Effectiveness of hysteroscopic techniques for endometrial polyp removal: the italian multicenter trial

Study Objective: To compare the effectiveness and safety of different techniques of hysteroscopic polypectomy. Design: Multicenter, prospective observational trial (Canadian Task Force classification II-2). Setting: Nineteen Italian gynecologic departments (university-affiliated or public hospitals). Patients: Consecutive patients suffering from endometrial polyps (EPs). Interventions: Hysteroscopic polypectomy, as performed through different techniques. Measurements and Main Results: Included in the study were 1404 patients (with 1825 EPs). The setting was an ambulatory care unit in 40.38% of the cases (567 women), of whom 97.7% (554) did not require analgesia/anesthesia. In the remaining 59.62% of women (837 women), the procedures were performed in an operating room under mild sedation, local or general anesthesia. Minor complications occurred in 32 patients (2.27%), without significant differences between the techniques used (p = ns). Uterine perforation occurred in 14 cases, all performed in the operating room with some kind of anesthesia, only 1 with a vaginoscopic technique and the remaining during blind dilatation (odds ratio [OR], 19.98; 95% confidence interval [CI], 1.19–335.79; p = .04). An incomplete removal of EPs was documented in 39 patients. Logistic regression analysis showed that a higher risk of residual EPs was associated with the use of a fiber-based 3.5-mm hysteroscope (OR, 6.78; 95% CI, 2.97–15.52; p <.001), the outpatient setting (OR, 2.17; 95% CI, 1.14–4.14; p = .019), and EPs located at the tubal corner (OR, 1.98; 95% CI, 1.03–2.79; p = .039). No association between incomplete EP removal and EP size or number was recorded (p = ns), as well as with the other variables evaluated. Conclusion: Outpatient polypectomy was associated with a minimal but significantly higher risk of residual EPs in comparison with inpatient polypectomy. Conversely, inpatient polypectomy was associated with a considerably higher risk of uterine perforation and penetration in comparison with office hysteroscopy. Because of lower intraoperative risks and higher cost-effectiveness, office hysteroscopy may be considered, whenever possible, as the gold standard technique for removing EPs.