Large uterus as a surgical challenge in robot-assisted vNOTES hysterectomy: a retrospective propensity score-matched...

To investigate how uterine weight influences perioperative outcomes in hysterectomy performed using robot-assisted vaginal natural orifice transluminal endoscopic surgery (RA-vNOTES). Between June 2019 and June 2025, RA-vNOTES hysterectomy cases from Baylor College of Medicine-affiliated hospitals in Houston, Texas, USA, were retrospectively analyzed. Patient characteristics and perioperative surgical outcomes were analyzed. Based on uterine weight, patients were divided into two cohorts. To control for confounding variables, propensity score matching (PSM) was performed. Of the 397 patients included, 324 had a uterine weight < 280 g, and 73 had a uterine weight > 280 g. PSM yielded a cohort of 132 patients, with 66 in each group. In the matched cohort, the group with uterine weight above 280 g showed significantly longer median total operative time (152 vs. 135 min), hysterectomy time (50 vs. 33 min), morcellation time (15 vs. 0 min), and higher blood loss (50 mL vs. 30 mL) than the group with uterine weight under 280 g. Same-day discharge and complication outcomes were similar across both patient groups. The total complication rate was 15.2% in the < 280 g group and 12.1% in the > 280 g group. No conversions occurred in either group. Despite the association between larger uterine weight and extended operative and hysterectomy times, RA-vNOTES hysterectomy demonstrates complication and conversion rates comparable to those observed in patients with smaller uteri. This supports its safety and feasibility as a surgical approach for patients with large uteri.