Complications of total laparoscopic hysterectomy: with vs. without a uterine manipulator

Uterine manipulators may decrease the incidence of complications associated with total laparoscopic hysterectomy (TLH), but contrary views exist regarding the use of uterine manipulators for TLH. There are insufficient data on the safety of TLH without a uterine manipulator in both benign and malignant cases. Data on the safety and outcomes of TLH performed without a uterine manipulator remain limited. While some studies have investigated this issue, direct comparisons between TLH with and without the use of a manipulator, particularly across both benign and malignant indications, are still relatively scarce.

The purpose of this study was to analyze the results and complications of TLH either with (group B) or without a uterine manipulator (group A), which was performed for benign and malignant indications.

A retrospective comparative study was conducted to evaluate the results of TLH with and without the use of a uterine manipulator. Group A included 138 patients, and Group B included 1300 patients. Patient characteristics, surgical indications, uterine weight, blood loss/transfusion, intraoperative urinary/intestinal complications, postoperative complications, and the rate of conversion to laparotomy were analyzed.

Patient characteristics and uterine weights were similar. There was a significant decrease in hemoglobin in group B (1.37 versus 1.52, p < 0.05). There was no significant difference in the transfusion rates between the two groups. The intraoperative complication rates were 4.3% in group A and 2.8% in group B (p > 0.05). After adjustment for malignant indication, group allocation was not significantly associated with intraoperative complications (OR = 0.57; 95% CI 0.23-1.42; p = 0.227). Rates of bladder, ureteral, and intestinal injuries were similar, although conversion to laparotomy was higher in group A (2.3% vs. 0%). Postoperative complication rates were also comparable between groups, and logistic regression showed no significant association after adjustment for malignancy (OR = 0.54; 95% CI 0.21-1.35; p = 0.184).

Our findings indicate that TLH without a uterine manipulator can be safely performed in selected patients. However, as the procedure is technically more demanding and evidence remains limited, further multicenter prospective studies are needed to validate these results and guide appropriate patient selection.

The study was conducted in accordance with the ethical standards set forth in the Declaration of Helsinki and approved by the Ethics Committee of Süleyman Demirel University (approval date: 08/06/2022, approval number: 12/165). Informed consent was obtained from the participants prior to participation.