"Pure" robot simple hysterectomy with four arms and no uterine manipulator: a retrospective, non-blind, and non-randomized, comparative study

Abstract Nearly 20 years have passed since the introduction of robotic surgery for total hysterectomy, and its development has accelerated. However, its advantages over laparoscopic and open surgeries remain unclear, especially since some its drawbacks include the requirement of skilled assistants and the effective use of the robotic arms. We developed a robotic hysterectomy technique (pure robotic simple hysterectomy [PRSH]). PRSH uses four robotic arms without interference and does not require a uterine manipulator, thereby minimizing the number of assistants. However, intraoperative use of a uterine manipulator may be necessary in some cases. We retrospectively compared the characteristics and surgical outcome of patients who underwent PRSH (113 patients) or PRSH with a uterine manipulator (58 patients). Patients in the PRSH group were significantly older and had significantly higher BMI than those in the PRSH with a uterine manipulator group (48.4 ± 6.3 versus 46.0 ± 5.5, P = 0.02 and 24.4 ± 4.3 versus 26.0 ± 4.6, P = 0.03, respectively). There were no statistically significant differences between the two subgroups in terms of type of benign disease. We additionally investigated the factors that necessitated the intraoperative use of a uterine manipulator using multivariate logistic analysis. We found that in complex cases, such as endometriosis with suspected Pouch of Douglas obliteration (PRSH versus PRSH with a uterine manipulator: 1.8% versus 25.9%, P < 0.0001) and cervical and broad ligament fibroids, it was difficult to continue with the uterine manipulator-free technique, requiring the intraoperative addition of a uterine manipulator. We suggest that in such cases, assistants should be prepared preoperatively to regulate uterine manipulation.