Uterine manipulator in total laparoscopic hysterectomy: safety and usefulness

The aim of this review is to evaluate the effectiveness and safety of uterine manipulators in facilitating total laparoscopic hysterectomy (TLH). A literature search in MEDLINE, EMBASE, Cochrane Library, UpToDate, SpringerLink, ClinicalKey and Elsevier ScienceDirect databases was performed, and articles describing TLH with or without the use of uterine manipulators were retrieved. Complications related to the use of uterine manipulators are numerous, and although uterine manipulator seems to facilitate TLH, the procedure without a uterine manipulator seems to have a comparable safety and effectiveness, although evidence based on a direct comparison of the two approaches is limited without available controlled trials. Uterine manipulator may provide support in cases of large uteri, severe endometriosis, recto vaginal adhesions and regional anesthesia, while its use may increase complications in cases of vaginal stenosis and nulliparity. Therefore, to perform TLH, the surgeon should individualize for each case if uterine manipulator is needed and which manipulator best suits the surgical procedure requirements and case characteristics. Further studies comparing the two approaches are mandatory.