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

"Pure" robot simple hysterectomy with four arms and no uterine manipulator: a retrospective, non-blind, and non-randomized, comparative study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article "Pure" robot simple hysterectomy with four arms and no uterine manipulator: a retrospective, non-blind, and non-randomized, comparative study Shogo Kawamura, Kuniaki Ota, Hitomi Fujiwara, Keiichiro Tasaka, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4418722/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version 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. Robotic simple hysterectomy Robot-assisted simple hysterectomy uterine manipulator da-Vinci Xi surgical system Pouch of Douglas obliteration assistant Figures Figure 1 Introduction Hysterectomy is the most frequent surgical procedure performed on women with uterine benign diseases such as uterine fibroids, adenomyosis, and prolapse, accounting for approximately 90% of hysterectomies, with millions of operations performed worldwide each year [ 1 ]. When there were no surgical robots, the laparoscopic approach was the only minimally invasive method. Its use, especially in complex cases, is limited by its rigorous learning curve and the need for sophisticated training and skills. Since the FDA approval of the da Vinci robot (Intuitive Surgical) in 2005, technological advances in robotic surgery for gynecologic diseases have significantly expanded the availability of robotic surgery. Increasing surgical experience and the availability of additional instrumentation have further facilitated the use of robotic devices [ 2 ]. Minimum invasive surgeries such as robotic surgery could be an advantageous modality to shorten admission terms, minimize the size of incisions, and lessen postoperative pain compared to laparotomy [ 3 ]. Remarkably, Robot-assisted laparoscopic hysterectomy is already the most common robotic surgery in gynecology and the second most common surgery performed after cesarean section in the United States[ 4 , 5 ]. Intuitive Surgical (Sunnyvale, CA, USA) remains the market leader, although other manufacturers are entering the surgical market. In 2014, the company replaced the da Vinci Si surgical system with the fourth-generation da Vinci Xi surgical system. The da Vinci Xi features an advanced scalable platform that enables the arms of the unit to move relative to the base. The da Vinci Xi allows surgeons to perform upper abdominal procedures, such as omentectomy, lymphadenectomy, or interdisciplinary surgery, without redocking because optics can be used in all four trocars [ 6 ]. However, the surgery was initially performed as a robot-assisted total hysterectomy (robot-assisted simple hysterectomy [RASH]) performed with one assist port and three robotic arms. da Vinci Xi has an improved interference between the arms compared to da Vinci Si, but the interference between the arms and the assistant has not be resolved, limiting the movement of the assisted forceps. da Vinci Xi is also limited in its uterine manipulation, not allowing the surgery to be performed as the surgeon intends. Therefore, the three-arm approach is mainly selected despite the multiple robotic arms in this newer surgical system. In addition, a three-arm approach is necessary to ensure the competency of the bedside assistant, who uses the assist port to handle procedures such as tissue traction, suction, irrigation, delivery of sutures, and exchanging instruments. This type of surgical setup may provide less autonomy to the console surgeon and result in greater dependence on the bedside surgical assistant. Therefore, the 4th arm is used instead of the assist port, which is why we developed pure robot simple hysterectomy (PRSH), in which all ports are operated by robotic arms. This technique takes advantage of the inherent characteristics of robotic surgery, where the surgeon is remotely located at a console away from the patient. PRSH does not use a uterine manipulator because the 4th arm regulates the position of the uterus. One of the greatest advantages of this method is that it does not require an assistant to regulate the uterine manipulator. There are cases in which the uterine manipulator must be used intraoperatively for PRSH, although the intraoperative addition of the uterine manipulator may elongate the operative time because of the rearrangement of all robotic arms. In addition, it is necessary to involve an assistant to regulate the manipulator during surgery, which creates human resource problems. Therefore, we believe that if we can predict which cases should have a manipulator placed preoperatively, we can prepare for RASH in these cases preoperatively. In this study, we introduced PRSH as a novel surgical technique, and the main objective was to analyze independent predictors of forced intraoperative manipulator use during PRSH using da Vinci Xi. Materials and Method Study design and data collection This study was reviewed and approved by the Human Research Ethics Committee of Kawasaki Medical School (trial registration no.: 5043-03). After institutional review board approval, this stadu was designed as a retrospective, non-blinded, non-randomized cohort study and reviewed all data from patients underwent PRSH between October 2020 and December 2022 at the Women's Medical Center, Kawasaki Medical School. Inclusion criteria included robotic hysterectomy for benign pathologies, including fibroids; adenomyosis; cervical diseases, such as high-grade cervical intraepithelial neoplasia; and endometrial diseases, such as typical endometrial hyperplasia, and all patients consented before the procedure was performed. Patients with indications of malignancy were excluded from this study. The robotic surgeries were performed by three skilled surgeons (Surgeons A, B, and C). Surgeon A was awarded a class B International license by The Japanese Society for Robotic Surgery and is a proctor in The Japan Society for Endoscopic Surgery and Intuitive Surgical; Surgeon B holds a class B domestic license from The Japanese Society for Robotic Surgery and is a proctor in Intuitive Surgical; and Surgeon C is a proctor in Intuitive Surgical. In each case, the bedside assistant was a gynecological resident who experienced robotic surgeries for at least 1 year (morer than 30 cases). We evaluated the differences between PRSH and PRSH with a uterine manipulator in terms of preoperative parameters (age, BMI, benign disease variation, prevalence of ovarian chocolate cysts, prevalence of Pouch of Douglas obliteration, and history of abdominal surgery), operative markers [estimated blood loss, operating time defined as the time from skin incision to skin closure for PRSH, and concomitant procedures], and postoperative outcomes (uterine volume excised). Surgical procedure Under general anesthesia, the patient was positioned lithotomy position with the Trendelenburg position. All robotic procedures were performed using the four-arm da Vinci Xi surgical system (Intuitive Surgical Inc., Sunnyvale, California, USA) (Fig. 1 a). First, the trocar was inserted 3 cm above the umbilicus as an 8 mm endoscope port, using the direct closed method, and pneumoperitoneum was performed. After pneumoperitoneum was established, trocars were inserted under visual control: three 8-mm robotic ports on the same horizontal line spaced 8 cm apart at the level of the endoscope port. The 2nd arm was used to insert the endoscope, and the fenestrated bipolar forceps in the 1st arm and Maryland bipolar forceps in the 3rd arm were operated using the double bipolar method previously described (Fig. 1 b) [ 7 ]. In this technique, the uterine manipulator is not used because the Cadiere forceps in the 4th arm manipulates the uterus (Fig. 1 c, d, Video1). For suturing, the 3rd arm was equipped with SutureCut needle driver from Maryland bipolar forceps, which enabled suturing and thread cutting. Probe Plus II (Ethicon, Tokyo, Japan) for suction and intra-abdominal transport of the needle was introduced into the abdominal cavity by pulling out the instrument in the 3rd arm (Video 2). The needle was also changed from CT-1 needle (Ethicon, Tokyo, Japan) to CT-2 needle (Ethicon, Tokyo, Japan) for No.0 Bicryl ® (Ethicon, Tokyo, Japan) and from CT-X needle (Ethicon, Tokyo, Japan) to TE needle (Ethicon, Tokyo, Japan) for 2 − 0 Bicryl ® (Ethicon, Tokyo, Japan), adjusting the curve and size of the needle. Hence, since all robotic arms are used for all ports, we named this technique " pure " robot simple hysterectomy (Fig. 1 d). However, when the uterus cannot be tractioned with the Cadiere forceps or when the bowel must be tractioned toward the head with the forceps, a uterine manipulator must be inserted for a clear surgical view. Simple hysterectomy was performed as described previously [ 8 ]. Briefly, all surgeries were performed according to our standard operating procedure for conventional robotic simple hysterectomy. We started by transecting the round ligament and dissecting the broad ligament anteriorly and posteriorly using the double bipolar method with the Maryland bipolar forceps hand and fenestrated bipolar forceps. Extra-adnexal hysterectomy was not performed in premenopausal women. The bladder was dissected from the proximal vagina. Subsequently, the cystouterine fossa peritoneum was incised and expanded, and the ureter and uterine artery, including the ureteral tunnel as the point of ureter-uterine artery crossover, were identified. Only the uterine artery was ligated at two points with 2 − 0 Vicryl, coagulated with fenestrated bipolar forceps, and transected using Maryland bipolar forceps. The ascending branches of the uterine vessels were ligated at two points with C 2 − 0 Vicryl (Ethicon, Tokyo, Japan), coagulated via electrocautery using the fenestrated bipolar forceps, and transected using Maryland bipolar forceps. After transecting the cardinal ligaments, colpotomy was performed using Maryland bipolar forceps, and the uterus was extracted vaginally. Large uteri were cut into extractable parts using a knife and removed vaginally. Vaginal cuff closure was performed using interrupted 0-Vicryl sutures (Ethicon, Tokyo, Japan). The PRSH technique is summarized in a video clip (Video 3). Statistical analysis Statistical analyses were performed using EZR (Saitama Medical Center, Jichi Medical University, Saitama, Japan), a graphical user interface for R (The R Foundation for Statistical Computing, Vienna, Austria) [ 9 ]. The one-sample Kolmogorov–Smirnov test was used to test the normal distribution of quantitative data. Variables are presented as mean ± standard deviation, and categorical variables are described as frequency and percentage and compared between the groups using the χ 2 test or Fisher's exact test, as appropriate. Multiple logistic regression analyses were performed to investigate potential influencing factors to evaluate PRSH with a uterine manipulator, employing a forward stepwise methodology to identify independent predictive factors. Specifically, odds ratios (ORs) and 95% confidence intervals (CIs) were calculated in the multivariate analyses, controlling for potential confounders such as age, BMI, surgeons, operating time, and blood loss. Statistical significance was set at P < 0.05. Results The characteristics of the patients who underwent PRSH (113 patients) or PRSH with a uterine manipulator (58 patients) are summarized in Table 1 . Patients in the PRSH group were significantly older than those in the PRSH with a uterine manipulator group (48.4 ± 6.3 versus 46.0 ± 5.5, P = 0.02) and BMI was significantly higher in the PRSH group (24.4 ± 4.3 versus 26.0 ± 4.6, P = 0.03). There were no statistically significant differences between the two subgroups in terms of the type of benign disease (fibroids, adenomyosis, cervical diseases, and endometrial diseases: 0.87, 1.00, 1.00, and 0.67, respectively). The prevalence of ovarian chocolate cysts and Pouch of Douglas obliteration were significantly lower in PRSH than in PRSH with a uterine manipulator (3.5% versus 22.4%, P = 0.0002 and 1.8% versus 25.9%, P < 0.0001, respectively). There was no significant difference in the history of abdominal surgery between the two groups (6.2% versus 8.6%, P = 0.544). Table 1 Characteristics of patients in the PRSH and PRSH with a uterine manipulator groups PRSH PRSH with the uterine manupulator P value Number 113 58 Age 48.4 ± 6.3 46.0 ± 5.5 0.02 BMI 24.4 ± 4.3 26.0 ± 4.6 0.03 Benign disease Fibroids (%) 73(64.6%) 39(67.2%) 0.87 Adenomyosis (%) 32(28.3%) 16(27.6%) 1.00 Cervical disease (%) 3(2.7%) 2(3.4%) 1.00 Endometrial disease (%) 5(4.4%) 1(1.7%) 0.67 Ovarian chocolate cyst (%) 4(3.5%) 13(22.4%) 0.0002 Pouch of Douglas obliteration (%) 2(1.8%) 15(25.9%) P < 0.0001 The history of abdominal surgery (%) 7(6.2%) 5(8.6%) 0.544 PRSH: pure robotic simple hysterectomy, BMI: body mass index The surgical outcomes of PRSH and PRSH with a uterine manipulator are summarized in Table 2 . Operating time was significantly shorter in PRSH than in PRSH with a uterine manupulator (126.0 ± 23.0 versus 153.5 ± 31.3, P < 0.001). Both blood loss and uterine volume were not significantly different between PRSH and PRSH with a uterine manipulator (44.2 ± 56.5 versus 48.9 ± 45.4, P = 0.6; 236.2 ± 172.0 versus 258.0 ± 152.3, P = 0.89, respectively). Regarding console surgeons, there was a significant difference in surgeons A and B between PRSH and PRSH with a uterine manipulator. Therefore, we considered console surgeon as a confounding factor for adjustment in the multivariate logistic regression analysis. Table 2 Surgical outcomes of PRSH and PRSH with a uterine manipulator PRSH (n = 113) PRSH with a uterine manipulator (n = 58) P value Operating time (minutes) 126.0 ± 23.0 153.5 ± 31.3 P < 0.001 Blood loss (mL) 44.2 ± 56.5 48.9 ± 45.4 0.6 Uterine volume (g) 236.2 ± 172.0 258.0 ± 152.3 0.89 Console Surgeons A 44(38.9%) 38(65.5%) 0.001 B 55(48.7%) 17(3.4%) 0.02 C 14(12.4%) 3(5.2%) 0.18 PRSH: pure robotic simple hysterectomy Surgeon A holds a class B International license from The Japanese Society for Robotic Surgery and is a proctor in The Japan Society for Endoscopic Surgery and Intuitive Surgical; Surgeon B holds a class B domestic license from The Japanese Society for Robotic Surgery and is a proctor in Intuitive Surgical; and Surgeon C is a proctor in Intuitive Surgical. In univariate analysis, we found that major Low Anterior Resection Syndrome was significantly associated with the prevalence of ovarian chocolate cysts and Pouch of Douglas obliteration. Multivariate logistic analysis further showed that fibroids [odds ratio (OR): 23.0, 95% confidence interval (CI) 2.26–235.0, P = 0.008], adenomyosis (OR: 12.1, 95% CI 1.18–124.0, P = 0.04), ovarian chocolate cysts (OR:6.63, 95% CI 1.13–38.7, P = 0.04), and Pouch of Douglas obliteration (OR: 18.1, 95% CI 2.55–128.0, P = 0.004) were independent predictors of PRSH with a uterine manupulator (Table 3). Table.3 Univariate and multivariate analyses of PRSH with a uterine manipulator Crude OR 95% CI P value Adjusted OR* 95% CI P value Fibroids 5.14 0.797-33.1 0.085 23.0 2.26-235.0 0.008 Adenomyosis 3.11 0.464-20.8 0.242 12.1 1.18-124.0 0.04 Ovarian chocolate cyst 8.07 1.80-36.3 0.006 6.63 1.13-38.7 0.04 Pouch of Douglas obliteration 16.5 2.94-92.1 0.001 18.1 2.55-128.0 0.004 History of abdominal surgery 1.01 0.224-4.51 0.995 0.493 0.07-3.24 0.46 Uterine volume 0.999 0.9996-1.00 0.517 0.997 0.994-1.00 0.08 * adjusted for age, BMI, surgeon, operating time, and blood loss OR, odds ratio; CI, confidence interval. Discussion One benefit of robotic surgery may be improved ergonomics for the operating surgeon. For the console surgeon, ergonomic benefits have been studied in terms of improved visualization, posture, and manipulation [ 10 ]. However, collisions can occur between robotic arms, stopping the surgery [ 11 ]. Hence, three of the four robotic arms are typically used, which is very stressful for the console surgeon. In particular, in cases where a uterine manipulator cannot be inserted, hysterectomy must be performed with only three robotic arms. However, because one arm is used for the camera port, two robotic arms are used for the surgery, which increases the surgical difficulty. Recently, a few reports have indicated that adding a 4th robotic arm to the standard 3-port setup may be an easy solution with great outcomes [ 12 , 13 ], although there is no established evidence for this technique. In this study, we demonstrated the feasibility of PRSH, which uses four robotic arms to perform a hysterectomy without the requirement of a uterine manipulator. However, since PRSH was not successful in all patients and resulted in the intraoperative use of a uterine manipulator, we analyzed strong predictors of PRSH incompletion without a uterine manipulator and found fibroids, endometriosis including adenomyosis and ovarian chocolate cysts, and Pouch of Douglas obliteration. Several studies have highlighted the importance of uterine manipulators in reducing complications during hysterectomy [ 14 , 15 ]. In particular, a uterine manipulator elevates the uterus, exposing the cul-de-sac to prevent bowel injury, especially in cases of endometriosis complicated by Pouch of Douglas obliteration. In the case of Pouch of Douglas obliteration, the Cadiere forceps in the 4th arm pulled the rectum toward the head, and the uterine manipulator firmly elevated the uterus, which released the Pouch of Douglas. In addition, the difficulty of a hysterectomy depends on the site of fibroid development, with cervical and broad ligament fibroids relatively increasing surgical difficulty [ 16 ]. Therefore, we added a subanalysis involving the site of fibroid development and found that cervical and broad ligament fibroids were a stronger predictor of the need to use a uterine manipulator than intramural fibroids (OR: 12.1, 95% CI 1.18–124.0, P = 0.04) (Supplemental Table 1). Based on this study, we have decided that in future cases of endometriosis with suspected Pouch of Douglas obliteration and those of cervical or intramural fibroids, we would preoperatively prepare additional assistants and use a manipulator during PRSH. Conventionally, RASH uses three robotic arms and an assistant port operated by an assistant. However, there are cases in which the assistant's grasp and grip of tissue using forceps makes it difficult to achieve the console surgeon's desired surgical field due to forceps angle problems and interference with the robotic arms. It is concerning that the the positions of the robot and assistant ports may affect the ergonomics of the assistants. van’t Hullenaa et al. reported that the position of the assistant port too close to the position of the robot ports may worsen surgical performances because of limitations for the assistant's workspace and non-ergonomic twisting and bending at the wrist and elbow [ 17 ]. To solve those problems, there are ways to improve the ergonomics of the assistant to increase additional access by adding more ports, two assistants at two different positions, or using more robotic arms. However, increasing the number of ports increases patient invasiveness, and increasing the number of assistants increases the requirement of valuable human resources. Recently, some investigators reported that using an additional robotic arm, that is, changing from three to four robotic arms, may result in less reliance on an assistant, without compromising patient outcomes since the da Vinci Xi platform reduces robotic arm collisions through an easy port configuration and port exchange flexibility [ 12 , 18 ]. However, several studies have suggested that the combined presence of experienced console surgeons and a well-trained assistant makes it unnecessary to use the 4th arm [ 19 , 20 ], and adding a 4th arm means higher costs for the hospital [ 21 ]. However, considering the time required to train an assistant as well as the cost of hiring an assistant, we believe that adding a 4th arm would be more cost-effective. In fact, we have been more successful in training senior residents as console surgeons than as assistants. This has increased the number of robotic surgeries performed in our hospital. Furthermore, the fact that the surgical outcomes of PRSH are comparable to those of RASH is a reason to promote PRSH. Our study had several limitations. First, tthe data may have incomplete information that was not full-filled in the patient record because of the retrospective nature of the study, which limits the generalizability of our findings. Second, three surgeons from our robotic surgical team performed the surgeries. Although most surgeons in the team were trained at the same institution, biases resulting from individual surgeon differences cannot be excluded. Moreover, the most proficient surgeon (Surgeon A) required a uterine manipulator for PRSH, which may have resulted in an unbalanced distribution of surgical difficulty and may have impacted the statistical analysis. Third, we could not directly compare PRSH with RASH because the number of patients who underwent RASH in our hospital was small. Furthermore, a multicenter comparative study of RASH and PRSH is required to demonstrate the superiority of PRSH. The study’s main strength is its description of a 4-arm approach to hysterectomy using da Vinci Xi without a uterine manipulator, which enabled minimal dependence on an assistant. Although previous reports have shown the superiority of a 4-arm hysterectomy approach for malignant gynecological diseases[ 12 ], this is the first study to demonstrate the superiority of this hysterectomy approach for benign gynecological diseases. Furthermore, this report seems worthwhile because pelvic occupying diseases, such as enlarged uterine fibroids, are more difficult to treat robotically than with radical total hysterectomy. In conclusion, the routine use of a fourth robotic arm during PRSH provides the operating surgeon with greater independence during critical phases of the procedure without the requirement of a uterine manipulator and assistant. This advantage translates into non-dependence on an assistant and the conservation of human resources. In addition, this study confirmed the feasibility and safety of robotic surgery for benign hysterectomy even in “complex cases, ” including those of endometriosis with suspected Pouch of Douglas obliteration and those of cervical and broad ligament fibroids, with surgeons preparing to use a uterine manipulator and adding an assistant preoperatively. Although we reanalyzed the cost-benefit of the system and the impact on surgical training, we need further research to establish the superiority of the 4-arm system over the 3-arm system. Declarations Funding Not applicable Competing Interests The authors have no relevant financial or non-financial interests to disclose. Author Contributions Study concepts: Y.O. and S.K. and M.S., Study design: K.S. and T.T., Data acquisition: H.F., K.T., H.O., Y.M.. and W.S., Data analysis and interpretation: S.S.and H.K., Statistical analysis: K.O.and T.T., Manuscript preparation: S.K, and K.O., Manuscript editing: Y.O., Manuscript review: E.K., T.T., M.S., and K.S. Ethics approval This study was reviewed and approved by the Human Research Ethics Committee of Kawasaki Medical School (trial registration no.: 5043-03). Consent to participate Written informed consent was obtained from all individual participants included in the study and their parents. Consent to publish Patients signed informed consent regarding publishing their data Acknowledgments We would like to thank all the staff in the operating room at Kawasaki Medical School and all the nurses who cared for our post-operative patients. We are also very grateful to M.S. Yoshimi Harada, secretary of the Department of Obstetrics and Gynecology at Kawasaki Medical School. References Garry R. Health economics of hysterectomy. Best practice & research Clinical obstetrics & gynaecology. 2005;19:451–465. Advincula AP, Song A. The role of robotic surgery in gynecology. Current Opinion in Obstetrics and Gynecology. 2007;19:331–336. Settnes A, Topsoee MF, Moeller C, et al. Reduced complications following implementation of laparoscopic hysterectomy: a Danish population-based cohort study of minimally invasive benign gynecologic surgery between 2004 and 2018. Journal of minimally invasive gynecology. 2020;27:1344–1353. e1343. Cohen SL, Ajao MO, Clark NV, Vitonis AF, Einarsson JI. Outpatient hysterectomy volume in the United States. Obstetrics & Gynecology. 2017;130:130–137. Gitas G, Alkatout I, Mettler L, et al. Incidence of unexpected uterine malignancies after electromechanical power morcellation: a retrospective multicenter analysis in Germany. Archives of Gynecology and Obstetrics. 2020;302:447–453. van der Schans EM, Hiep MAJ, Consten ECJ, Broeders IAMJ. From Da Vinci Si to Da Vinci Xi: realistic times in draping and docking the robot. Journal of Robotic Surgery. 2020;14:835–839. Katsuno H, Hanai T, Endo T, Morise Z, Uyama I. The double bipolar method for robotic total mesorectal excision in patients with rectal cancer. Surgery Today. 2022;52:978–985. Ota Y, Ota K, Takahashi T, Suzuki S, Sano R, Shiota M. Robotic-assisted Total Hysterectomy with Low Pneumoperitoneal Pressure (6 mmHg) and Use of Surgical Plume Evacuator System to Minimize Potential Airborne Particles According to the Joint Statement on Minimally Invasive Gynecologic Surgery during the COVID-19 Pandemic: A Case Report from Japan. Gynecol Minim Invasive Ther. 2022;11:127–130. Kanda Y. Investigation of the freely available easy-to-use software ‘EZR’for medical statistics. Bone marrow transplantation. 2013;48:452–458. Corman ML, Corman ML. Colon and rectal surgery : Lippincott Williams & Wilkins Philadelphia; 2005. Wong SW, Ang ZH, Crowe P. Improving ergonomics for the bedside assistant in robotic colorectal surgery. J Surg Case Rep. 2023;2023:rjad007. Yim GW, Eoh KJ, Chung YS, et al. Perioperative Outcomes of 3-Arm Versus 4-Arm Robotic Radical Hysterectomy in Patients with Cervical Cancer. Journal of Minimally Invasive Gynecology. 2018;25:823–831. Barger A, Haworth L, Bennett M, Hudgens J, Woo J. The 4th arm solution: an easy answer to the robotic hysterectomy without a uterine manipulator. American Journal of Obstetrics & Gynecology. 2024;230:S1296. Abdel Khalek Y, Bitar R, Christoforou C, et al. Uterine manipulator in total laparoscopic hysterectomy: safety and usefulness. Updates in Surgery. 2020;72:1247–1254. van den Haak L, Alleblas C, Nieboer TE, Rhemrev JP, Jansen FW. Efficacy and safety of uterine manipulators in laparoscopic surgery: a review. Archives of Gynecology and Obstetrics. 2015;292:1003–1011. Hiramatsu Y. Hysterectomy for cervical and intraligamental fibroids. The Surgery Journal. 2020;6:S2-S10. van’t Hullenaar CD, Bos P, Broeders IA. Ergonomic assessment of the first assistant during robot-assisted surgery. Journal of robotic surgery. 2019;13:283–288. El-Asmar JM, Sebaaly R, Mailhac A, et al. Use of bariatric ports in 4-arm robotic partial nephrectomy: a comparative study with the standard 3-arm technique. Cureus. 2021;13. Feliciano J, Stifelman M. Robotic retroperitoneal partial nephrectomy: a four-arm approach. JSLS: Journal of the Society of Laparoendoscopic Surgeons. 2012;16:208. Rogers CG, Laungani R, Bhandari A, et al. Maximizing console surgeon independence during robot-assisted renal surgery by using the fourth arm and tilepro™. Journal of endourology. 2009;23:115–122. Johnson BA, Crivelli J, Sorokin I, Gahan J, Cadeddu JA. Surgical outcomes of three vs four arm robotic partial nephrectomy: is the fourth arm necessary? Urology. 2019;123:140–145. Additional Declarations No competing interests reported. Supplementary Files PureRSHSupplementalTableSubmitted.docx Video1.mp4 video.mp4 Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4418722","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":306133847,"identity":"9e02aed7-7703-46b2-8b35-aafe6bdb4f76","order_by":0,"name":"Shogo Kawamura","email":"","orcid":"","institution":"Kawasaki Medical School","correspondingAuthor":false,"prefix":"","firstName":"Shogo","middleName":"","lastName":"Kawamura","suffix":""},{"id":306133850,"identity":"9bb88b39-3ba1-4e8d-84b9-e8c8f5d3362d","order_by":1,"name":"Kuniaki Ota","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA30lEQVRIie3RMQrCMBSA4UAhXR50fdLSMxQKRXDwKorglHgC6ehUdPUYTp1TinXpAbILDtJBKYiDiImTUxs3wfwQkkA+SAghNtsPhmoIIvTkCL0PzAkQOtF7MCIaKQKRXvaTwZYX4l4Pw7Fbt2e5HAJxy/2ui/i4mBSZxBiA5yNWqYvBfC67SIgsEnDBaUZ4HjOqCELSS4qHJl5zitnTgPiKlCAVQeYc+cqADLImKoNavUWeEoevEWjfW/DA4mtTpaG7mR1bdktDzy2rTvIZfX8SNT2ucy7fnLbZbLb/6QUQq0ZkLuM4bgAAAABJRU5ErkJggg==","orcid":"","institution":"Kawasaki Medical School","correspondingAuthor":true,"prefix":"","firstName":"Kuniaki","middleName":"","lastName":"Ota","suffix":""},{"id":306133852,"identity":"c31c3e19-45f0-47d3-8846-9b100a3dacde","order_by":2,"name":"Hitomi Fujiwara","email":"","orcid":"","institution":"Kawasaki Medical School","correspondingAuthor":false,"prefix":"","firstName":"Hitomi","middleName":"","lastName":"Fujiwara","suffix":""},{"id":306133854,"identity":"88ffa43f-98f7-49af-95a5-d2186ec5d625","order_by":3,"name":"Keiichiro Tasaka","email":"","orcid":"","institution":"Kawasaki Medical School","correspondingAuthor":false,"prefix":"","firstName":"Keiichiro","middleName":"","lastName":"Tasaka","suffix":""},{"id":306133855,"identity":"85306849-28ad-4753-a19b-e4ac5bc08371","order_by":4,"name":"Hana Okamoto","email":"","orcid":"","institution":"Kawasaki Medical School","correspondingAuthor":false,"prefix":"","firstName":"Hana","middleName":"","lastName":"Okamoto","suffix":""},{"id":306133857,"identity":"c3e3fd37-a655-4c61-abd9-5c4c326d27a9","order_by":5,"name":"Yumiko Morimoto","email":"","orcid":"","institution":"Kawasaki Medical School","correspondingAuthor":false,"prefix":"","firstName":"Yumiko","middleName":"","lastName":"Morimoto","suffix":""},{"id":306133858,"identity":"b706b2c6-e6df-4e11-b87f-1d21a2190ade","order_by":6,"name":"Wataru Saito","email":"","orcid":"","institution":"Kawasaki Medical School","correspondingAuthor":false,"prefix":"","firstName":"Wataru","middleName":"","lastName":"Saito","suffix":""},{"id":306133860,"identity":"54269f9d-126a-4d53-9145-9125f2d7aa56","order_by":7,"name":"Sayaka Sugihara","email":"","orcid":"","institution":"Kawasaki Medical School","correspondingAuthor":false,"prefix":"","firstName":"Sayaka","middleName":"","lastName":"Sugihara","suffix":""},{"id":306133861,"identity":"8b64c72a-fe5c-47f3-aa22-484ca7c57d87","order_by":8,"name":"Eiji Koike","email":"","orcid":"","institution":"Koike Hospital","correspondingAuthor":false,"prefix":"","firstName":"Eiji","middleName":"","lastName":"Koike","suffix":""},{"id":306133863,"identity":"fd70707b-a231-4ddc-bfc5-0f2eaa167f01","order_by":9,"name":"Toshifumi Takahashi","email":"","orcid":"","institution":"Fukushima Medical University","correspondingAuthor":false,"prefix":"","firstName":"Toshifumi","middleName":"","lastName":"Takahashi","suffix":""},{"id":306133865,"identity":"65cc89b2-8402-4f6b-b167-4392eb1c66d3","order_by":10,"name":"Mitsuru Shiota","email":"","orcid":"","institution":"Kawasaki Medical School","correspondingAuthor":false,"prefix":"","firstName":"Mitsuru","middleName":"","lastName":"Shiota","suffix":""},{"id":306133868,"identity":"fef2063b-4014-4c67-b3af-c8809ca366be","order_by":11,"name":"Koichiro Shimoya","email":"","orcid":"","institution":"Kawasaki Medical School","correspondingAuthor":false,"prefix":"","firstName":"Koichiro","middleName":"","lastName":"Shimoya","suffix":""},{"id":306133869,"identity":"b45123a4-f49b-4552-893b-8df5f9c5ba89","order_by":12,"name":"Yoshiaki Ota","email":"","orcid":"","institution":"Kawasaki Medical School","correspondingAuthor":false,"prefix":"","firstName":"Yoshiaki","middleName":"","lastName":"Ota","suffix":""}],"badges":[],"createdAt":"2024-05-14 11:11:55","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4418722/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4418722/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":57442750,"identity":"4311d3bf-27d7-4762-bb50-fa5dbb7162a8","added_by":"auto","created_at":"2024-05-30 18:48:16","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":2178853,"visible":true,"origin":"","legend":"\u003cp\u003e(a) The robotic 4-arm da Vinci Xi surgical system: the 1st to 4th arms are named from right to left. (b) Cadiere forceps are used to manipulate the uterus. Instead of a uterine manipulator, Cadiere forceps pulls the round ligament to the right cranial side, facilitating approach to the left (white arrow). (C) This forceps is also used to pull the round ligament to the left cranial side, facilitating approach to the right (black arrow). (d) \"\u003cem\u003epure\u003c/em\u003e\" robot simple hysterectomy means that the 1st arm is used with the fenestrated bipolar forceps, the 2nd arm is used to insert the endoscope, the 3rd arm is used to handle Maryland bipolar forceps, and the 4th arm is used to handle Cadiere forceps.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4418722/v1/1f5e5a082557288339cc5ef7.png"},{"id":57444709,"identity":"d161955b-8f94-4e80-a3b4-4156aee4cece","added_by":"auto","created_at":"2024-05-30 19:04:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4682877,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4418722/v1/7061873b-1d1e-499f-8f66-176fc533f0e5.pdf"},{"id":57442751,"identity":"ddc22a87-4ca5-4a1c-aa42-8f1d94af9513","added_by":"auto","created_at":"2024-05-30 18:48:16","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":16294,"visible":true,"origin":"","legend":"","description":"","filename":"PureRSHSupplementalTableSubmitted.docx","url":"https://assets-eu.researchsquare.com/files/rs-4418722/v1/204d7a218b19cad0284c1d28.docx"},{"id":57442753,"identity":"2abe6250-6ce8-435f-ae48-7f04bb5b3f56","added_by":"auto","created_at":"2024-05-30 18:48:17","extension":"mp4","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":5774894,"visible":true,"origin":"","legend":"","description":"","filename":"Video1.mp4","url":"https://assets-eu.researchsquare.com/files/rs-4418722/v1/023240093fef54705ddee2d9.mp4"},{"id":57442752,"identity":"a43f85b5-c23a-4243-ae36-9e97b45771c5","added_by":"auto","created_at":"2024-05-30 18:48:16","extension":"mp4","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":20537998,"visible":true,"origin":"","legend":"","description":"","filename":"video.mp4","url":"https://assets-eu.researchsquare.com/files/rs-4418722/v1/e9c99e12d8b4f24dd3403d3b.mp4"}],"financialInterests":"No competing interests reported.","formattedTitle":"\"Pure\" robot simple hysterectomy with four arms and no uterine manipulator: a retrospective, non-blind, and non-randomized, comparative study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHysterectomy is the most frequent surgical procedure performed on women with uterine benign diseases such as uterine fibroids, adenomyosis, and prolapse, accounting for approximately 90% of hysterectomies, with millions of operations performed worldwide each year [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. When there were no surgical robots, the laparoscopic approach was the only minimally invasive method. Its use, especially in complex cases, is limited by its rigorous learning curve and the need for sophisticated training and skills. Since the FDA approval of the da Vinci robot (Intuitive Surgical) in 2005, technological advances in robotic surgery for gynecologic diseases have significantly expanded the availability of robotic surgery. Increasing surgical experience and the availability of additional instrumentation have further facilitated the use of robotic devices [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Minimum invasive surgeries such as robotic surgery could be an advantageous modality to shorten admission terms, minimize the size of incisions, and lessen postoperative pain compared to laparotomy [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Remarkably, Robot-assisted laparoscopic hysterectomy is already the most common robotic surgery in gynecology and the second most common surgery performed after cesarean section in the United States[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIntuitive Surgical (Sunnyvale, CA, USA) remains the market leader, although other manufacturers are entering the surgical market. In 2014, the company replaced the da Vinci Si surgical system with the fourth-generation da Vinci Xi surgical system. The da Vinci Xi features an advanced scalable platform that enables the arms of the unit to move relative to the base. The da Vinci Xi allows surgeons to perform upper abdominal procedures, such as omentectomy, lymphadenectomy, or interdisciplinary surgery, without redocking because optics can be used in all four trocars [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. However, the surgery was initially performed as a robot-assisted total hysterectomy (robot-assisted simple hysterectomy [RASH]) performed with one assist port and three robotic arms. da Vinci Xi has an improved interference between the arms compared to da Vinci Si, but the interference between the arms and the assistant has not be resolved, limiting the movement of the assisted forceps. da Vinci Xi is also limited in its uterine manipulation, not allowing the surgery to be performed as the surgeon intends. Therefore, the three-arm approach is mainly selected despite the multiple robotic arms in this newer surgical system. In addition, a three-arm approach is necessary to ensure the competency of the bedside assistant, who uses the assist port to handle procedures such as tissue traction, suction, irrigation, delivery of sutures, and exchanging instruments. This type of surgical setup may provide less autonomy to the console surgeon and result in greater dependence on the bedside surgical assistant. Therefore, the 4th arm is used instead of the assist port, which is why we developed pure robot simple hysterectomy (PRSH), in which all ports are operated by robotic arms. This technique takes advantage of the inherent characteristics of robotic surgery, where the surgeon is remotely located at a console away from the patient. PRSH does not use a uterine manipulator because the 4th arm regulates the position of the uterus. One of the greatest advantages of this method is that it does not require an assistant to regulate the uterine manipulator.\u003c/p\u003e \u003cp\u003eThere are cases in which the uterine manipulator must be used intraoperatively for PRSH, although the intraoperative addition of the uterine manipulator may elongate the operative time because of the rearrangement of all robotic arms. In addition, it is necessary to involve an assistant to regulate the manipulator during surgery, which creates human resource problems. Therefore, we believe that if we can predict which cases should have a manipulator placed preoperatively, we can prepare for RASH in these cases preoperatively. In this study, we introduced PRSH as a novel surgical technique, and the main objective was to analyze independent predictors of forced intraoperative manipulator use during PRSH using da Vinci Xi.\u003c/p\u003e"},{"header":"Materials and Method","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and data collection\u003c/h2\u003e \u003cp\u003eThis study was reviewed and approved by the Human Research Ethics Committee of Kawasaki Medical School (trial registration no.: 5043-03). After institutional review board approval, this stadu was designed as a retrospective, non-blinded, non-randomized cohort study and reviewed all data from patients underwent PRSH between October 2020 and December 2022 at the Women's Medical Center, Kawasaki Medical School. Inclusion criteria included robotic hysterectomy for benign pathologies, including fibroids; adenomyosis; cervical diseases, such as high-grade cervical intraepithelial neoplasia; and endometrial diseases, such as typical endometrial hyperplasia, and all patients consented before the procedure was performed. Patients with indications of malignancy were excluded from this study. The robotic surgeries were performed by three skilled surgeons (Surgeons A, B, and C). Surgeon A was awarded a class B International license by The Japanese Society for Robotic Surgery and is a proctor in The Japan Society for Endoscopic Surgery and Intuitive Surgical; Surgeon B holds a class B domestic license from The Japanese Society for Robotic Surgery and is a proctor in Intuitive Surgical; and Surgeon C is a proctor in Intuitive Surgical. In each case, the bedside assistant was a gynecological resident who experienced robotic surgeries for at least 1 year (morer than 30 cases). We evaluated the differences between PRSH and PRSH with a uterine manipulator in terms of preoperative parameters (age, BMI, benign disease variation, prevalence of ovarian chocolate cysts, prevalence of Pouch of Douglas obliteration, and history of abdominal surgery), operative markers [estimated blood loss, operating time defined as the time from skin incision to skin closure for PRSH, and concomitant procedures], and postoperative outcomes (uterine volume excised).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSurgical procedure\u003c/h2\u003e \u003cp\u003eUnder general anesthesia, the patient was positioned lithotomy position with the Trendelenburg position. All robotic procedures were performed using the four-arm da Vinci Xi surgical system (Intuitive Surgical Inc., Sunnyvale, California, USA) (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e1\u003c/span\u003ea).\u003c/p\u003e \u003cp\u003eFirst, the trocar was inserted 3 cm above the umbilicus as an 8 mm endoscope port, using the direct closed method, and pneumoperitoneum was performed. After pneumoperitoneum was established, trocars were inserted under visual control: three 8-mm robotic ports on the same horizontal line spaced 8 cm apart at the level of the endoscope port. The 2nd arm was used to insert the endoscope, and the fenestrated bipolar forceps in the 1st arm and Maryland bipolar forceps in the 3rd arm were operated using the double bipolar method previously described (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e1\u003c/span\u003eb) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In this technique, the uterine manipulator is not used because the Cadiere forceps in the 4th arm manipulates the uterus (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e1\u003c/span\u003ec, d, Video1). For suturing, the 3rd arm was equipped with SutureCut needle driver from Maryland bipolar forceps, which enabled suturing and thread cutting. Probe Plus II (Ethicon, Tokyo, Japan) for suction and intra-abdominal transport of the needle was introduced into the abdominal cavity by pulling out the instrument in the 3rd arm (Video 2). The needle was also changed from CT-1 needle (Ethicon, Tokyo, Japan) to CT-2 needle (Ethicon, Tokyo, Japan) for No.0 Bicryl\u003csup\u003e\u0026reg;\u003c/sup\u003e (Ethicon, Tokyo, Japan) and from CT-X needle (Ethicon, Tokyo, Japan) to TE needle (Ethicon, Tokyo, Japan) for 2\u0026thinsp;\u0026minus;\u0026thinsp;0 Bicryl \u003csup\u003e\u0026reg;\u003c/sup\u003e (Ethicon, Tokyo, Japan), adjusting the curve and size of the needle.\u003c/p\u003e \u003cp\u003eHence, since all robotic arms are used for all ports, we named this technique \"\u003cem\u003epure\u003c/em\u003e\" robot simple hysterectomy (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e1\u003c/span\u003ed).\u003c/p\u003e \u003cp\u003eHowever, when the uterus cannot be tractioned with the Cadiere forceps or when the bowel must be tractioned toward the head with the forceps, a uterine manipulator must be inserted for a clear surgical view. Simple hysterectomy was performed as described previously [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Briefly, all surgeries were performed according to our standard operating procedure for conventional robotic simple hysterectomy. We started by transecting the round ligament and dissecting the broad ligament anteriorly and posteriorly using the double bipolar method with the Maryland bipolar forceps hand and fenestrated bipolar forceps. Extra-adnexal hysterectomy was not performed in premenopausal women. The bladder was dissected from the proximal vagina. Subsequently, the cystouterine fossa peritoneum was incised and expanded, and the ureter and uterine artery, including the ureteral tunnel as the point of ureter-uterine artery crossover, were identified. Only the uterine artery was ligated at two points with 2\u0026thinsp;\u0026minus;\u0026thinsp;0 Vicryl, coagulated with fenestrated bipolar forceps, and transected using Maryland bipolar forceps. The ascending branches of the uterine vessels were ligated at two points with C 2\u0026thinsp;\u0026minus;\u0026thinsp;0 Vicryl (Ethicon, Tokyo, Japan), coagulated via electrocautery using the fenestrated bipolar forceps, and transected using Maryland bipolar forceps. After transecting the cardinal ligaments, colpotomy was performed using Maryland bipolar forceps, and the uterus was extracted vaginally. Large uteri were cut into extractable parts using a knife and removed vaginally. Vaginal cuff closure was performed using interrupted 0-Vicryl sutures (Ethicon, Tokyo, Japan). The PRSH technique is summarized in a video clip (Video 3).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses were performed using EZR (Saitama Medical Center, Jichi Medical University, Saitama, Japan), a graphical user interface for R (The R Foundation for Statistical Computing, Vienna, Austria) [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The one-sample Kolmogorov\u0026ndash;Smirnov test was used to test the normal distribution of quantitative data. Variables are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, and categorical variables are described as frequency and percentage and compared between the groups using the \u003cem\u003eχ\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e test or Fisher's exact test, as appropriate. Multiple logistic regression analyses were performed to investigate potential influencing factors to evaluate PRSH with a uterine manipulator, employing a forward stepwise methodology to identify independent predictive factors. Specifically, odds ratios (ORs) and 95% confidence intervals (CIs) were calculated in the multivariate analyses, controlling for potential confounders such as age, BMI, surgeons, operating time, and blood loss. Statistical significance was set at P\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe characteristics of the patients who underwent PRSH (113 patients) or PRSH with a uterine manipulator (58 patients) are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Patients in the PRSH group were significantly older than those in the PRSH with a uterine manipulator group (48.4\u0026thinsp;\u0026plusmn;\u0026thinsp;6.3 versus 46.0\u0026thinsp;\u0026plusmn;\u0026thinsp;5.5, P\u0026thinsp;=\u0026thinsp;0.02) and BMI was significantly higher in the PRSH group (24.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.3 versus 26.0\u0026thinsp;\u0026plusmn;\u0026thinsp;4.6, P\u0026thinsp;=\u0026thinsp;0.03). There were no statistically significant differences between the two subgroups in terms of the type of benign disease (fibroids, adenomyosis, cervical diseases, and endometrial diseases: 0.87, 1.00, 1.00, and 0.67, respectively). The prevalence of ovarian chocolate cysts and Pouch of Douglas obliteration were significantly lower in PRSH than in PRSH with a uterine manipulator (3.5% versus 22.4%, P\u0026thinsp;=\u0026thinsp;0.0002 and 1.8% versus 25.9%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001, respectively). There was no significant difference in the history of abdominal surgery between the two groups (6.2% versus 8.6%, P\u0026thinsp;=\u0026thinsp;0.544).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of patients in the PRSH and PRSH with a uterine manipulator groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePRSH\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePRSH with the uterine manupulator\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e113\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48.4\u0026thinsp;\u0026plusmn;\u0026thinsp;6.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46.0\u0026thinsp;\u0026plusmn;\u0026thinsp;5.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.0\u0026thinsp;\u0026plusmn;\u0026thinsp;4.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBenign disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFibroids (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e73(64.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39(67.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.87\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdenomyosis (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32(28.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16(27.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCervical disease (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3(2.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(3.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEndometrial disease (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5(4.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(1.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.67\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOvarian chocolate cyst (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4(3.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13(22.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.0002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePouch of Douglas obliteration (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(1.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15(25.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP\u0026thinsp;\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe history of abdominal surgery (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7(6.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5(8.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.544\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003ePRSH: pure robotic simple hysterectomy, BMI: body mass index\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe surgical outcomes of PRSH and PRSH with a uterine manipulator are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Operating time was significantly shorter in PRSH than in PRSH with a uterine manupulator (126.0\u0026thinsp;\u0026plusmn;\u0026thinsp;23.0 versus 153.5\u0026thinsp;\u0026plusmn;\u0026thinsp;31.3, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Both blood loss and uterine volume were not significantly different between PRSH and PRSH with a uterine manipulator (44.2\u0026thinsp;\u0026plusmn;\u0026thinsp;56.5 versus 48.9\u0026thinsp;\u0026plusmn;\u0026thinsp;45.4, P\u0026thinsp;=\u0026thinsp;0.6; 236.2\u0026thinsp;\u0026plusmn;\u0026thinsp;172.0 versus 258.0\u0026thinsp;\u0026plusmn;\u0026thinsp;152.3, P\u0026thinsp;=\u0026thinsp;0.89, respectively). Regarding console surgeons, there was a significant difference in surgeons A and B between PRSH and PRSH with a uterine manipulator. Therefore, we considered console surgeon as a confounding factor for adjustment in the multivariate logistic regression analysis.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSurgical outcomes of PRSH and PRSH with a uterine manipulator\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePRSH (n\u0026thinsp;=\u0026thinsp;113)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePRSH with a uterine manipulator (n\u0026thinsp;=\u0026thinsp;58)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperating time (minutes)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e126.0\u0026thinsp;\u0026plusmn;\u0026thinsp;23.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e153.5\u0026thinsp;\u0026plusmn;\u0026thinsp;31.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood loss (mL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44.2\u0026thinsp;\u0026plusmn;\u0026thinsp;56.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48.9\u0026thinsp;\u0026plusmn;\u0026thinsp;45.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUterine volume (g)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e236.2\u0026thinsp;\u0026plusmn;\u0026thinsp;172.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e258.0\u0026thinsp;\u0026plusmn;\u0026thinsp;152.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConsole Surgeons\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44(38.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38(65.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55(48.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17(3.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14(12.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3(5.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003ePRSH: pure robotic simple hysterectomy\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eSurgeon A holds a class B International license from The Japanese Society for Robotic Surgery and is a proctor in The Japan Society for Endoscopic Surgery and Intuitive Surgical; Surgeon B holds a class B domestic license from The Japanese Society for Robotic Surgery and is a proctor in Intuitive Surgical; and Surgeon C is a proctor in Intuitive Surgical.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn univariate analysis, we found that major Low Anterior Resection Syndrome was significantly associated with the prevalence of ovarian chocolate cysts and Pouch of Douglas obliteration. Multivariate logistic analysis further showed that fibroids [odds ratio (OR): 23.0, 95% confidence interval (CI) 2.26\u0026ndash;235.0, P\u0026thinsp;=\u0026thinsp;0.008], adenomyosis (OR: 12.1, 95% CI 1.18\u0026ndash;124.0, P\u0026thinsp;=\u0026thinsp;0.04), ovarian chocolate cysts (OR:6.63, 95% CI 1.13\u0026ndash;38.7, P\u0026thinsp;=\u0026thinsp;0.04), and Pouch of Douglas obliteration (OR: 18.1, 95% CI 2.55\u0026ndash;128.0, P\u0026thinsp;=\u0026thinsp;0.004) were independent predictors of PRSH with a uterine manupulator (Table\u0026nbsp;3).\u003c/p\u003e\u003cp\u003eTable.3 Univariate and multivariate analyses of PRSH with a uterine manipulator\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.02729044834308%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.717348927875245%\" valign=\"top\"\u003e\n \u003cp\u003eCrude OR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.840155945419104%\" valign=\"top\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.840155945419104%\" valign=\"top\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.865497076023392%\" valign=\"top\"\u003e\n \u003cp\u003eAdjusted OR*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.988304093567251%\" valign=\"top\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.721247563352826%\" valign=\"top\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.02729044834308%\" valign=\"top\"\u003e\n \u003cp\u003eFibroids\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.717348927875245%\" valign=\"top\"\u003e\n \u003cp\u003e5.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.840155945419104%\" valign=\"top\"\u003e\n \u003cp\u003e0.797-33.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.840155945419104%\" valign=\"top\"\u003e\n \u003cp\u003e0.085\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.865497076023392%\" valign=\"top\"\u003e\n \u003cp\u003e23.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.988304093567251%\" valign=\"top\"\u003e\n \u003cp\u003e2.26-235.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.721247563352826%\" valign=\"top\"\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.02729044834308%\" valign=\"top\"\u003e\n \u003cp\u003eAdenomyosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.717348927875245%\" valign=\"top\"\u003e\n \u003cp\u003e3.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.840155945419104%\" valign=\"top\"\u003e\n \u003cp\u003e0.464-20.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.840155945419104%\" valign=\"top\"\u003e\n \u003cp\u003e0.242\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.865497076023392%\" valign=\"top\"\u003e\n \u003cp\u003e12.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.988304093567251%\" valign=\"top\"\u003e\n \u003cp\u003e1.18-124.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.721247563352826%\" valign=\"top\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.02729044834308%\" valign=\"top\"\u003e\n \u003cp\u003eOvarian chocolate cyst\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.717348927875245%\" valign=\"top\"\u003e\n \u003cp\u003e8.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.840155945419104%\" valign=\"top\"\u003e\n \u003cp\u003e1.80-36.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.840155945419104%\" valign=\"top\"\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.865497076023392%\" valign=\"top\"\u003e\n \u003cp\u003e6.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.988304093567251%\" valign=\"top\"\u003e\n \u003cp\u003e1.13-38.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.721247563352826%\" valign=\"top\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.02729044834308%\" valign=\"top\"\u003e\n \u003cp\u003ePouch of Douglas obliteration\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.717348927875245%\" valign=\"top\"\u003e\n \u003cp\u003e16.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.840155945419104%\" valign=\"top\"\u003e\n \u003cp\u003e2.94-92.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.840155945419104%\" valign=\"top\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.865497076023392%\" valign=\"top\"\u003e\n \u003cp\u003e18.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.988304093567251%\" valign=\"top\"\u003e\n \u003cp\u003e2.55-128.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.721247563352826%\" valign=\"top\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.02729044834308%\" valign=\"top\"\u003e\n \u003cp\u003eHistory of abdominal surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.717348927875245%\" valign=\"top\"\u003e\n \u003cp\u003e1.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.840155945419104%\" valign=\"top\"\u003e\n \u003cp\u003e0.224-4.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.840155945419104%\" valign=\"top\"\u003e\n \u003cp\u003e0.995\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.865497076023392%\" valign=\"top\"\u003e\n \u003cp\u003e0.493\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.988304093567251%\" valign=\"top\"\u003e\n \u003cp\u003e0.07-3.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.721247563352826%\" valign=\"top\"\u003e\n \u003cp\u003e0.46\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.02729044834308%\" valign=\"top\"\u003e\n \u003cp\u003eUterine volume\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.717348927875245%\" valign=\"top\"\u003e\n \u003cp\u003e0.999\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.840155945419104%\" valign=\"top\"\u003e\n \u003cp\u003e0.9996-1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.840155945419104%\" valign=\"top\"\u003e\n \u003cp\u003e0.517\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.865497076023392%\" valign=\"top\"\u003e\n \u003cp\u003e0.997\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.988304093567251%\" valign=\"top\"\u003e\n \u003cp\u003e0.994-1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.721247563352826%\" valign=\"top\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e* adjusted for age, BMI, surgeon, operating time, and blood loss\u003c/p\u003e\n\u003cp\u003eOR, odds ratio; CI, confidence interval.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOne benefit of robotic surgery may be improved ergonomics for the operating surgeon. For the console surgeon, ergonomic benefits have been studied in terms of improved visualization, posture, and manipulation [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, collisions can occur between robotic arms, stopping the surgery [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Hence, three of the four robotic arms are typically used, which is very stressful for the console surgeon. In particular, in cases where a uterine manipulator cannot be inserted, hysterectomy must be performed with only three robotic arms. However, because one arm is used for the camera port, two robotic arms are used for the surgery, which increases the surgical difficulty. Recently, a few reports have indicated that adding a 4th robotic arm to the standard 3-port setup may be an easy solution with great outcomes [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], although there is no established evidence for this technique. In this study, we demonstrated the feasibility of PRSH, which uses four robotic arms to perform a hysterectomy without the requirement of a uterine manipulator. However, since PRSH was not successful in all patients and resulted in the intraoperative use of a uterine manipulator, we analyzed strong predictors of PRSH incompletion without a uterine manipulator and found fibroids, endometriosis including adenomyosis and ovarian chocolate cysts, and Pouch of Douglas obliteration. Several studies have highlighted the importance of uterine manipulators in reducing complications during hysterectomy [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In particular, a uterine manipulator elevates the uterus, exposing the cul-de-sac to prevent bowel injury, especially in cases of endometriosis complicated by Pouch of Douglas obliteration. In the case of Pouch of Douglas obliteration, the Cadiere forceps in the 4th arm pulled the rectum toward the head, and the uterine manipulator firmly elevated the uterus, which released the Pouch of Douglas. In addition, the difficulty of a hysterectomy depends on the site of fibroid development, with cervical and broad ligament fibroids relatively increasing surgical difficulty [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Therefore, we added a subanalysis involving the site of fibroid development and found that cervical and broad ligament fibroids were a stronger predictor of the need to use a uterine manipulator than intramural fibroids (OR: 12.1, 95% CI 1.18\u0026ndash;124.0, P\u0026thinsp;=\u0026thinsp;0.04) (Supplemental Table\u0026nbsp;1). Based on this study, we have decided that in future cases of endometriosis with suspected Pouch of Douglas obliteration and those of cervical or intramural fibroids, we would preoperatively prepare additional assistants and use a manipulator during PRSH.\u003c/p\u003e \u003cp\u003eConventionally, RASH uses three robotic arms and an assistant port operated by an assistant. However, there are cases in which the assistant's grasp and grip of tissue using forceps makes it difficult to achieve the console surgeon's desired surgical field due to forceps angle problems and interference with the robotic arms. It is concerning that the the positions of the robot and assistant ports may affect the ergonomics of the assistants. van\u0026rsquo;t Hullenaa et al. reported that the position of the assistant port too close to the position of the robot ports may worsen surgical performances because of limitations for the assistant's workspace and non-ergonomic twisting and bending at the wrist and elbow [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. To solve those problems, there are ways to improve the ergonomics of the assistant to increase additional access by adding more ports, two assistants at two different positions, or using more robotic arms. However, increasing the number of ports increases patient invasiveness, and increasing the number of assistants increases the requirement of valuable human resources. Recently, some investigators reported that using an additional robotic arm, that is, changing from three to four robotic arms, may result in less reliance on an assistant, without compromising patient outcomes since the da Vinci Xi platform reduces robotic arm collisions through an easy port configuration and port exchange flexibility [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, several studies have suggested that the combined presence of experienced console surgeons and a well-trained assistant makes it unnecessary to use the 4th arm [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], and adding a 4th arm means higher costs for the hospital [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. However, considering the time required to train an assistant as well as the cost of hiring an assistant, we believe that adding a 4th arm would be more cost-effective. In fact, we have been more successful in training senior residents as console surgeons than as assistants. This has increased the number of robotic surgeries performed in our hospital. Furthermore, the fact that the surgical outcomes of PRSH are comparable to those of RASH is a reason to promote PRSH.\u003c/p\u003e \u003cp\u003eOur study had several limitations. First, tthe data may have incomplete information that was not full-filled in the patient record because of the retrospective nature of the study, which limits the generalizability of our findings. Second, three surgeons from our robotic surgical team performed the surgeries. Although most surgeons in the team were trained at the same institution, biases resulting from individual surgeon differences cannot be excluded. Moreover, the most proficient surgeon (Surgeon A) required a uterine manipulator for PRSH, which may have resulted in an unbalanced distribution of surgical difficulty and may have impacted the statistical analysis. Third, we could not directly compare PRSH with RASH because the number of patients who underwent RASH in our hospital was small. Furthermore, a multicenter comparative study of RASH and PRSH is required to demonstrate the superiority of PRSH. The study\u0026rsquo;s main strength is its description of a 4-arm approach to hysterectomy using da Vinci Xi without a uterine manipulator, which enabled minimal dependence on an assistant. Although previous reports have shown the superiority of a 4-arm hysterectomy approach for malignant gynecological diseases[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], this is the first study to demonstrate the superiority of this hysterectomy approach for benign gynecological diseases. Furthermore, this report seems worthwhile because pelvic occupying diseases, such as enlarged uterine fibroids, are more difficult to treat robotically than with radical total hysterectomy.\u003c/p\u003e \u003cp\u003eIn conclusion, the routine use of a fourth robotic arm during PRSH provides the operating surgeon with greater independence during critical phases of the procedure without the requirement of a uterine manipulator and assistant. This advantage translates into non-dependence on an assistant and the conservation of human resources. In addition, this study confirmed the feasibility and safety of robotic surgery for benign hysterectomy even in \u0026ldquo;complex cases, \u0026rdquo; including those of endometriosis with suspected Pouch of Douglas obliteration and those of cervical and broad ligament fibroids, with surgeons preparing to use a uterine manipulator and adding an assistant preoperatively. Although we reanalyzed the cost-benefit of the system and the impact on surgical training, we need further research to establish the superiority of the 4-arm system over the 3-arm system.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudy concepts: Y.O. and S.K. and M.S., Study design: K.S. and T.T., Data acquisition: H.F., K.T., H.O., Y.M.. and W.S., Data analysis and interpretation: S.S.and H.K., Statistical analysis: K.O.and T.T., Manuscript preparation: S.K, and K.O., Manuscript editing: Y.O., Manuscript review: E.K., T.T., M.S., and K.S.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was reviewed and approved by the Human Research Ethics Committee of Kawasaki Medical School (trial registration no.: 5043-03).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from all individual participants included in the study and their parents.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients signed informed consent regarding publishing their data\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank all the staff in the operating room at Kawasaki Medical School and all the nurses who cared for our post-operative patients. We are also very grateful to M.S. Yoshimi Harada, secretary of the Department of Obstetrics and Gynecology at Kawasaki Medical School.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGarry R. Health economics of hysterectomy. Best practice \u0026amp; research Clinical obstetrics \u0026amp; gynaecology. 2005;19:451\u0026ndash;465.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdvincula AP, Song A. The role of robotic surgery in gynecology. Current Opinion in Obstetrics and Gynecology. 2007;19:331\u0026ndash;336.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSettnes A, Topsoee MF, Moeller C, et al. Reduced complications following implementation of laparoscopic hysterectomy: a Danish population-based cohort study of minimally invasive benign gynecologic surgery between 2004 and 2018. Journal of minimally invasive gynecology. 2020;27:1344\u0026ndash;1353. e1343.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCohen SL, Ajao MO, Clark NV, Vitonis AF, Einarsson JI. Outpatient hysterectomy volume in the United States. Obstetrics \u0026amp; Gynecology. 2017;130:130\u0026ndash;137.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGitas G, Alkatout I, Mettler L, et al. Incidence of unexpected uterine malignancies after electromechanical power morcellation: a retrospective multicenter analysis in Germany. Archives of Gynecology and Obstetrics. 2020;302:447\u0026ndash;453.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan der Schans EM, Hiep MAJ, Consten ECJ, Broeders IAMJ. From Da Vinci Si to Da Vinci Xi: realistic times in draping and docking the robot. Journal of Robotic Surgery. 2020;14:835\u0026ndash;839.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKatsuno H, Hanai T, Endo T, Morise Z, Uyama I. The double bipolar method for robotic total mesorectal excision in patients with rectal cancer. Surgery Today. 2022;52:978\u0026ndash;985.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOta Y, Ota K, Takahashi T, Suzuki S, Sano R, Shiota M. Robotic-assisted Total Hysterectomy with Low Pneumoperitoneal Pressure (6 mmHg) and Use of Surgical Plume Evacuator System to Minimize Potential Airborne Particles According to the Joint Statement on Minimally Invasive Gynecologic Surgery during the COVID-19 Pandemic: A Case Report from Japan. Gynecol Minim Invasive Ther. 2022;11:127\u0026ndash;130.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKanda Y. Investigation of the freely available easy-to-use software \u0026lsquo;EZR\u0026rsquo;for medical statistics. Bone marrow transplantation. 2013;48:452\u0026ndash;458.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCorman ML, Corman ML. \u003cem\u003eColon and rectal surgery\u003c/em\u003e: Lippincott Williams \u0026amp; Wilkins Philadelphia; 2005.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWong SW, Ang ZH, Crowe P. Improving ergonomics for the bedside assistant in robotic colorectal surgery. J Surg Case Rep. 2023;2023:rjad007.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYim GW, Eoh KJ, Chung YS, et al. Perioperative Outcomes of 3-Arm Versus 4-Arm Robotic Radical Hysterectomy in Patients with Cervical Cancer. Journal of Minimally Invasive Gynecology. 2018;25:823\u0026ndash;831.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarger A, Haworth L, Bennett M, Hudgens J, Woo J. The 4th arm solution: an easy answer to the robotic hysterectomy without a uterine manipulator. American Journal of Obstetrics \u0026amp; Gynecology. 2024;230:S1296.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbdel Khalek Y, Bitar R, Christoforou C, et al. Uterine manipulator in total laparoscopic hysterectomy: safety and usefulness. Updates in Surgery. 2020;72:1247\u0026ndash;1254.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan den Haak L, Alleblas C, Nieboer TE, Rhemrev JP, Jansen FW. Efficacy and safety of uterine manipulators in laparoscopic surgery: a review. Archives of Gynecology and Obstetrics. 2015;292:1003\u0026ndash;1011.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHiramatsu Y. Hysterectomy for cervical and intraligamental fibroids. The Surgery Journal. 2020;6:S2-S10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan\u0026rsquo;t Hullenaar CD, Bos P, Broeders IA. Ergonomic assessment of the first assistant during robot-assisted surgery. Journal of robotic surgery. 2019;13:283\u0026ndash;288.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEl-Asmar JM, Sebaaly R, Mailhac A, et al. Use of bariatric ports in 4-arm robotic partial nephrectomy: a comparative study with the standard 3-arm technique. Cureus. 2021;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFeliciano J, Stifelman M. Robotic retroperitoneal partial nephrectomy: a four-arm approach. JSLS: Journal of the Society of Laparoendoscopic Surgeons. 2012;16:208.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRogers CG, Laungani R, Bhandari A, et al. Maximizing console surgeon independence during robot-assisted renal surgery by using the fourth arm and tilepro\u0026trade;. Journal of endourology. 2009;23:115\u0026ndash;122.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohnson BA, Crivelli J, Sorokin I, Gahan J, Cadeddu JA. Surgical outcomes of three vs four arm robotic partial nephrectomy: is the fourth arm necessary? Urology. 2019;123:140\u0026ndash;145.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Robotic simple hysterectomy, Robot-assisted simple hysterectomy, uterine manipulator, da-Vinci Xi surgical system, Pouch of Douglas obliteration, assistant","lastPublishedDoi":"10.21203/rs.3.rs-4418722/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4418722/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eNearly 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.\u003c/p\u003e \u003cp\u003eWe 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\u0026thinsp;\u0026plusmn;\u0026thinsp;6.3 versus 46.0\u0026thinsp;\u0026plusmn;\u0026thinsp;5.5, P\u0026thinsp;=\u0026thinsp;0.02 and 24.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.3 versus 26.0\u0026thinsp;\u0026plusmn;\u0026thinsp;4.6, P\u0026thinsp;=\u0026thinsp;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\u0026thinsp;\u0026lt;\u0026thinsp;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.\u003c/p\u003e","manuscriptTitle":"\"Pure\" robot simple hysterectomy with four arms and no uterine manipulator: a retrospective, non-blind, and non-randomized, comparative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-30 18:48:11","doi":"10.21203/rs.3.rs-4418722/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9dd1bbda-f0e0-4932-a118-8b8aab0757a6","owner":[],"postedDate":"May 30th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-05-30T18:48:14+00:00","versionOfRecord":[],"versionCreatedAt":"2024-05-30 18:48:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4418722","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4418722","identity":"rs-4418722","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}