Modern hysteroscopic management of congenital uterine anomalies: current techniques, emerging technologies, and...

Congenital uterine anomalies are clinically relevant in reproductive medicine, particularly among women with infertility, recurrent pregnancy loss, adverse obstetric outcomes, or obstructive symptoms. Hysteroscopy has transformed the management of correctable intracavitary anomalies by enabling conservative, image-guided reconstruction of the uterine cavity while avoiding the morbidity of historical abdominal metroplasty.

This narrative review critically examines contemporary hysteroscopic management of septate uterus, dysmorphic uterus, bicorporeal septate uterus and rare obstructive malformations, such as Robert's uterus. We discuss the implications of the ESHRE/ESGE, CUME, and ASRM classification systems; the role of three-dimensional transvaginal ultrasound and magnetic resonance imaging in preoperative mapping; and the technical principles that guide metroplasty, cavity remodeling, ultrasound-guided hysteroscopy, office-based metroplasty, and staged approaches in complex anatomy.

Bipolar saline-based platforms, miniaturized resectoscopes, bipolar needle electrodes, cold scissors, and selected tissue removal systems have expanded the therapeutic spectrum and improved safety. The evidence supporting surgery remains heterogeneous: the TRUST randomized trial challenged routine septum resection in unselected women, whereas data for T-shaped and other dysmorphic uteri remain largely observational. Emerging technologies, including laser platforms, artificial intelligence-assisted hysteroscopy, and robotic concepts, are promising, but currently lack prospective validation.

Optimal management should therefore be individualized, anatomy-driven, and grounded in shared decision-making, with careful preservation of endometrium and myometrium. Standardized reporting, multicenter registries, and prospective comparative studies are needed to define which patients benefit most from hysteroscopic correction.