Operative hysteroscopy is widely used for intrauterine pathologies, but the impact of hysteroscope diameter on intraoperative safety remains under-evaluated. This study compared intraoperative complications using 18 Fr versus 26 Fr operative hysteroscopes.

We conducted a prospective single-center observational study in a French university hospital. Women undergoing operative hysteroscopy for polypectomy, myomectomy, or endometrial resection between June 2023 and May 2024 were included without exclusion criteria. Procedures were performed by four senior surgeons who regularly used both systems. Hysteroscope selection (18 Fr vs 26 Fr) was at the surgeon’s discretion based on clinical and technical considerations. The primary outcome was intraoperative complications. Secondary outcomes included procedure completeness, operative time, postoperative pain, and distension fluid deficit.

A total of 117 procedures were analyzed (18 Fr, n = 89; 26 Fr, n = 28). Intraoperative complications occurred in 11 cases (9.4%), including 9 cervical lacerations and 2 uterine perforations. Complications were less frequent with the 18 Fr hysteroscope (5.6%vs 21.4%; OR 0.22; 95% CI, 0.06–0.78). Procedure completeness (89.8%vs 85.2%; p = 0.51), operative time (18.2 ± 9.1 vs 23.0 ± 11.8 min; p = 0.09), and postoperative pain (4.5%vs 3.6%; p = 0.88) were similar. A fluid deficit ≥1500 mL occurred less frequently with 18 Fr (2.2%vs 14.3%; OR 0.14; 95% CI, 0.02–0.80).

Smaller diameter hysteroscopes were associated with fewer intraoperative complications, particularly cervical trauma, without compromising procedural outcomes.

Use of an 18 Fr operative hysteroscope was associated with improved intraoperative safety without loss of effectiveness or efficiency.