No difference is seen with regard to reproductive outcome between both electrosurgical techniques mentioned before, so the choice of technique depends on the cost of instrumentation, operating time, and rate of complication. The resectoscopes offer that advantage of no requirement for disposable or specific equipments because the unipolar electrosurgery unit is usually available in most operating rooms and also nonexpensive and readily feasible. On the other hand, because of the shorter operating time, the easier feasibility, the lower incidence of complications, and the general improved safety, in experienced hands the small-diameter hysteroscope technique is a valuable and valid alternative to resectoscopy and should be preferred for the septate uterus class Vb (Colacurci et al. 2007).

Resection of polyp with the loop resectoscope

Resection of fibroid with the loop resectoscope

There are many different resectoscopes available for treatment of endometrial polyps and fibroids. The current standard of treatment is resectoscopic surgery under general or epidural anesthesia. Marketing of small-diameter operative hysteroscopes, uterine distention by liquid delivered at controlled pressure, visualization supported by videocamera, and the vaginoscopic approach rendered hysteroscopic polypectomy toward a one-stop diagnostic and therapeutic step, safely and effectively accomplished in an office setting (Bettocchi et al. 2002; Garuti et al. 2004; Sesti et al. 2000).

Transvaginal ultrasound, saline infusion sonography, diagnostic hysteroscopy.

Transvagial ultrasound

Mechanical or electrosurgical outpatient polypectomy is equally safe and effective and does not differ in terms of operating time or induced pelvic discomfort (Garuti et al. 2008). Bipolar electrodes appear to have a safer profile compared with monopolar electrodes because of the unchanged serum sodium (Berg et al. 2009). Small versus big loops. A smaller loop will cut more superficially and remove a smaller amount of tissue. Subsequently, it may be necessary to resect twice at the same level to remove the basal layer, and this may increase operating time (Berg et al. 2009).

The differences between the various systems for the resection of fibroids need further evaluation (efficacy, speed, safety), although the learning curve seems to be shorter for mechanical myomectomy (van Dongen et al. 2008) and therefore this technique might be more appropriate for less experienced physicians.

There are two techniques of endometrial resection/ablation: hysteroscopic guided or first-generation endometrial ablation and nonhysteroscopic second-generation endometrial ablation. The first-generation endometrial ablation techniques are considered the gold standard for endometrial ablation, these techniques include transcervical endometrial resection by resectoscope, rollerball electrocoagulation and laser ablation (Papadopoulos and Magos 2007). Second-generation endometrial techniques include thermal balloon ablation, microwave endometrial ablation, hydrotherm ablation, electrode ablation, and cryoablation (Overton et al. 1997). In experienced hands, a significant difference in efficacy between first and second-generation ablation techniques for the treatment of heavy menstrual bleeding has not been found. Second-generation techniques however are less operator-dependent, easier and appear to have a lower complication rate (van Dongen et al. 2008).

Transvaginal ultrasound, office hysteroscopy, and endometrial biopsy (Gupta et al. 2006; Litta et al. 2006; Perino et al. 2004; Rosati et al. 2008).

Studies showed no significant difference in menstrual improvement and patient satisfaction for the three different first-generation techniques (Papadopoulos and Magos 2007). Loop resection provides tissue for histology and is suitable even when endometrium is thick, but requires the most skill and therefore bares the greatest risk of uterine perforation. The rollerball is easier to learn and faster than the laser, but it provides no tissue for histology and fails to treat submucous fibroids. The laser can vaporize small fibroids and polyps, but is the most expensive and slowest of all three techniques (Papadopoulos and Magos 2007). Therefore, the choice of technique should depend on the operator’s preference.