Robotic Versus Laparoscopic Hysterectomy for Extremely Large Uteri: A Systematic Review

Introduction: Hysterectomy for very large uteri is technically challenging and often requires open surgery. Minimally invasive approaches, such as robotic and laparoscopic techniques, provide alternatives, but their comparative safety and effectiveness for extremely large uteri remain uncertain. Methods: A systematic review was conducted following PRISMA 2020 guidelines. “PubMed and Scopus were searched through June 2025 using predefined keywords (e.g., ‘hysterectomy,’ ‘robotic,’ ‘robot-assisted,’ ‘laparoscopic,’ ‘uterus,’ ‘large,’ ‘enlarged,’ ‘size,’ ‘weight’); no prospective or randomized trials were identified.” for studies comparing robotic and laparoscopic hysterectomy in women with large or extremely large uteri Results: Robotic hysterectomy (RH) showed advantages in selected outcomes for extremely large uteri. One study reported a 70-minute reduction in operative time with RH for uteri >1000 g. RH was also associated with lower conversion rates (0–4.3%) compared to laparoscopic hysterectomy (LH) (5.3–10.9%). In moderately large uteri (~500–750 g), RH reduced hemoglobin drops but had longer operative times. Complication rates were generally low, although ureteral injury was more frequent with RH in two studies. Length of hospital stay was similar across approaches. Conclusion: Robotic hysterectomy may offer clinical and economic advantages over conventional laparoscopy for extremely large uteri but the impact of surgical experience should be carefully considered. Limitations include the retrospective design of all four cohorts, small sample sizes, the absence of randomized trials, and clinical and methodological heterogeneity precluding meta-analysis.