Hysterectomy for oncological and non-oncological reasons in patients over 70 years of age - comparison of robot-assisted, laparoscopic, and open approaches.

The study included 213 patients who underwent hysterectomy at the Department of Obstetrics, Gynaecology, and Gynaecologic Oncology of the Regional Polyclinical Hospital in Grudziądz, Poland, between July 2022 and April 2025. The mean age of the patients was 61.4 years, with ages ranging from 34 to 87 years. The target group comprised 56 patients (26.2%) aged 70 years and older, while the comparison group consisted of 157 patients (73.8%) under the age of 70. There were no statistically significant differences between the two groups in terms of BMI or prior abdominal surgeries. However, the groups differed significantly in ASA classification, with a higher proportion of patients in the older group falling into ASA classes III and IV. A significant association was also observed between age and the presence of comorbidities, which were more frequent among older patients. A detailed comparison of the two groups is provided in Table  1 . The indications for surgical treatment were also examined across both age groups. The most common oncologic indication was endometrial cancer, while the leading non-oncologic indications included endometrial hyperplasia, uterine fibroids, and cervical dysplasia. Table 1 Clinical characteristics of the study subjects < 70 (N = 157)  ≥ 70 (N = 56) p BMI  (kg/m 2 ) 28.65 30.41 0.0775 ASA score  I 5 (3.18%) 0 (0%) 0.0001  II 116 (73.88%) 24 (42.86%)  III 35 (22.29%) 29 (51.79%)  IV 1 (0.64%) 3 (5.36%) Comorbidities  Yes 101 (64.33%) 46 (82.14%) 0.0133  No 56 (35.67%) 10 (17.86%) Blood morphology parameters (before surgical treatment)  HGB (g/dL) 13.6 13.5 0.7473  HCT (%) 40.4 39.95 0.6081  E (mln/μl) 4.56 4.46 0.0729 History of prior surgical treatment  Yes 30 (21.43%) 17 (32.08%) 0.124  No 110 (78.57%) 36 (67.92%) BMI, Body Mass Index; ASA score, American Society of Anesthesiologists score; HGB, haemoglobin; HCT, haematocrit; E, erythrocytes p -value < 0.05 - statistically significant p -value < 0.01 - high statistical significance Clinical characteristics of the study subjects BMI, Body Mass Index; ASA score, American Society of Anesthesiologists score; HGB, haemoglobin; HCT, haematocrit; E, erythrocytes p -value < 0.05 - statistically significant p -value < 0.01 - high statistical significance Patients were qualified for hysterectomy using the following surgical techniques: 61 patients for surgery assisted by the Versius CMR surgical robot, 104 patients for laparoscopic surgery, and 48 patients for laparotomy. We evaluated the duration of surgery in the two age groups based on the type of surgical technique used. The results of the comparison are presented in Table  2 . A statistically significant difference ( p  < 0.01) in surgical duration between age groups was observed only for laparotomy, with longer operative times recorded in the younger patient group. We also evaluated the association between operative time and the type of hysterectomy performed (total vs. radical). A highly significant difference ( p  < 0.01) was found, with radical hysterectomies taking considerably longer—an average of 146.03 min (SD 34.76) compared to 102.42 min (SD 41.31) for total hysterectomies. The relationship between operative time and patients’ BMI was also analyzed; however, no statistically significant correlation was identified. Additionally, we assessed changes in patients’ blood morphology parameters—specifically haemoglobin, haematocrit, and erythrocyte levels—before and after surgery, across both age groups and according to surgical technique. These findings are presented in Table  3 . No statistically significant differences were found in the changes in the patients’ blood morphology parameters (before and after surgical treatment between the two age groups, taking into account the three types of surgical treatment (robot-assisted, laparoscopy and laparotomy). Table 2 Duration of surgery in two age groups (divided into types of surgery) Total Laparotomy Laparoscopy Robot assisted  < 70 years  ≥ 70 years  < 70 years  ≥ 70 years  < 70 years  ≥ 70 years  < 70 years  ≥ 70 years N 157 56 33 15 74 30 50 11 Mean 123.53 110.98 144.54 105.67 106.76 105.67 134.5 132.72 Median 120 105 140 105 95 105 125 130 Minimum 40 55 85 60 40 55 65 95 Maximum 305 215 240 155 220 215 305 190 Q1 90 85 105 80 75 85 106,25 115 Q3 160 131,25 170 130 130 123,75 160 147.5 U Mann–Whitney test Z 1.6306 3.0187 0.3448 0.094 p 0.103 0.0025 0.7303 0.9251 Q1, first quartile; Q3, third quartile Table 3 Changes in the blood morphology parameters of the patients (before vs. after surgical treatment), including haemoglobin, haematocrit, and erythrocyte concentrations, in the two age groups (divided into types of surgical treatment) Laparotomy HGB (g/dL) HCT (%) E (mln/µL)  < 70 years  ≥ 70 years  < 70 years    ≥ 70 years   < 70 years    ≥ 70lat N 33 15 33 15 33 15 Mean −1.5242 −1.9467 −4.4818 −6.2467 −0.5336 −0.6413 Median −1.5 −1.7 −3.5 −5.8 −0.56 −0.6 Minimum −4.1 −4.4 −14 −13.5 −1.68 −1.42 Maximum 0.7 0.1 2.1 −0.9 0.24 0.03 Q1 −2.3 −2.85 −6.4 −8.5 −0.8 −0.905 Q3 −0.6 −1.25 −1.8 −3.3 −0.17 −0.395 U Mann–Whitney test Z 0.9346 1.4682 0.7563 p 0.35 0.1421 0.4495 Laparoscopy HGB (g/dL) HCT (%) E (mln/µL)  < 70 years  ≥ 70 years  < 70 years    ≥70 years ≥< 70 years   ≥70 years N 74 30 74 30 74 30 Mean −1.5446 −1.5567 −4.6703 −4.9333 -0.5226 −0.516 Median −1.55 −1.6 −4.4 −5.7 −0.49 −0.53 Minimum −5.6 −3.6 −17 −11.2 −2.08 −1.1 Maximum 0.5 −0.1 2.9 0.8 0.33 0.13 Q1 −1.975 −1.9 −6.15 −6.5 −0.7 −0.6475 Q3 −0.95 −1.1 −2.9 −3.275 −0.335 −0.3825 U Mann–Whitney test Z 0.2082 0.9831 0.165 p 0.8351 0.3255 0.8689 Robot-assisted surgery HGB (g/dL) HCT (%) E (mln/µL)  < 70 years  ≥ 70 years  < 70 years  ≥70 years  <70 years    ≥70 years N 50 11 50 11 50 11 Mean −1.5522 −1.3727 −4.768 −1.6636 −0.5478 −0.4618 Median −1.5 −1.7 −4.2 −3.9 −0.55 −0.57 Minimum −3.7 −2.9 −10.6 −7.4 −1.3 −0.96 Maximum −0.2 1.5 −0.8 19.9 −0.09 0.59 Q1 −2 −2.05 −6.375 −6.25 −0.68 −0.73 Q3 −1.1 −1.2 −3.175 −2 −0.3825 −0.395 U Mann–Whitney test Z 0.3379 0.8068 −0.0094 p 0.7354 0.4198 0.9925 Q1, first quartile; Q3, third quartile; HGB, haemoglobin; HCT, haematocrit; E, erythrocytes Duration of surgery in two age groups (divided into types of surgery) Q1, first quartile; Q3, third quartile Changes in the blood morphology parameters of the patients (before vs. after surgical treatment), including haemoglobin, haematocrit, and erythrocyte concentrations, in the two age groups (divided into types of surgical treatment) Q1, first quartile; Q3, third quartile; HGB, haemoglobin; HCT, haematocrit; E, erythrocytes In the analysed cohort, surgical conversion to an alternative approach was required in nine cases—eight in the younger group and one in the older group. Six procedures were converted from laparoscopy to laparotomy, and three from robot-assisted surgery to laparoscopy. The primary reasons for conversion were extensive intra-abdominal adhesions ( n  = 5) and intraoperative diagnosis of malignant ovarian tumours based on frozen-section pathology ( n  = 4). These findings are detailed in Table  4 . No statistically significant association was found between the occurrence of surgical conversion and patient age group ( p  > 0.05). Postoperative hospital discharge timing was also examined across the two age groups, both overall and by surgical technique. The data, summarised in Table  5 , showed no significant differences in discharge day distributions between age groups ( p  > 0.05). Table 4 Conversion to other types of surgical treatment in the two age groups Age  < 70 years old  ≥ 70 years old N % N % No 149 94.9% 55 98.21% Yes 8 5.1% 1 1.79% Cochran’s condition Unfulfilled Pearson’s chi 2 statistic 1.1174 Degrees of freedom 1 p-value 0.2905 Fisher’s exact test 0.4508 Table 5 Discharge from hospital after surgical treatment in the two age groups (overall and by type of surgical treatment) Total Laparotomy Laparoscopy Robot assisted  < 70 years  ≥ 70 years  < 70 years  ≥ 70 years  < 70 years  ≥ 70 years  < 70 years  ≥ 70 years N 157 56 33 15 74 30 50 11 Mean 2.8535 3.4821 4.9697 6.6 2.3514 2.3667 2.2 2.2727 Median 2 2 4 4 2 2 2 2 Minimum 1 2 3 3 1 2 2 2 Maximum 16 30 16 30 6 5 3 3 Q1 2 2 4 4 2 2 2 2 Q3 4 4 5 6 2 2 2 2.5 U Mann–Whitney test Z 1.1535 0.6469 0.5463 0.5157 p 0.2487 0.5177 0.5849 0.6061 Q1, first quartile; Q3, third quartile Conversion to other types of surgical treatment in the two age groups Discharge from hospital after surgical treatment in the two age groups (overall and by type of surgical treatment) Q1, first quartile; Q3, third quartile We further analysed postoperative complications across age groups (Table  6 ). Complications were reported in 13 patients (6.1%)—eight from the younger group and five from the older group—with no statistically significant association between age and complication rates ( p  > 0.05). Among these, seven complications followed open hysterectomy (3.3%), and six occurred after minimally invasive surgeries (laparoscopic or robotic assisted, 2.8%). Three complications required reoperation, while the rest were managed conservatively with local wound care or pharmacological therapy. A breakdown by surgical technique is provided in Table  7 . Table 6 Post-surgery complications in the two age groups Age  < 70 years old  ≥ 70 years old N % N % No 149 94.9% 51 91.07% Yes 8 5.1% 5 8.93% Cochran’s condition unfulfilled Pearson’s chi 2 statistic 1.0582 Degrees of freedom 1 p-value 0.3036 Fisher’s exact test 0.3335 Table 7 Complications after various types of surgical treatment Patient no Age Indications Type of surgery Complications Days after the surgery Clavien– Dindo classification 1 34 Borderline ovarian tumour Total laparoscopic hysterectomy Discomfort and femoral pain 5 I 2 48 Endometrial hyperplasia Robot-assisted total hysterectomy Vaginal cuff bleeding 4 I 3 58 Cervical cancer Laparotomy Radical hysterectomy Pelvic lymphadenectomy Ileus eventration 6 IIIB 4 58 Uterine fibroids Total laparoscopic hysterectomy Vaginal cuff bleeding 3 I 5 62 Ovarian tumour Laparotomy Hysterectomy bilateral oophorosalpingectomy Abdominal wound infection 7 I 6 62 Endometrioid cancer Laparotomy Radical hysterectomy Pelvic lymphadenectomy Urinary infection 3 I 7 65 Cervical cancer Laparotomy Radical hysterectomy Pelvic lymphadenectomy Abdominal wound infection Abdominal wound dehiscence Eventration 7 IIIB 8 68 Cervical dysplasis Total laparoscopic hysterectomy Vaginal cuff infection 16 I 9 70 Endometrial hyperplasia Laparotomy Hysterectomy bilateral oophorosalpingectomy Abdominal wound infection 23 I 10 70 Endometrioid cancer Laparotomy Radical hysterectomy Pelvic lymphadenectomy Nausea Vomiting 3 I 11 72 Uterine fibroids Laparotomy Radical hysterectomy Pelvic lymphadenectomy Abdominal wound dehiscence Eventration 7 IIIB 12 73 Endometrial hyperplasia Total laparoscopic hysterectomy Abdominal wound dehiscence 5 IIIA 13 75 Endometrioid cancer Radical laparoscopic hysterectomy pelvic lymphadenectomy Vaginal cuff partial dehiscence 17 II Post-surgery complications in the two age groups Complications after various types of surgical treatment Laparotomy Radical hysterectomy Pelvic lymphadenectomy Ileus eventration Laparotomy Radical hysterectomy Pelvic lymphadenectomy Laparotomy Radical hysterectomy Pelvic lymphadenectomy Abdominal wound infection Abdominal wound dehiscence Eventration Laparotomy Radical hysterectomy Pelvic lymphadenectomy Nausea Vomiting Laparotomy Radical hysterectomy Pelvic lymphadenectomy Abdominal wound dehiscence Eventration The analysis of the correlation between age and postoperative complications confirmed no statistically significant relationship ( p  > 0.05). Conversely, a strong association was observed between BMI and complication risk ( p  < 0.01): patients with normal BMI had the lowest risk, and each one-unit increase in BMI was associated with an approximately 10% increase in complication likelihood (Fig.  1 ). Fig. 1 Occurrence of postoperative complications by patient BMI (kg/m 2 ) Occurrence of postoperative complications by patient BMI (kg/m 2 ) We also assessed the link between the type of surgical technique and the rate of postoperative complications. As presented in Table  8 , a significant association was found ( p  < 0.05): complications were more frequent following laparotomy (14.58%) and less common after minimally invasive surgery (3.64%). Furthermore, we examined associations between complications and both ASA classification and the nature of the surgical indication (oncologic vs. non-oncologic). No significant associations were detected ( p  > 0.05), indicating that neither ASA score nor surgical indication type significantly influenced postoperative complication rates. Table 8 Association between postoperative complications and the type of surgical technique used Complications No Yes N % N % Laparoscopy and robot assisted 159 96.36% 6 3.64% Laparotomy 41 85.42% 7 14.58% Cochran’s condition Unfulfilled Pearson’s chi 2 statistic 7.7753 Degrees of freedom 1 p-value 0.0053 Fisher’s exact test 0.0112 Association between postoperative complications and the type of surgical technique used Rehospitalisation within 30 days of surgery occurred in three patients—two from the younger group and one from the older group—due to lower abdominal pain, vaginal stump bleeding, or wound infection. None of these patients required reoperation. No significant correlation was observed between age group and rehospitalisation ( p  > 0.05). Reoperations were performed in three patients—two younger and one older—all within seven days of the initial procedure and during the same hospital stay. Each of these patients had undergone open abdominal hysterectomy. Two had cervical cancer, and one had uterine fibroids. The reoperations were prompted by eventration, with one case also involving a wound infection. No reoperations were necessary after robotic or laparoscopic hysterectomy. Again, no statistically significant association was found between reoperation rates and patient age group ( p  > 0.05). During the 90-day postoperative observation period for the entire study population for which hysterectomy was performed using various surgical techniques, no treatment-related deaths or admissions to the intensive care unit were recorded.

This study involved patients who underwent surgery for both oncological and non-oncological conditions at the Department of Obstetrics, Gynaecology, and Gynaecologic Oncology at the Regional Polyclinical Hospital in Grudziadz, Poland, between June 2022 and April 2025. Demographic and clinical data were collected through a comprehensive review of medical records generated during the study and follow-up periods. A retrospective analysis was conducted utilising anonymised data from patient interviews, physical examinations, and diagnostic tests regarding surgical indications, treatment methods, and related parameters. All surgical procedures were performed by two accredited, high-volume consultant gynaecological surgeons specialising in obstetrics, gynaecology, and gynaecologic oncology. Both surgeons possessed extensive expertise in open and MIS techniques. Our primary outcome was the comparison of different hysterectomy techniques (robot assisted, laparoscopic, and open) in two age groups: patients under 70 years of age and those aged 70 and above. The comparison included the duration of the hysterectomy procedure depending on the surgical method, changes in blood morphology parameters (haemoglobin, haematocrit, and red blood cell count), early surgical outcomes, the incidence and type of complications, and the rate of reoperations. Secondary outcomes focused on surgical results, including the length of hospital stay and the occurrence of postoperative complications within 30 days after surgery. Such complications included postoperative infections, readmissions, step-down or intensive care unit admissions, and 90-day mortality rates. Patients were stratified by hysterectomy approach and age group, which allowed us to assess whether minimally invasive techniques, such as laparoscopy or surgery assisted by the Versius CMR robotic system, represent a safe option for patients over the age of 70. The study included a total of 213 patients with oncological or non-oncological indications undergoing robot-assisted surgery utilising the CMR Versius system, laparoscopic surgery, or open surgery. The qualification for surgical treatment and the selection of the surgical approach (robot assisted, laparoscopic, or open) were determined by a single specialist—consultant gynaecological surgeon. These decisions were made during outpatient consultations approximately four weeks prior to the planned surgery. Patients were qualified for surgical treatment due to the presence of either benign lesions (e.g. cervical dysplasia, abnormal uterine bleeding, uterine fibroids, endometrial hyperplasia, or adenomyosis) or malignant lesions (e.g. endometrial, cervical, or ovarian cancer). Prior to undergoing surgery, each patient underwent an anaesthesiology consultation to confirm readiness for the procedure. The study was based on comprehensive patient demographics and preoperative data, including age, BMI, ASA scores, physical status, and surgical history. Intraoperative data encompassed operative time (from skin incision to skin closure, including console time for robotic procedures), conversions to alternative surgical techniques (laparoscopic or open surgery), changes in blood morphology parameters, and the need for reoperation. The duration of the operation was determined as the time from the skin incision to the closure of the incisions, while the hospitalisation time was calculated from the time from surgery to discharge day. Complications observed within 30 days after surgery were considered postoperative complications. Postoperative data included the length of hospital stay (from the procedure to discharge), complications occurring within 90 days of surgery and their association with the surgical device, reoperations, hospital readmissions within 30 days (including reasons for readmission), and any other notable outcomes, such as return to the operating room or mortality within 90 days of surgery. All postoperative complications were classified using the Clavien–Dindo classification system. All histopathological examinations of the specimens were performed at the Department of Pathomorphology of the Regional Polyclinical Hospital in Grudziadz. The study was conducted in accordance with the Declaration of Helsinki and was approved by the Bioethics Committee at the Kujawsko-Pomorskie Regional Chamber of Physicians in Torun (authorisation number: 20/KB/2023). Statistical analyses were conducted using the PQStat v. 1.8.4 software package. Comparisons between the two age groups were made using the Mann–Whitney U test. Categorical variables were analysed using the chi-square test of independence and Fisher’s exact test. The relationship between parameters was assessed using Spearman’s rank correlation coefficient. Logistic regression models were used to evaluate the relationship between the occurrence of complications and the variables of age, BMI, and surgery duration. A p -value of < 0.05 was considered statistically significant, while a p -value of < 0.01 indicated high statistical significance.

In the era of personalized medicine, it is particularly important to tailor the scope of treatment to the patient’s age, physiological capacity, and overall health status, with a preference for minimally invasive techniques that allow the removal of the affected organ at an early stage of the disease [ 7 , 8 ]. Hysterectomy in elderly women requires careful assessment of overall health, cmorbidities, underlying pathology, and the risks and benefits of each surgical approach. A multicentre study by Uccella et al. of 1,606 women aged 65 + with endometrial cancer found that laparoscopic surgery was associated with fewer complications, lower transfusion rates, and shorter hospital stays—even for those aged ≥ 80 years [ 9 ]. Further research confirmed the safety and effectiveness of robotic, laparoscopic, and vaginal approaches in women aged ≥ 85 years, although robotic surgery was linked to longer operative times and hospital stays [ 10 ]. These findings support the use of MIS regardless of age. In our cohort, 26.2% ( N  = 56) were over 70 years of age. These patients had more comorbidities and were mostly in higher ASA classes (III/IV). Oncologic indications, primarily endometrial cancer, were more common in older women, while younger patients had more benign conditions like fibroids, endometrial hyperplasia, and cervical dysplasia. This aligns with Puntambekar et al.'s findings, where fibroids and adenomyosis were leading benign indications [ 11 ]. In our study patients underwent one of three surgical approaches: 61 robotic (Versius system), 104 laparoscopic, and 48 open abdominal. Surgical method selection was guided by uterine pathology, anatomy, adhesions, and surgeon experience [ 12 ]. Nine conversions occurred—six from laparoscopy to laparotomy and three from robotic to laparoscopy—primarily due to adhesions or unexpected malignancies. These factors, not patient age, were the main contributors to conversion, consistent with previous research [ 11 ]. Minimally invasive hysterectomy (laparoscopic and robotic) offers clear advantages over open laparotomy, including fewer perioperative complications, shorter hospital stays, faster recovery, and reduced healthcare costs [ 13 , 14 ]. In our study, laparotomy was significantly associated with higher postoperative complication rates, while MIS approaches had a combined rate of only 3.64%. No significant association was found between complications and patient age or indication type (oncologic vs. non-oncologic). Similarly, haematologic changes before and after surgery showed no significant age-related differences. Laparoscopic hysterectomy generally has low morbidity, with reported complication rates of 4–5% [ 15 ]. These include febrile episodes, urinary retention, and port-site infections. A review by Puntambekar et al. found a 7.6% complication rate among 1,200 laparoscopic cases, all managed conservatively [ 11 ]. In our study, 13 patients experienced complications (8 younger, 5 older); 7 followed open hysterectomy, 6 after MIS. Three patients—all after open surgery—required reoperation, mostly due to eventration and wound infection. No reoperations occurred following laparoscopic or robotic procedures. Across all patient groups in our study—regardless of whether they underwent open or MIS procedures—there were no treatment-related deaths or admissions to the intensive care unit during the 90-day postoperative period. The length of hospital stay after hysterectomy did not differ significantly between younger and older patients. Furthermore, the 30-day readmission rate was low, with only three patients (two younger and one older) requiring rehospitalisation for issues such as lower abdominal pain, vaginal stump bleeding, or wound infection. None of these cases required reoperation. These findings align with those reported in the broader literature, which have shown low reoperation rates following minimally invasive hysterectomy. For instance, in a study analysing over 1,500 laparoscopic hysterectomies, the reoperation rate was 1.2%, with the most postoperative complications managed conservatively [ 16 – 19 ]. For malignancies—most commonly endometrial, ovarian, and cervical cancers—hysterectomy remains a cornerstone of curative treatment [ 20 ]. Open radical hysterectomy has long been the standard for gynaecologic cancers, but its association with large incisions, higher complication rates, and longer recovery is well-documented [ 21 , 22 ]. Given the ageing global population, it is crucial to refine both the process through which the appropriateness of hysterectomy is determined and the quality of perioperative and oncologic care provided to older women. This includes enhancing surgeon training, expanding access to MIS techniques, and improving patient selection strategies, particularly for elderly individuals and those with complex conditions. The LAP2 trial and related studies confirmed that laparoscopic surgery is as safe and effective as laparotomy for early endometrial cancer staging, offering lower complication and conversion rates [ 17 , 23 ]. Laparoscopic radical hysterectomy has since gained popularity for its reduced blood loss, fewer wound issues, and shorter hospital stays, with comparable oncologic outcomes [ 24 ]. Robotic-assisted techniques further enhance precision and visualization, though global adoption for cervical cancer remains limited, and long-term data are still evolving [ 25 , 26 ]. Following the 2018 LACC trial, which showed worse outcomes for MIS in early-stage cervical cancer, many centres returned to open surgery despite improved perioperative techniques [ 27 , 28 ]. In our study, all patients with invasive cervical cancer underwent open radical hysterectomy with lymphadenectomy. These procedures had the longest operative times—particularly in younger patients—reflecting the complexity of their oncologic cases. Radical hysterectomies consistently took longer than other procedures, and among laparotomy cases, younger patients had longer operative times, likely due to the higher prevalence of extensive oncologic procedures such as those for cervical or ovarian cancer. Minimally invasive hysterectomy offers clear benefits—less blood loss, reduced pain, and faster recovery—but also carries risks such as vaginal cuff dehiscence (VCD), a rare yet serious complication linked to thermal injury during colpotomy and intracorporeal suturing. VCD occurs more frequently after laparoscopic (0.64–1.35%) and robot-assisted hysterectomy (1.64%) than with open or vaginal techniques [ 29 , 30 ]. Prevention involves precise surgical technique and careful postoperative guidance [ 31 ]. In our study, one 75-year-old patient developed partial VCD post-radical laparoscopy owing to endometrial cancer, which resolved with conservative management. We also observed that higher BMI significantly increased complication risk, age and ASA classification, however, did not show a significant impact. Interestingly, some data suggest that obesity and older age may offer protection against VCD, possibly due to reduced thermal spread and mechanical tension at the vaginal cuff [ 32 ]. These findings underscore the need for personalized surgical planning and further research on tissue healing and activity levels post-surgery. Beyond laparoscopy and robotic-assisted MIS, emerging techniques such as Vaginal Natural Orifice Transluminal Endoscopic Surgery (V-NOTES) merit discussion. V-NOTES has gained traction—particularly for hysterectomy—due to its minimally traumatic nature, faster recovery, and favourable outcomes, which may be especially relevant in women over 70 [ 33 ]. Performed transvaginally, V-NOTES is associated with reduced surgical trauma, less postoperative pain, shorter hospital stays, and lower complication rates. For pelvic organ prolapse (POP), V-NOTES offers an advantageous alternative to laparoscopy, with lateral suspension achieving comparable success rates to laparoscopic lateral suspension but with shorter hospitalisation and fewer complications [ 34 , 35 ]. Comparing V-NOTES hysterectomy with MIS approaches would require a dedicated study, potentially yielding valuable insights for older women. Another noteworthy minimally invasive option is minilaparoscopy, which can positively influence treatment outcomes in elderly patients. Minilaparoscopic hysterectomy (MLH) effectively treats various gynaecologic conditions while offering aesthetic benefits, reduced perioperative pain, and faster recovery, with smaller-calibre instruments preserving the ergonomics of standard laparoscopy for ease of adoption by experienced surgeons [ 36 ]. POP—often associated with prior hysterectomy—is common in women over 70 and frequently requires surgical treatment. Laparoscopic approaches generally offer greater efficiency, speed, and ease of execution compared with robotic surgery, although hospital stay and complication rates are similar [ 37 , 38 ]. Prevention of complications such as urinary incontinence depends heavily on postoperative care, including timely physiotherapy and other techniques like sacral neuromodulation [ 39 , 40 ]. Modern minimally invasive surgical methods and proper technique can prevent POP, preserve pelvic floor function, and, in younger patients, maintain fertility [ 41 ]. For younger patients, fertility preservation after cancer treatment should be an integral part of survivorship care, requiring timely counselling, multidisciplinary collaboration, and education on medical, ethical, and legal aspects—supported by broad stakeholder consensus to align new technologies with core values in medicine [ 42 – 44 ]. This study’s retrospective design, limited sample size, and the predominance of oncologic indications in the older cohort may have influenced complication rates and recovery outcomes, necessitating cautious interpretation. However, a major strength lies in the consistency of surgical methods, as all procedures were performed by one experienced team at a single institution, ensuring technical uniformity. Standardized data collection further enhanced the reliability of the findings. Notably, this is among the first studies to assess the use of the Versius CMR robotic system in women over 70 undergoing gynaecologic surgery.

Minimally invasive hysterectomy—whether laparoscopic or robotic assisted—is safe and effective in older women, achieving outcomes comparable to younger populations. Surgical approaches should be tailored to the patient’s anatomy, comorbidities, and indication type. In experienced centres, these techniques consistently yield low complication rates, even among patients with high BMI or multiple health conditions. Robotic platforms like the Versius system enhance surgical precision and safety in complex cases. When combined with careful preoperative assessment and personalized planning, they offer substantial benefits, particularly for elderly patients.

Surgical treatment in patients over the age of 70 presents distinct challenges due to a combination of their overall health status and age-related physiological changes. The presence of certain comorbidities, such as hypertension, diabetes, heart failure, and chronic obstructive pulmonary disease, significantly increases perioperative risks, these conditions elevate the likelihood of complications during surgery [ 1 , 2 ]. Hysterectomy remains one of the most frequently performed surgeries in women. Advancements in surgical techniques, especially the introduction of minimally invasive surgery (MIS), which has facilitated the development of laparoscopic and robotic-assisted hysterectomy, have transformed the standard of care [ 3 ]. For older patients, MIS offers additional benefits by lowering cardiovascular and infectious risks, which allows for better tolerance of surgery while maintaining oncologic efficacy [ 4 ]. The emergence of robotic systems, such as the Versius robotic platform, has promoted ongoing innovations in the field [ 5 ]. These systems enhance precision and further improve surgical outcomes, especially in elderly patients who already have increased surgical risks. Studies comparing various techniques for hysterectomy in patients over 70 emphasise the importance of individualised approaches to treatment and care. Comprehensive preoperative assessments and the selection of MIS techniques are critical to achieving favourable outcomes while minimising risks [ 6 ]. This study aims to evaluate the use of different hysterectomy techniques—both for oncologic and non-oncologic indications—in women over the age of 70, as well as in younger cohorts. Special emphasis is placed on assessing outcomes associated with MIS approaches, including conventional laparoscopy and robotic-assisted procedures using the Versius surgical system, as well as traditional open surgery. In addition to analysing the clinical utilisation of these techniques, the study compares early and long-term surgical outcomes across the three methods. By highlighting the role of technological innovation and emphasising the importance of individualised treatment strategies, this research seeks to contribute to the optimisation of surgical care for the expanding population of elderly female patients.