Remimazolam Versus Propofol During Hysteroscopy: A Systematic Review And Meta-Analysis of Nine Randomized Controlled Trials

Purpose To compare the efficacy and safety of remimazolam (RMZ) versus propofol during hysteroscopy.Methods A systematic review and meta-analysis synthesizing evidence from randomized controlled trials (RCTs) obtained from PubMed, Google Scholar, EMBASE, CENTRAL, Scopus, and Web of Science until February 2025. We pooled dichotomous outcomes and continuous outcomes using relative risk (RR) and standardized mean difference, respectively, with a 95% confidence interval (CI).Findings Nine RCTs and 1164 patients were included. RMZ was significantly associated with decreased incidence of injection pain (RR = 0.07; with 95% CI, [0.02, 0.20]; P = 0.001), hypotension (RR = 0.33; with 95% CI, [0.22, 0.50]; P = 0.001), and low SpO₂/respiratory depression (RR = 0.26; with 95% CI, [0.18, 0.38]; P = 0.001). However, RMZ was significantly associated with an increased incidence of hiccough (RR = 10.37; with 95% CI, [2.94, 36.62]; P = 0.001), with no significant difference between both groups regarding bradycardia (RR = 0.32; with 95% CI, [0.08, 1.18]; P = 0.09), and body movement (RR = 1.17; with 95% CI, [0.95, 1.44]; P = 0.15). Additionally, there was no significant difference between the 2 groups regarding sedation success (P = 0.83), recovery duration (P = 0.05), and total procedural duration (P = 0.07).Implications RMZ may provide a safer alternative to propofol during hysteroscopy, with similar procedural outcomes and fewer injection-related and cardiorespiratory adverse events.