Incidence and Prevention of Vaginal Cuff Dehiscence After Laparoscopic and Robotic Hysterectomy in Benign Conditions:...

Background and Objectives: Vaginal cuff dehiscence (VCD) represents a rare but relevant complication that occurs following minimally invasive hysterectomy. With the rising frequency of this procedure, it is crucial to continuously evaluate VCD incidence, risk factors, and prevention strategies. This systematic review and meta-analysis aimed to update the evidence on VCD incidence and to assess the role of various surgical techniques and materials adopted for vaginal cuff closure. Materials and Methods: A systematic literature search was conducted in PubMed, Scopus, Web of Science, EMBASE, and the Cochrane Library for studies published up to January 2025. Eligible studies reported VCD rates after laparoscopic or robotic hysterectomy for benign conditions and compared different closure techniques. The primary outcome was the incidence of VCD across closure methods, while secondary outcomes included potential risk factors. A random-effects model estimated pooled VCD rates with 95% confidence intervals (CI), and heterogeneity was assessed using I² tests. Results: Twenty-six studies involving 10,039 patients were analyzed. The overall pooled incidence of VCD was 0.7% (95% CI: 0.4-1.1%), with higher estimates in randomized controlled trials (RCTs) (1.4%) compared to non-RCTs (0.5%). Robotic-assisted hysterectomy had a pooled VCD rate of 1.7%, compared to laparoscopic hysterectomy at 0.7%. Although not statistically significant, transvaginal closure showed a higher VCD risk than laparoscopic closure (2.3% vs. 1.16%; OR 0.97, 95% CI, 0.33-2.82; OR 2.53 (95% CI, 1.10-5.82) when considering only RCTs), and barbed sutures showed a lower VCD incidence (0.35%) than conventional sutures (1.52%) (OR 0.37, 95% CI, 0.13-1.02). Smoking was identified as a significant risk factor for VCD, while the impact of early postoperative sexual activity remains inconclusive. Conclusions: Laparoscopic closure rather than transvaginal cuff closure and barbed sutures were neither significantly associated with reducing VCD risk. Emphasizing smoking cessation preoperatively is essential for VCD prevention. Future studies should investigate the effects of postoperative sexual activity and refine surgical techniques to minimize VCD risk and improve outcomes.