Remimazolam versus propofol for procedural sedation in hysteroscopic surgery: a meta-analysis of randomized controlled trials

Abstract

Procedural sedation is widely used to improve patient tolerability and satisfaction and minimize complications. Propofol is the most commonly used agent in procedural sedation, but its use is associated with a number of adverse effects. Remimazolam, which has a different mechanism of action compared to propofol, is a short-acting GABA-A receptor agonist. It is being increasingly used in procedural sedation. This meta-analysis aims to clarify the efficacy and safety of remimazolam versus propofol for procedural sedation in hysteroscopic surgery. We systematically searched studies published in PubMed, EMBASE, Web of Science, and the Cochrane Central Register of Controlled Trials from the inception of the databases to February 28, 2025, for randomized controlled trials (RCTs) comparing the effect of remimazolam and propofol in procedural sedation for hysteroscopic surgery. Seven RCTs (n = 664 patients) met our inclusion criteria. The pooled results showed that remimazolam significantly reduced the risk of injection pain, hypoxemia, and hypotension (all P < 0.0001) in hysteroscopic surgery, with a sedation success rate comparable to that of propofol (P = 0.05). There were no significant differences in the risks of postoperative dizziness, postoperative nausea and vomiting (PONV), or bradycardia. Findings from sensitivity analyses suggested a potentially higher risk of body movement with remimazolam. We conclude that the sedation success rate of remimazolam is non-inferior to that of propofol, and patients who receive remimazolam for hysteroscopy exhibit lower incidences of hypotension, hypoxemia, and injection pain than patients who receive propofol. Therefore, remimazolam represents a safer alternative to propofol for procedural sedation in hysteroscopic procedures, with a distinct safety profile. Nevertheless, its risk-benefit profile should be carefully evaluated in clinical practice.