Surgical and Reproductive Outcomes of a Standardized Hysteroscopic Approach to Treat Septate Uterus and Associated Complex Anomalies

Background/Objectives: Septate uterus is the most prevalent uterine malformation and is commonly associated with impaired reproductive outcomes. Hysteroscopic metroplasty is the gold standard treatment, but surgical management of complex septate uteri with associated cervical and vaginal anomalies remains challenging. This study aimed to evaluate surgical and reproductive outcomes following a standardized minimally invasive hysteroscopic approach using a 15 Fr bipolar mini-resectoscope across different subtypes. Methods: This retrospective single-center, single-surgeon study included women who underwent hysteroscopic correction of partial and complete septate uterus, with or without cervical and/or vaginal anomalies, between January 2021 and January 2025 at the Digital Hysteroscopic Clinic CLASS Hysteroscopy, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy. Preoperative assessment included three-dimensional transvaginal ultrasound and diagnostic hysteroscopy. All procedures were performed using a standardized hysteroscopic technique with a 15 Fr bipolar mini-resectoscope. Surgical outcomes included operative time and the need for second-step surgery. Reproductive outcomes included clinical pregnancy rate (CPR), live birth rate (LBR), and miscarriage rate (MR). Results: A total of 154 patients were included, comprising 70 partial and 84 complete septate uteri; 52.4% of complete septa were associated with cervical and/or vaginal anomalies. Median operative time was 18.0 min for partial septa and 31.0 min for complete septa (p < 0.01), and a second surgical step was required in only 5/84 complete septa (5.9%) and in none of the partial septa. Reproductive outcomes were analyzed in a subgroup of 70 patients who attempted conception. After metroplasty, CPR increased from 35.7% to 84.3% (p < 0.01), LBR per pregnancy increased from 16.0% to 78.0% (p < 0.01), and MR per pregnancy decreased from 84.0% to 10.2% (p < 0.01). Postoperative reproductive outcomes appeared comparable between partial and complete septa and according to the presence of associated anomalies. Conclusions: A standardized hysteroscopic technique using a 15 Fr bipolar mini-resectoscope is feasible and effective for treating septate uterus, including complex cases associated with cervical and/or vaginal anomalies. Favorable reproductive outcomes can be achieved regardless of anomaly complexity when accurate preoperative diagnosis and a structured surgical approach are applied.