlation coefficients close to zero. This finding indicates that subjective pain assessment (VAS) does not correspond to the ANI values, which reflects the physiological autonomic response. Conclusions: Further research on pain assessment during hysteroscopy is warranted. Future studies should include larger patient populations, conduct continuous ANI monitoring, and correlate ANI with real-time subjective pain assessments (e.g., VAS during the procedure). The determination of psychological factors, such as pre-procedural anxiety, and the use of additional autonomic nervous system measures (e.g., skin conductance and pupillometry) could facilitate the development of a comprehensive model for objective pain assessment in patients undergoing gynecological procedures through hysteroscopy. Full article

(This article belongs to the Special Issue Advanced Hysteroscopic Technology for Gynecological Disease)

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10 pages, 5192 KB

Open AccessArticle

Clinical Outcomes After Hysteroscopic Removal of Retained Products of Conception with or Without Prior Uterine Artery Embolization

by Eva Skuk, Polona Vihtelič, Peter Popovič, Kaja Kovač, Ivan Verdenik and Nataša Kenda Šuster

J. Clin. Med. 2025, 14(22), 8020; https://doi.org/10.3390/jcm14228020 - 12 Nov 2025

Cited by 1 | Viewed by 1933

Abstract

Purpose: Retained products of conception (RPOC) are a common complication after pregnancy. While hysteroscopic resection is the standard treatment when RPOC does not resolve spontaneously, highly vascular tissue can lead to severe bleeding during the procedure. This study assessed clinical outcomes, procedural safety, and reproductive performance in patients with highly vascular RPOC treated with uterine artery embolization (UAE) prior to hysteroscopy, compared to those treated with hysteroscopy alone. Methods: This retrospective study included 42 women diagnosed with RPOC at University Medical Centre Ljubljana, Slovenia (2010–2020). Patients were divided into two groups: UAE followed by hysteroscopic resection (UAE + HSC, n = 21) and hysteroscopic resection alone (HSC-only, n = 21). Data on clinical outcomes, complications, and reproductive history were analyzed using Fisher’s exact and t-tests (p < 0.05). Results: Groups were similar in baseline characteristics, except for greater vascularity in the UAE + HSC group (100% vs. 4.8%, p < 0.05). Bleeding >300 mL occurred more often in the UAE + HSC group, but all cases were managed conservatively and only one patient required transfusion. No uterine perforations occurred. Residual RPOC was found in one patient per group. Rates of endometritis, menstrual changes, and pelvic pain were comparable. Among those who attempted conception, live birth and miscarriage rates did not differ significantly. Conclusions: UAE prior to hysteroscopic surgery appears to be a safe and effective option for highly vascular RPOC, especially in patients at risk of hemorrhage, with no adverse impact on fertility. Further prospective studies are recommended. Full article

(This article belongs to the Special Issue Advanced Hysteroscopic Technology for Gynecological Disease)

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14 pages, 490 KB

Open AccessArticle

Assessment of Pain Complaints and Perioperative and Delayed Complications of Hysteroscopy Performed Under Local Anesthesia—A Retrospective Analysis

by Agnieszka Lach, Maciej Wilczak, Adam Malinger, Adrian Nowak, Piotr Piekarski, Adrian Mruczyński, Kinga Bednarek and Karolina Chmaj-Wierzchowska

J. Clin. Med. 2025, 14(16), 5646; https://doi.org/10.3390/jcm14165646 - 9 Aug 2025

Cited by 2 | Viewed by 2544

Abstract

Modern, small-diameter endoscopic instruments, such as resectoscopes (e.g., the GUBBINI System) and mini-hysteroscopes, are widely used in clinical practice. These tools allow endoscopic procedures to be conducted without cervical dilation, often in an outpatient setting, and under local anesthesia alone. Background/Objectives: The present retrospective study aimed to analyze the perioperative and delayed complications of hysteroscopy performed under local anesthesia. This study also assessed the pain experienced during hysteroscopy under local anesthesia, depending on the type of procedure performed. Methods: A retrospective analysis was conducted in 1945 patients who underwent hysteroscopy under local anesthesia at the Center for Hysteroscopy, Heliodor Święcicki Gynecological and Obstetrical Clinical Hospital, Karol Marcinkowski Medical University, Poznań, Poland, between January 2021 and December 2023. Hysteroscopic procedures were performed with the GUBBINI Mini Hystero-Resectoscope through a paracervical block using lignocaine. Results: The procedure was discontinued in 46 patients, accounting for 2.36% of all hysteroscopies. The most common reasons for procedure discontinuation were severe pain and uterine perforation, accounting for 52.8% and 13% of discontinued procedures, respectively. The complication rates were low: uterine perforation occurred in 0.3% of cases (n = 6), and late complications requiring readmission occurred in 0.2% (n = 3). The average pain intensity score for all the patients was 2 points (2.8 ± 2.14). Conclusions: Our study confirmed that hysteroscopy performed under local anesthesia is a safe and effective diagnostic and therapeutic method for selected uterine pathologies, noting increased risks in cases such as extensive intrauterine adhesions. The low complication rates in both the perioperative and postoperative stages indicate the high safety profile of this procedure, particularly when performed by experienced personnel using standardized, validated protocols. Full article

(This article belongs to the Special Issue Advanced Hysteroscopic Technology for Gynecological Disease)

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11 pages, 383 KB

Open AccessSystematic Review

The Role of Hysteroscopy for the Treatment of Interstitial Ectopic Pregnancy: A Systematic Review

by Guglielmo Stabile, Laura Vona, Stefania Carlucci, Francesco Nappi, Stefania Biffi, Anna Pitsillidi, Stefano Restaino, Giuseppe Vizzielli and Luigi Nappi

J. Clin. Med. 2026, 15(6), 2158; https://doi.org/10.3390/jcm15062158 - 12 Mar 2026

Viewed by 743

Abstract

Background/Objectives: Interstitial ectopic pregnancy is a rare and potentially life-threatening condition, accounting for 1–6% of ectopic pregnancies. Its location complicates diagnosis and management, and no standardized treatment guidelines exist. Fertility-preserving, minimally invasive approaches have been proposed as alternatives to medical therapy or radical surgery. This systematic review evaluates the safety and effectiveness of hysteroscopic treatment, focusing on uterine preservation and reproductive outcomes. Methods: This systematic review was conducted according to PRISMA guidelines and registered in PROSPERO (CRD420251249508). Web of Science, Scopus, and PubMed were searched from inception to January 2026. Eligible articles included case reports and case series describing interstitial pregnancies managed hysteroscopically, alone or combined with minimally invasive treatments, without medical therapy. Study quality was assessed using the JBI Checklist. Results: Eight studies comprising 21 patients were included. Mean gestational age at diagnosis was 55 days, and mean β-hCG level was 7981 IU/L (range 1440–32,000 IU/L). Hysteroscopic management was successful in 16 of 21 cases (76%). Five patients required rescue therapy. Reduced residual myometrial thickness was the main factor associated with treatment failure. Mean time to β-hCG normalization was 32 days. Conclusions: Hysteroscopic management is a safe and effective minimally invasive option for clinically stable patients with interstitial ectopic pregnancy. It allows direct visualization, targeted tissue removal, and preservation of uterine integrity and fertility, with limited morbidity. Ultrasound guidance is generally sufficient, reserving laparoscopy for high-risk cases. These findings support hysteroscopy as a fertility-preserving strategy, though larger prospective studies are needed to confirm long-term reproductive outcomes. Full article

(This article belongs to the Special Issue Advanced Hysteroscopic Technology for Gynecological Disease)

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