A safety and feasibility study of Manual Vacuum Aspiration for Endometrial Polyp- like Lesions; A case series

A safety and feasibility study of Manual Vacuum Aspiration for Endometrial Polyp- like Lesions; A case series | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A safety and feasibility study of Manual Vacuum Aspiration for Endometrial Polyp- like Lesions; A case series Akihiko MISAWA, Kiyono OSANAI, Naomi FURUMA, Kazuki ASAI, Yasunori SATO, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7183522/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 22 Nov, 2025 Read the published version in BMC Women's Health → Version 1 posted 28 You are reading this latest preprint version Abstract Study Objective: We conducted a clinical evaluation of safety and feasibility of manual vacuum aspiration (MVA) for the removal of endometrial polyp-like lesions. Design: Prospective study (case series) Setting and Participants: This study included patients at our hospital who were suspected of having endometrial polypoid lesions based on ultrasound findings and who provided informed consent. Resectoscope (26Fr rigid hysteroscopy) was performed to examine the uterine cavity and identify polypoid lesions. The endometrial tissue, including polyp-like lesions, was aspirated using the MVA system, immediately followed by a resectoscope to detect any residual tissue. This study was conducted with the approval of the hospital’s institutional review board. Interventions: For each enrolled patient, clinical data were collected. Results: A total of 29 patients were enrolled. Complete resection was achieved in 25 cases (86.2%), whereas 4 cases (13.8%) with larger lesions required resectoscope for complete removal. The number of aspirations in cases of complete resection ranged from 1 to 3, whereas no complications were observed. The lesions that could not be completely resected exceeded 20 mm in size and consisted of thick stalks. Conclusion: The use of MVA for the removal of endometrial polyp-like lesions is easy and safe, similar to its use in miscarriage and abortion procedures. Therefore, excluding particularly large polyps, MVA is a viable option for the removal of endometrial polyp-like lesions, without the need to purchase new, expensive equipment. endometrial polyps manual vacuum aspiration polypectomy trans cervical resection Figures Figure 1 Figure 2 Figure 3 Background With advances in ultrasound technology, it has become easier to visualize polypoid lesions within the uterine cavity. Endometrial polypoid lesions include endometrial polyps, submucosal fibroids, malignant tumors, and other endometrial abnormalities. Although ultrasound is a simple and convenient first-line diagnostic tool, it is difficult to differentiate and diagnose these conditions, and it does not provide a pathological diagnosis ( 1 ). Endometrial polyps can cause bleeding, infertility, and rarely, malignancy. The removal of polyps in infertile women improves pregnancy rates. Therefore, hysteroscopic surgery with a resectoscope is recommended for both diagnosis and treatment; however, blind dilation and curettage (D&C) is another technique that may be used ( 1 ). WHO stated that traditional D&C should be avoided during miscarriage and abortion procedures to ensure safety and quality of care; vacuum aspiration is recommended instead ( 2 ). Hysteroscopy with grasping forceps or resectoscope helps diagnose and treat endometrial polyps ( 3 ); however, they are expensive and not readily available at every institutions. We hypothesized that if MVA alone can be used for the removal of endometrial polypoid lesions, it would offer a simple procedure similar to miscarriage management, while protecting the endometrium, and reducing the burden on patients. Therefore, we performed a clinical evaluation of safety and feasibility of MVA for removing endometrial polypoid lesions, with the use of a trans cervical resectoscope. In Japan, smaller-diameter hysteroscopes were only covered by the medical insurance treatment in 2024; therefore, they are neither used widely nor have been introduced at our hospital. Consequently, we utilized a resectoscope to ensure definitive lesion resection. Methods This study included all patients who underwent transvaginal ultrasonography at our hospital and were suspected of having endometrial polypoid lesions between January 2021 to December 2021. The patients provided informed consent for the collection and removal of these lesions. This study was conducted with the approval of our hospital’s institutional review board (Approval No. 2020011). For preoperative preparation, a 3 mm polyvinyl alcohol cervical dilator (Lamicel, Medtronic Japan) was used. The MVA system (Women’s Health Japan) (Fig. 1 ) was used for manual vacuum aspiration. The procedure was done in the operating room under intravenous anesthesia managed by the anesthesiology department as follows: Before performing MVA, the uterine cavity was examined with a resectoscope (26Fr rigid hysteroscope, OES Pro Resectoscope, Olympus) (Fig. 1 ) to confirm the presence and status of polypoid lesions. The endometrium, including the polypoid lesions, was aspirated with the MVA kit until no more tissue could be aspirated. A resectoscope was performed to detect any residual endometrial polyp tissue. Using resectoscope, remnant tissue was removed and any necessary hemostasis was performed. We considered complete resection when no lesions were present after using the resectoscope; furthermore, we used ultrasound as an adjunct to confirm the thinning of the uterine cavity. The removal specimens were submitted for pathological examination. The evaluation criteria included the feasibility of lesion removal, the operability of the sampling instruments, patient pain and blood loss, the frequency of intraoperative and postoperative complications, such as uterine perforation, and a pathological assessment of the excised specimens. Results A total of 29 cases were included in this study. The average age of the patients was 40 years (± 8.9 SD). The primary complaints were bleeding in 15 cases, asymptomatic lesions detected during health check-ups in seven cases, infertility in six cases, and tamoxifen administration in one case. The average maximum diameter of the lesions diagnosed preoperatively by the ultrasound examination was 18.79 mm (± 9.872 SD). Polypoid lesions were found in all cases using a pre-MVA resectoscope. Complete resection was achieved in 25 cases, whereas 4 cases required resectoscopic removal (Table 1 ). Table 1 Comparison of polypectomy using MVA in 29 patients Case No. Age Operative time (min) Preoperative polyp size (TVUS) Complete resection case Endometrial polyp 22 45 (9.1) 11.5 (4.1) 17.2 (7.7) Endometrial tissue 2 42( 4 ) 8.5 (1.5) 4.15 (1.10) Leiomyoma 1 75 11 12 Total 25 46.0 (10.5) 11.2 (3.99) 15.9 (8.20) Incomplete resection case Endometrial polyp 4 46.7 (6.94) 20.6 (5.56) 41.3 (15.06) Adenomyomatous polyp, Leimoma 1 37 31 37 Total 5 46.6 (6.94) 23.3 (6.57) 40.25 (13.17) Total 29 46.0 (10.0) 12.9(6.07) 4.1 (1.00) (mean ± SD) In cases of complete resection, the number of aspirations with the MVA ranged from 1 to 3, and the tissue was collected using an 8 mm or 9 mm cannula. A resectoscopic examination before and after MVA confirmed complete removal without residual lesions (Fig. 2 ). None of the cases required hemostasis during the procedure. Minimal postoperative bleeding was observed; however, during the follow-up visit approximately one week later, bleeding had ceased in all cases, and there was no retention within the uterus. For the cases with complete resection, the median surgical time was 11 minutes (± 3.9 SD), whereas it required 23 minutes (± 6.5 SD) for cases in which complete resection was not possible. Despite being diagnosed as endometrial polyps preoperatively, one patient presented with uterine fibroids, and three patients had larger lesions (41 mm ± 15 SD) that were not resectable (Table 2 , Fig. 3 ). Table 2 Incomplete resection cases Case Age Preoperation polyp size (mm) Operation time (min) Pathological diagnosis Intraoperative blood loss Complications 1 50 46 13 Endometrial polyp Less than 5cc (−) 2 53 57 23 Endometrial polyp Less than 5cc (−) 3 37 21 26 Endometrial polyp Less than 5cc (−) 4 46 37 31 Adenomyomatous polyp, Leimoma Less than 5cc (−) Normal menstruation was observed among the 23 patients who experienced menstrual cycles, and transvaginal ultrasonography demonstrated a normal endometrium. There were no indications of Asherman’s syndrome. All procedures were performed under intravenous anesthesia managed by the anesthesiology department, which ensured adequate pain control during the operation. No postoperative pain requiring analgesics was observed after the patients woke up from anesthesia. Discussion Endometrial polyps are benign tumors of the endometrium that can occur as single or multiple lesions, with a reported prevalence ranging from 7.9–34.9% ( 1 ). They can be pedunculated or sessile, with single or multiple growths, and vary in size from a few millimeters to several centimeters ( 4 ). Diagnostic methods include 2D or 3D ultrasonography, hysterosalpingography (HSG), sonohysterography, and hysteroscopy. Of these, ultrasonography is simple and noninvasive, but not specific to endometrial polyps, making it difficult to distinguish them from other endometrial abnormalities, such as submucosal fibroids; however, it cannot provide a pathological diagnosis. Therefore, hysteroscopic biopsy is considered the gold standard for diagnosis, although sonohysterography is considered a simpler diagnostic method with an accuracy comparable to that of hysteroscopy ( 5 ). In the present study, we did not perform prior sonohysterography or hysterofiber for patients with endometrial polypoid lesions that were detected by transvaginal ultrasonography. Instead, we proceeded directly to hysteroscopy using a resectoscope for diagnosis and treatment. This approach enabled us to evaluate the uterine cavity and address any residual tissue or bleeding, while using MVA to remove and collect the endometrial tissue, including the polypoid lesions. According to the 2024 guidelines of the Japan Society of Obstetrics and Gynecology Endoscopy, hysteroscopic surgery is recommended for endometrial polyps because of its superior outcomes in improving abnormal bleeding, pregnancy rates, and tissue diagnosis (Recommendation Level 2, Evidence Level C) ( 3 ). This recommendation is based on evidence that approximately 8% of endometrial polyps can be removed with endometrial curettage alone. Although the use of polyp forceps can increase the removal rate to 41%, it is less than 50%, which indicates that endometrial curettage is unsuitable when hysteroscopy is available ( 1 , 6 ). Hysteroscopy for the removal of endometrial polyps has advanced with the use of smaller, higher-resolution fiber scopes, which enables the procedure to be performed on an outpatient basis without general anesthesia, thus reducing cost. However, the overall residual rate of polyps following hysteroscopic resection is 2.7%, whereas it increases to 16% with thinner scopes ( 7 ). In the present study, the residual rate was 4 out of 29 cases (13.8%), which is comparable with that of previous studies. All four cases involved lesions larger than 20 mm; thus, the size and thick stalks are too big for the polyps to fit into the MVA cannula. Although this study involved inpatient procedures with general anesthesia because of the use of a resectoscope, outpatient MVA may be a simple and effective diagnostic technique for endometrial polypoid lesions identified by ultrasound. A PubMed search revealed only one report on the use of MVA for endometrial polyps, which similarly compared hysteroscopy plus MVA to hysteroscopic resection alone. They found MVA to be effective even for larger or multiple polyps, with comparable outcomes to hysteroscopic resection ( 8 ). Endometrial polyps are a known cause of infertility and 6–32% of women undergoing hysteroscopy before IVF have them. Hysteroscopic polypectomy results in a pregnancy rate of over 63% ( 9 ). Hysteroscopic surgery for endometrial polyps has a lower incidence of intrauterine adhesions compared with surgeries for fibroids or septa, and it is recommended for protecting the endometrium ( 3 , 10 ). Although this study did not specifically examine infertility, MVA is also recommended for miscarriage procedures because of its protective effect on the endometrium with fewer complications. From the endometrial preservation viewpoint, 1.2% of patients treated with D&C alone or with a combination of D&C and electric vacuum aspiration (EVA) developed Asherman’s syndrome. In contrast, a report indicated that there was no occurrence of Asherman’s syndrome in patients who underwent MVA ( 11 ). MVA does not require the use of a curette, thereby reducing the risk of injuring the basal layer of the endometrium. Moreover, the plastic cannula used in MVA has an optimal balance of rigidity and flexibility, minimizing endometrial damage and thinning, thereby lowering the risk of Asherman’s syndrome ( 12 ). Herein, hysteroscopic examinations were not performed for the 23 patients who continued to menstruate; however, based on their menstrual cycles and ultrasound findings, no signs indicative of Asherman’s syndrome were observed. Although no cases of malignancy were observed in this study, we previously encountered one case of atypical endometrial hyperplasia that was not diagnosed by ultrasound, but was detected and diagnosed by MVA ( 13 ). The incidence of malignancy increases with age, particularly in postmenopausal women with bleeding, and the risk for these women was reported to be 4.93% and 5.14%, respectively ( 14 ). Therefore, histological exclusion of malignancy is important, particularly for symptomatic or postmenopausal cases, and monitoring without intervention is not recommended, regardless of size. Overall, MVA is a useful technique for the diagnosis and treatment of endometrial polypoid lesions. It enables the collection of sufficient tissue for pathological diagnosis, including coexistent malignancies. In this study, we completely removed endometrial polypoid lesions using MVA alone in 86.2% of the patients. The procedure was easy and safe to perform, suggesting that MVA should be considered a viable option for endometrial polypectomy. A key advantage is that complete removal can be achieved without the need to purchase new, expensive equipment. As MVA can be performed on an outpatient basis, we plan to accumulate further case evaluations to establish more precise criteria for lesion removal and potentially facilitate its transition into office gynecology settings in the future. Abbreviations D&C dilation and curettage EVA electric vacuum aspiration MVA manual vacuum aspiration Declarations Consent for publication Not Applicable Ethics approval and consent to participate This study was approved by our hospital’s institutional review board on January 4, 2024 (approval number: 2020011). This study adhered to the Declaration of Helsinki. Written informed consent was obtained from all patients. Competing interests The authors declare that they have no competing interests. Consent for publication Not Applicable Funding Not applicable. Author Contribution A.M.: designed the study, performed the analyses, wrote the first draft of the manuscript, contributed to the interpretation of the results and critically revised the manuscript.K.O.: contributed to the interpretation of the results and critically revised the manuscript.N.F.: contributed to the interpretation of the results and critically revised the manuscript.K.A.: contributed to the interpretation of the results and critically revised the manuscript.Y.S.: contributed to the interpretation of the results and critically revised the manuscript.E.K.: contributed to the interpretation of the results, and critically revised the manuscript.A. S.: designed the study, contributed to the interpretation of the results, and critically revised the manuscript. Acknowledgements Not applicable. Data Availability All data generated or analyzed during this study are included in this published article. References American Association of Gynecologic Laparoscopists. AAGL practice report: practice guidelines for the diagnosis and management of endometrial polyps. J Minim Invasive Gynecol. 2012;19:3–10. World Health Organization: Abortion care guideline. 2022. https://iris.who.int/bitstream/handle/10665/349316/9789240039483-eng.pdf?sequence=1 . Accessed 15 Sep 2024. Japan Society of Gynecologic and Obstetric Endoscopy and minimally Invasive Therapy. JSGOE Guidelines for Endoscopic surgery in Gynecology and Obstetrics 2024.Tokyo: kanehara-shuppan. Volume 36. CQ; 2024. pp. 216–20. (Japanese). Di Spiezio Sardo A, Calagna G, Guida M, Perino A, Nappi C. Hysteroscopy and treatment of uterine polyps. Best Pract Res Clin Obstet Gynaecol. 2015;29:908–19. Salim S, Won H, Nesbitt-Hawes E, Campbell N, Abbott J. Diagnosis and management of endometrial polyps: a critical review of the literature. J Minim Invasive Gynecol. 2011;18:569–81. Baikpour M, Hurd WW. Hysteroscopic endometrial polypectomy with manual vacuum aspiration compared to mechanical morcellation. J Minim Invasive Gynecol. 2019;26:1050–5. Gimpelson RJ, Rappold HO. A comparative study between panoramic hysteroscopy with directed biopsies and dilatation and curettage. A review of 276 cases. Am J Obstet Gynecol. 1988;158:489–92. Luerti M, Vitagliano A, Sardo AD, et al. Effectiveness of hysteroscopic techniques for endometrial polyp removal: The Italian multicenter trial. J Minim Invasive Gynecol. 2019;26:1169–76. Vitale SG, Haimovich S, Laganà AS, Alonso L, Di Spiezio Sardo A, Carugno J. From the Global Community of Hysteroscopy Guidelines Committee. Endometrial polyps. An evidence-based diagnosis and management guide. Eur J Obstet Gynecol Reprod Biol. 2021;260:70–7. Deans R, Abbott J. Review of intrauterine adhesions. J Minim Invasive Gynecol. 2010;17:555–69. Gilman Barber AR, Rhone SA, Fluker MR. Curettage and Asherman’s syndrome-lessons to (Re-) learn? J Obstet Gynaecol Can. 2014;36:997–1001. Azumaguchi A, Henmi H, Ohnishi H, Endo T, Saito T. Role of dilatation and curettage performed for spontaneous or induced abortion in the etiology of endometrial thinning. J Obstet Gynaecol Res. 2017;43:523–9. Akihiko M, Eizo K, Kazuki A, Tsushima K, Kiyono O, Atsushi S. Surgical resection of endometrial polyps using Manual vacuum aspiration. Tokyo J Obstet Gynecol. 2023;72:409–13. Uglietti A, Buggio L, Farella M, et al. The risk of malignancy in uterine polyps: a systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2019;237:48–56. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 22 Nov, 2025 Read the published version in BMC Women's Health → Version 1 posted Editorial decision: Revision requested 02 Sep, 2025 Reviews received at journal 02 Sep, 2025 Reviews received at journal 02 Sep, 2025 Reviews received at journal 02 Sep, 2025 Reviews received at journal 01 Sep, 2025 Reviewers agreed at journal 31 Aug, 2025 Reviewers agreed at journal 31 Aug, 2025 Reviewers agreed at journal 28 Aug, 2025 Reviewers agreed at journal 28 Aug, 2025 Reviewers agreed at journal 28 Aug, 2025 Reviews received at journal 28 Aug, 2025 Reviewers agreed at journal 27 Aug, 2025 Reviews received at journal 27 Aug, 2025 Reviewers agreed at journal 27 Aug, 2025 Reviews received at journal 26 Aug, 2025 Reviewers agreed at journal 26 Aug, 2025 Reviews received at journal 26 Aug, 2025 Reviewers agreed at journal 26 Aug, 2025 Reviewers agreed at journal 26 Aug, 2025 Reviews received at journal 15 Aug, 2025 Reviewers agreed at journal 15 Aug, 2025 Reviews received at journal 14 Aug, 2025 Reviewers agreed at journal 14 Aug, 2025 Reviewers invited by journal 13 Aug, 2025 Editor assigned by journal 13 Aug, 2025 Editor invited by journal 24 Jul, 2025 Submission checks completed at journal 23 Jul, 2025 First submitted to journal 23 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7183522","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":502150131,"identity":"68c0161a-8775-4c8e-bc69-1f45b1018161","order_by":0,"name":"Akihiko MISAWA","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9klEQVRIiWNgGAWjYDACHsYGIGnD2AbmsTHwgGkJwlrSYFoMiNECJg+DNYK0EHYXf8/hBqYbf87L9rGfPfiBoeyPDIN08wEGyx24tUicbWxgzuG5bdzGk5cswXAO6DCZYwkMkmfwWHOesf13jsTtxDaGHAMJxjagFokcAwbJNtw65M8zAm0xOJfYxv/G+AdES/4HvFoMwA5LOJDYJpFjBrOFAa8WwzMHgVoOJBu3Sbwxs0g4Z8zDJpFmcACfX+TOpD9gzvljJzu/P8f4xocyOXt+ieSHjyXxhBgqSGAAJQBgNEk2EKsFBhg/kqxlFIyCUTAKhjEAAAKESEOyuYHLAAAAAElFTkSuQmCC","orcid":"","institution":"Kyorin University Suginami Hospital","correspondingAuthor":true,"prefix":"","firstName":"Akihiko","middleName":"","lastName":"MISAWA","suffix":""},{"id":502150132,"identity":"58449704-9efd-47e3-a301-6d476d3b8761","order_by":1,"name":"Kiyono OSANAI","email":"","orcid":"","institution":"Kyorin University Suginami 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2","display":"","copyAsset":false,"role":"figure","size":1519729,"visible":true,"origin":"","legend":"\u003cp\u003eHysteroscopic (TCR)-visualized findings\u003c/p\u003e","description":"","filename":"FIG2opt.png","url":"https://assets-eu.researchsquare.com/files/rs-7183522/v1/c6a3ca4650f2b53d885e424b.png"},{"id":89592001,"identity":"9aa6b70e-252e-47b6-833a-e8f1df99871d","added_by":"auto","created_at":"2025-08-21 16:11:23","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1211752,"visible":true,"origin":"","legend":"\u003cp\u003eIncomplete resection cases (TVUS image and TCR-visual findings)\u003c/p\u003e","description":"","filename":"FIG3ver2.png","url":"https://assets-eu.researchsquare.com/files/rs-7183522/v1/3fe7ee64a27ed5859243bce9.png"},{"id":96650181,"identity":"fca83199-6c4d-447d-884f-ef1d2f4fe9ec","added_by":"auto","created_at":"2025-11-24 16:09:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4648109,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7183522/v1/f44298f2-1921-4d36-9728-b09ac2fc4330.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A safety and feasibility study of Manual Vacuum Aspiration for Endometrial Polyp- like Lesions; A case series","fulltext":[{"header":"Background","content":"\u003cp\u003eWith advances in ultrasound technology, it has become easier to visualize polypoid lesions within the uterine cavity. Endometrial polypoid lesions include endometrial polyps, submucosal fibroids, malignant tumors, and other endometrial abnormalities. Although ultrasound is a simple and convenient first-line diagnostic tool, it is difficult to differentiate and diagnose these conditions, and it does not provide a pathological diagnosis (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eEndometrial polyps can cause bleeding, infertility, and rarely, malignancy. The removal of polyps in infertile women improves pregnancy rates. Therefore, hysteroscopic surgery with a resectoscope is recommended for both diagnosis and treatment; however, blind dilation and curettage (D\u0026amp;C) is another technique that may be used (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWHO stated that traditional D\u0026amp;C should be avoided during miscarriage and abortion procedures to ensure safety and quality of care; vacuum aspiration is recommended instead (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Hysteroscopy with grasping forceps or resectoscope helps diagnose and treat endometrial polyps (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e); however, they are expensive and not readily available at every institutions.\u003c/p\u003e\u003cp\u003eWe hypothesized that if MVA alone can be used for the removal of endometrial polypoid lesions, it would offer a simple procedure similar to miscarriage management, while protecting the endometrium, and reducing the burden on patients. Therefore, we performed a clinical evaluation of safety and feasibility of MVA for removing endometrial polypoid lesions, with the use of a trans cervical resectoscope. In Japan, smaller-diameter hysteroscopes were only covered by the medical insurance treatment in 2024; therefore, they are neither used widely nor have been introduced at our hospital. Consequently, we utilized a resectoscope to ensure definitive lesion resection.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study included all patients who underwent transvaginal ultrasonography at our hospital and were suspected of having endometrial polypoid lesions between January 2021 to December 2021. The patients provided informed consent for the collection and removal of these lesions. This study was conducted with the approval of our hospital’s institutional review board (Approval No. 2020011).\u003c/p\u003e\u003cp\u003eFor preoperative preparation, a 3 mm polyvinyl alcohol cervical dilator (Lamicel, Medtronic Japan) was used. The MVA system (Women’s Health Japan) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) was used for manual vacuum aspiration. The procedure was done in the operating room under intravenous anesthesia managed by the anesthesiology department as follows:\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eBefore performing MVA, the uterine cavity was examined with a resectoscope (26Fr rigid hysteroscope, OES Pro Resectoscope, Olympus) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) to confirm the presence and status of polypoid lesions.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eThe endometrium, including the polypoid lesions, was aspirated with the MVA kit until no more tissue could be aspirated.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eA resectoscope was performed to detect any residual endometrial polyp tissue. Using resectoscope, remnant tissue was removed and any necessary hemostasis was performed.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eWe considered complete resection when no lesions were present after using the resectoscope; furthermore, we used ultrasound as an adjunct to confirm the thinning of the uterine cavity.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eThe removal specimens were submitted for pathological examination.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe evaluation criteria included the feasibility of lesion removal, the operability of the sampling instruments, patient pain and blood loss, the frequency of intraoperative and postoperative complications, such as uterine perforation, and a pathological assessment of the excised specimens.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 29 cases were included in this study. The average age of the patients was 40 years (\u0026plusmn;\u0026thinsp;8.9 SD). The primary complaints were bleeding in 15 cases, asymptomatic lesions detected during health check-ups in seven cases, infertility in six cases, and tamoxifen administration in one case. The average maximum diameter of the lesions diagnosed preoperatively by the ultrasound examination was 18.79 mm (\u0026plusmn;\u0026thinsp;9.872 SD). Polypoid lesions were found in all cases using a pre-MVA resectoscope. Complete resection was achieved in 25 cases, whereas 4 cases required resectoscopic removal (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of polypectomy using MVA in 29 patients\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCase No.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eOperative time (min)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003ePreoperative polyp size (TVUS)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eComplete resection case\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEndometrial polyp\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e45 (9.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e11.5 (4.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e17.2 (7.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEndometrial tissue\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e42(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8.5 (1.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e4.15 (1.10)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLeiomyoma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e46.0 (10.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e11.2 (3.99)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e15.9 (8.20)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eIncomplete resection case\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEndometrial polyp\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e46.7 (6.94)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e20.6 (5.56)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e41.3 (15.06)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAdenomyomatous polyp,\u003c/p\u003e\u003cp\u003eLeimoma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e37\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e46.6 (6.94)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e23.3 (6.57)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e40.25 (13.17)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cem\u003eTotal\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e29\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003e46.0 (10.0)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003e12.9(6.07)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003e4.1 (1.00)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003e(mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIn cases of complete resection, the number of aspirations with the MVA ranged from 1 to 3, and the tissue was collected using an 8 mm or 9 mm cannula. A resectoscopic examination before and after MVA confirmed complete removal without residual lesions (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). None of the cases required hemostasis during the procedure. Minimal postoperative bleeding was observed; however, during the follow-up visit approximately one week later, bleeding had ceased in all cases, and there was no retention within the uterus. For the cases with complete resection, the median surgical time was 11 minutes (\u0026plusmn;\u0026thinsp;3.9 SD), whereas it required 23 minutes (\u0026plusmn;\u0026thinsp;6.5 SD) for cases in which complete resection was not possible. Despite being diagnosed as endometrial polyps preoperatively, one patient presented with uterine fibroids, and three patients had larger lesions (41 mm\u0026thinsp;\u0026plusmn;\u0026thinsp;15 SD) that were not resectable (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eIncomplete resection cases\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCase\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePreoperation polyp size\u003c/p\u003e\u003cp\u003e(mm)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eOperation time\u003c/p\u003e\u003cp\u003e(min)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePathological diagnosis\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eIntraoperative blood loss\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eComplications\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eEndometrial polyp\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eLess than 5cc\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e(\u0026minus;)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eEndometrial polyp\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eLess than 5cc\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e(\u0026minus;)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eEndometrial polyp\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eLess than 5cc\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e(\u0026minus;)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAdenomyomatous polyp,\u003c/p\u003e\u003cp\u003eLeimoma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eLess than 5cc\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e(\u0026minus;)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eNormal menstruation was observed among the 23 patients who experienced menstrual cycles, and transvaginal ultrasonography demonstrated a normal endometrium. There were no indications of Asherman\u0026rsquo;s syndrome.\u003c/p\u003e\u003cp\u003eAll procedures were performed under intravenous anesthesia managed by the anesthesiology department, which ensured adequate pain control during the operation. No postoperative pain requiring analgesics was observed after the patients woke up from anesthesia.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eEndometrial polyps are benign tumors of the endometrium that can occur as single or multiple lesions, with a reported prevalence ranging from 7.9\u0026ndash;34.9% (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). They can be pedunculated or sessile, with single or multiple growths, and vary in size from a few millimeters to several centimeters (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Diagnostic methods include 2D or 3D ultrasonography, hysterosalpingography (HSG), sonohysterography, and hysteroscopy. Of these, ultrasonography is simple and noninvasive, but not specific to endometrial polyps, making it difficult to distinguish them from other endometrial abnormalities, such as submucosal fibroids; however, it cannot provide a pathological diagnosis. Therefore, hysteroscopic biopsy is considered the gold standard for diagnosis, although sonohysterography is considered a simpler diagnostic method with an accuracy comparable to that of hysteroscopy (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn the present study, we did not perform prior sonohysterography or hysterofiber for patients with endometrial polypoid lesions that were detected by transvaginal ultrasonography. Instead, we proceeded directly to hysteroscopy using a resectoscope for diagnosis and treatment. This approach enabled us to evaluate the uterine cavity and address any residual tissue or bleeding, while using MVA to remove and collect the endometrial tissue, including the polypoid lesions.\u003c/p\u003e\u003cp\u003eAccording to the 2024 guidelines of the Japan Society of Obstetrics and Gynecology Endoscopy, hysteroscopic surgery is recommended for endometrial polyps because of its superior outcomes in improving abnormal bleeding, pregnancy rates, and tissue diagnosis (Recommendation Level 2, Evidence Level C) (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). This recommendation is based on evidence that approximately 8% of endometrial polyps can be removed with endometrial curettage alone. Although the use of polyp forceps can increase the removal rate to 41%, it is less than 50%, which indicates that endometrial curettage is unsuitable when hysteroscopy is available (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eHysteroscopy for the removal of endometrial polyps has advanced with the use of smaller, higher-resolution fiber scopes, which enables the procedure to be performed on an outpatient basis without general anesthesia, thus reducing cost. However, the overall residual rate of polyps following hysteroscopic resection is 2.7%, whereas it increases to 16% with thinner scopes (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). In the present study, the residual rate was 4 out of 29 cases (13.8%), which is comparable with that of previous studies. All four cases involved lesions larger than 20 mm; thus, the size and thick stalks are too big for the polyps to fit into the MVA cannula.\u003c/p\u003e\u003cp\u003eAlthough this study involved inpatient procedures with general anesthesia because of the use of a resectoscope, outpatient MVA may be a simple and effective diagnostic technique for endometrial polypoid lesions identified by ultrasound. A PubMed search revealed only one report on the use of MVA for endometrial polyps, which similarly compared hysteroscopy plus MVA to hysteroscopic resection alone. They found MVA to be effective even for larger or multiple polyps, with comparable outcomes to hysteroscopic resection (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eEndometrial polyps are a known cause of infertility and 6\u0026ndash;32% of women undergoing hysteroscopy before IVF have them. Hysteroscopic polypectomy results in a pregnancy rate of over 63% (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Hysteroscopic surgery for endometrial polyps has a lower incidence of intrauterine adhesions compared with surgeries for fibroids or septa, and it is recommended for protecting the endometrium (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Although this study did not specifically examine infertility, MVA is also recommended for miscarriage procedures because of its protective effect on the endometrium with fewer complications.\u003c/p\u003e\u003cp\u003eFrom the endometrial preservation viewpoint, 1.2% of patients treated with D\u0026amp;C alone or with a combination of D\u0026amp;C and electric vacuum aspiration (EVA) developed Asherman\u0026rsquo;s syndrome. In contrast, a report indicated that there was no occurrence of Asherman\u0026rsquo;s syndrome in patients who underwent MVA (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMVA does not require the use of a curette, thereby reducing the risk of injuring the basal layer of the endometrium. Moreover, the plastic cannula used in MVA has an optimal balance of rigidity and flexibility, minimizing endometrial damage and thinning, thereby lowering the risk of Asherman\u0026rsquo;s syndrome (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eHerein, hysteroscopic examinations were not performed for the 23 patients who continued to menstruate; however, based on their menstrual cycles and ultrasound findings, no signs indicative of Asherman\u0026rsquo;s syndrome were observed.\u003c/p\u003e\u003cp\u003eAlthough no cases of malignancy were observed in this study, we previously encountered one case of atypical endometrial hyperplasia that was not diagnosed by ultrasound, but was detected and diagnosed by MVA (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The incidence of malignancy increases with age, particularly in postmenopausal women with bleeding, and the risk for these women was reported to be 4.93% and 5.14%, respectively (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Therefore, histological exclusion of malignancy is important, particularly for symptomatic or postmenopausal cases, and monitoring without intervention is not recommended, regardless of size.\u003c/p\u003e\u003cp\u003eOverall, MVA is a useful technique for the diagnosis and treatment of endometrial polypoid lesions. It enables the collection of sufficient tissue for pathological diagnosis, including coexistent malignancies.\u003c/p\u003e\u003cp\u003eIn this study, we completely removed endometrial polypoid lesions using MVA alone in 86.2% of the patients. The procedure was easy and safe to perform, suggesting that MVA should be considered a viable option for endometrial polypectomy. A key advantage is that complete removal can be achieved without the need to purchase new, expensive equipment. As MVA can be performed on an outpatient basis, we plan to accumulate further case evaluations to establish more precise criteria for lesion removal and potentially facilitate its transition into office gynecology settings in the future.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eD\u0026amp;C\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003edilation and curettage\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eEVA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eelectric vacuum aspiration\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMVA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003emanual vacuum aspiration\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by our hospital\u0026rsquo;s institutional review board on January 4, 2024 (approval number: 2020011). This study adhered to the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from all patients.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eA.M.: designed the study, performed the analyses, wrote the first draft of the manuscript, contributed to the interpretation of the results and critically revised the manuscript.K.O.: contributed to the interpretation of the results and critically revised the manuscript.N.F.: contributed to the interpretation of the results and critically revised the manuscript.K.A.: contributed to the interpretation of the results and critically revised the manuscript.Y.S.: contributed to the interpretation of the results and critically revised the manuscript.E.K.: contributed to the interpretation of the results, and critically revised the manuscript.A. S.: designed the study, contributed to the interpretation of the results, and critically revised the manuscript.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this published article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAmerican Association of Gynecologic Laparoscopists. AAGL practice report: practice guidelines for the diagnosis and management of endometrial polyps. J Minim Invasive Gynecol. 2012;19:3\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization: Abortion care guideline. 2022. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://iris.who.int/bitstream/handle/10665/349316/9789240039483-eng.pdf?sequence=1\u003c/span\u003e\u003cspan address=\"https://iris.who.int/bitstream/handle/10665/349316/9789240039483-eng.pdf?sequence=1\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 15 Sep 2024.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJapan Society of Gynecologic and Obstetric Endoscopy and minimally Invasive Therapy. JSGOE Guidelines for Endoscopic surgery in Gynecology and Obstetrics 2024.Tokyo: kanehara-shuppan. Volume 36. CQ; 2024. pp. 216\u0026ndash;20. (Japanese).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDi Spiezio Sardo A, Calagna G, Guida M, Perino A, Nappi C. Hysteroscopy and treatment of uterine polyps. Best Pract Res Clin Obstet Gynaecol. 2015;29:908\u0026ndash;19.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSalim S, Won H, Nesbitt-Hawes E, Campbell N, Abbott J. Diagnosis and management of endometrial polyps: a critical review of the literature. J Minim Invasive Gynecol. 2011;18:569\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBaikpour M, Hurd WW. Hysteroscopic endometrial polypectomy with manual vacuum aspiration compared to mechanical morcellation. J Minim Invasive Gynecol. 2019;26:1050\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGimpelson RJ, Rappold HO. A comparative study between panoramic hysteroscopy with directed biopsies and dilatation and curettage. A review of 276 cases. Am J Obstet Gynecol. 1988;158:489\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLuerti M, Vitagliano A, Sardo AD, et al. Effectiveness of hysteroscopic techniques for endometrial polyp removal: The Italian multicenter trial. J Minim Invasive Gynecol. 2019;26:1169\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVitale SG, Haimovich S, Lagan\u0026agrave; AS, Alonso L, Di Spiezio Sardo A, Carugno J. From the Global Community of Hysteroscopy Guidelines Committee. Endometrial polyps. An evidence-based diagnosis and management guide. Eur J Obstet Gynecol Reprod Biol. 2021;260:70\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDeans R, Abbott J. Review of intrauterine adhesions. J Minim Invasive Gynecol. 2010;17:555\u0026ndash;69.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGilman Barber AR, Rhone SA, Fluker MR. Curettage and Asherman\u0026rsquo;s syndrome-lessons to (Re-) learn? J Obstet Gynaecol Can. 2014;36:997\u0026ndash;1001.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAzumaguchi A, Henmi H, Ohnishi H, Endo T, Saito T. Role of dilatation and curettage performed for spontaneous or induced abortion in the etiology of endometrial thinning. J Obstet Gynaecol Res. 2017;43:523\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAkihiko M, Eizo K, Kazuki A, Tsushima K, Kiyono O, Atsushi S. Surgical resection of endometrial polyps using Manual vacuum aspiration. Tokyo J Obstet Gynecol. 2023;72:409\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eUglietti A, Buggio L, Farella M, et al. The risk of malignancy in uterine polyps: a systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2019;237:48\u0026ndash;56.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"endometrial polyps, manual vacuum aspiration, polypectomy, trans cervical resection","lastPublishedDoi":"10.21203/rs.3.rs-7183522/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7183522/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eStudy Objective:\u003c/strong\u003e We conducted a clinical evaluation of safety and feasibility of manual vacuum aspiration (MVA) for the removal of endometrial polyp-like lesions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDesign:\u003c/strong\u003e Prospective study (case series)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSetting and Participants:\u003c/strong\u003e This study included patients at our hospital who were suspected of having endometrial polypoid lesions based on ultrasound findings and who provided informed consent. Resectoscope (26Fr rigid hysteroscopy) was performed to examine the uterine cavity and identify polypoid lesions. The endometrial tissue, including polyp-like lesions, was aspirated using the MVA system, immediately followed by a resectoscope to detect any residual tissue. This study was conducted with the approval of the hospital’s institutional review board.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInterventions:\u003c/strong\u003e For each enrolled patient, clinical data were collected.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e A total of 29 patients were enrolled. Complete resection was achieved in 25 cases (86.2%), whereas 4 cases (13.8%) with larger lesions required resectoscope for complete removal. The number of aspirations in cases of complete resection ranged from 1 to 3, whereas no complications were observed. The lesions that could not be completely resected exceeded 20 mm in size and consisted of thick stalks.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e The use of MVA for the removal of endometrial polyp-like lesions is easy and safe, similar to its use in miscarriage and abortion procedures. Therefore, excluding particularly large polyps, MVA is a viable option for the removal of endometrial polyp-like lesions, without the need to purchase new, expensive equipment.\u003c/p\u003e","manuscriptTitle":"A safety and feasibility study of Manual Vacuum Aspiration for Endometrial Polyp- like Lesions; A case series","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-21 16:11:18","doi":"10.21203/rs.3.rs-7183522/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision 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