Total Laparoscopic Hysterectomy Without a Uterine Manipulator in more than 2000 Consecutive Patients: Updated Insights from a Large Retrospective, multicenter, multinational Study

Total Laparoscopic Hysterectomy Without a Uterine Manipulator in more than 2000 Consecutive Patients: Updated Insights from a Large Retrospective, multicenter, multinational 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 Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Total Laparoscopic Hysterectomy Without a Uterine Manipulator in more than 2000 Consecutive Patients: Updated Insights from a Large Retrospective, multicenter, multinational Study Dimitrios Zygouris, Antonios Gkoutzioulis, Panagiotis Papandreou, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-10773840/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Purpose In 2020, we reported the outcomes of 1,023 TLH procedures performed withouta uterine manipulator. In this study we present updated data on 2,162 cases, providing the largest multi-center experience to date, aiming to evaluate the safety and outcomes in a large patient cohort. Methods We retrospectively reviewed 2,162 consecutive patients who underwent TLH for benign indications, between 1/2011 and 1/2026. Results The mean patient age was 52.9 years and the mean body mass index was 27.9 kg/m². The most common indication was fibroid 56%, adenomyosis uteri 12%, followed by endometrial hyperplasia 11.0% and cervical intraepithelial neoplasia 5.5%. The mean operative time was 76 minutes, with an estimated mean blood loss of 54 ml. In three cases conversion to laparotomy was needed due to major bleeding and blood transfusion was necessary in 23 patients (1.1%). Intraoperative complications included one ureteral injury (0.05%), four bladder injuries (0.2%). The mean hospital stay was 1.2 days, with 51 patients requiring hospitalization for more than two days. Postoperative complications included vault hematoma in two and vault dehiscence in ten. Conclusions This expanded multicenter, multinational series of 2,162 patients confirm our previous findings that TLH without a uterine manipulator is feasible, safe, and reproducible technique with low rates of intra- and postoperative complications and short hospital stay. With appropriate surgical expertise, this technique shortens operative time and may serve as a first step in the training of gynecologists for performing advanced laparoscopic surgeries, such as radical hysterectomy. Total laparoscopic Hysterectomy Uterine manipulator Complication rate Ureter injury Vaginal vault complications Introduction Hysterectomy remains the most frequently performed gynecological surgery and can be conducted via abdominal, vaginal, laparoscopic, or robotic approaches, each with various technical modifications [ 1 ]. The laparoscopic technique was first introduced approximately three decades ago [ 2 ] and since then laparoscopy has progressively evolved into the preferred route for hysterectomy as it revealed reduced blood loss, shorter hospital stay, faster recovery and improved postoperative outcomes compared to open surgery, while continuous refinements in laparoscopic instruments and surgical techniques have further contributed to its widespread adoption [ 3 ]. A uterine manipulator is used to mobilize the uterus, improve exposure, define colpotomy point, and reduce intraoperative risks—especially bladder and ureter injury [ 4 – 6 ]. However, the publication of the Laparoscopic Approach to Cervical Cancer (LACC) trial [ 7 , 8 ] brought renewed scrutiny to the use of uterine manipulators, raising questions about their potential impact on oncologic and surgical outcomes [ 9 , 10 ]. Notably, we had already highlighted similar concerns nearly a decade earlier, when we published our technique for total laparoscopic hysterectomy (TLH) performed without a uterine manipulator [ 11 ]. This method was later extended to laparoscopic nerve-sparing radical hysterectomy, particularly in studies conducted in the wake of the LACC trial findings [ 12 ]. In 2020, we reported outcomes from 1,023 TLH cases performed in two hospitals by the same surgical team, without the use of a uterine manipulator, demonstrating the safety and efficiency of this approach [ 13 ]. In the following years, we expanded our series to 2,162 consecutive TLH cases performed without a uterine manipulator, representing one of the largest cohorts worldwide. The present study aims to validate our previous results in a larger population and to evaluate the reproducibility, perioperative outcomes, and long-term safety of TLH without a uterine manipulator. Materials and Methods Study design and population This is a retrospective study of 2,162 consecutive patients undergoing TLH without a uterine manipulator between January 2011 and January 2026 at St. Luke’s Hospital in Thessaloniki, Greece, and at the Mother and Child Medical Center in Nicosia, Cyprus. All data were retrospectively collected and analyzed after obtaining approval from the hospitals’ ethics committees. Prior to surgery, all patients provided written informed consent following a comprehensive explanation of the procedure. Each operation was documented using the ENDOBASE digital recording system (Olympus, Hamburg, Germany). Patients Patient demographic data, including age, weight, body mass index (BMI) and surgical history, were retrospectively retrieved from hospitals’ medical records. Information regarding the indications for hysterectomy, surgical parameters, and intra- and postoperative complications was also collected. All hysterectomies were performed for benign indications. Exclusion criteria included suspected or confirmed malignancy of the endometrium, cervix, or ovary, as well as patients with Stage III–IV pelvic organ prolapse, who were scheduled for laparoscopic sacrocolpopexy. Preoperative evaluation included a detailed clinical history, physical examination and transvaginal ultrasound. All patients underwent routine laboratory testing (complete blood count, liver, and kidney function tests) and had nothing by mouth for eight hours before surgery and no additional bowel preparation was performed. Intraoperatively, a single dose of prophylactic antibiotics (cefuroxime 1.5 g) was administered intravenously. Antithrombotic prophylaxis was initiated eight hours postoperatively and continued until hospital discharge. Patients were mobilized within 6–10 hours of surgery and a follow-up complete blood count was performed at 24 hours. The transurethral catheter was removed once the patient was fully mobilized and no drainage was not routinely used. Estimated blood loss was calculated from the change in hemoglobin levels between the preoperative and 24-hour postoperative measurements. Operative time was defined as the interval from the first umbilical incision to skin closure at the final incision site. All procedures were carried out by the same surgical team (AK and DZ) using a previously described technique [ 11 ], without the use of a uterine manipulator. Surgical technique The standardized technique was consistent with our previously described protocol. The patient is placed in modified lithotomy position and after pneumoperitoneum, four trocars were inserted. The uterus is mobilized using grasping forceps and laparoscopic instruments. For the colpotomy the surgeon, standing on the patient’s right side, introduced the left index finger vaginally to identify the dissection plane, after which the anterior wall was incised with laparoscopic scissors. The assistant then grasped the vaginal wall, a compress was inserted to maintain pneumoperitoneum, and the surgeon continued after changing gloves. The cervix was mobilized cephalad and dissected circumferentially close to its margin to preserve cervical length and avoid uterosacral ligament transection, facilitating future vault suspension. Thermal energy use during colpotomy was minimized, and the vagina was closed laparoscopically with interrupted O-Vicryl sutures using intracorporeal knotting. Results A total of 2,162 patients met the inclusion criteria and underwent TLH for benign indications. Patients’ characteristics, including age, BMI, menopausal status and history of previous laparotomy or caesarean section, are presented in Table 1 . The mean age was 52.9 years (range 37–86) and the mean BMI was 27.9 kg/m² (range 19.8–48.6). A total of 670 women (31.0%) were postmenopausal and 1,227 patients (56.7%) underwent TLH with adnexectomy. Table 1 Patient demographic characteristics TLH 2162 – TLH without adnexectomy 935 (43.3%) – TLH with adnexectomy 1227 (56.7%) Menopausal status 670 (31%) Previous laparotomy or caesarean 1232 (57%) Age (years) 52.9 (37–86)* BMI (kg/m²) 27.9 (19.8–48.6)* *Values are presented as mean (range). TLH = total laparoscopic hysterectomy; CS = caesarean section; BMI = body mass index. Table 2 outlines the indications for hysterectomy. The common indication was fibroids (1,230; 56.9%) and adenomyosis (260; 12%), while endometrial hyperplasia accounted for 237 cases (11.0%). We also included 241 (11%) cases of Menorrhagia / DUB and 118 (5.5%) cases of CIN that after detailed consultation TLH was decided. Table 2 Indications for Hysterectomy Fibroids n = 2162 1230 (56.9%) Adenomyosis 260 (12%) Endometrial hyperplasia 237 (11%) CIN 118 (5.5%) Menorrhagia / DUB 241(11%) Other 76 (3.5%) CIN = cervical intraepithelial neoplasia; DUB = dysfunctional uterine bleeding. Intraoperative data are shown in Table 3 . The mean operative time was 76 minutes (range 41–182), including 73 minutes (range 41–149) in cases of TLH without adnexectomy or opportunistic salpingectomy and 81 minutes (range 20–182) for TLH with adnexectomy. The mean estimated blood loss was 54 mL (range 20–390) and the mean uterine weight was 269 g (range 40–1,730). There were 3 cases of conversion to laparotomy due to major bleeding and blood transfusion was required in 23 patients (1.1%). Intraoperative complications included one ureteral injury (0.05%), four bladder injuries (0.2%). All complications were recognized intraoperatively and managed laparoscopically. Table 3 Intraoperative outcomes (n = 2162) Operating time, all cases (range) 76 (41–182) min Operating time, TLH (range) 73 (41–149) min Operating time, TLH + adnexectomy (range) 81 (20–182) min Estimated blood loss (range) 54 (20–390) mL Uterine weight (range) 269 (40–11730) g Conversion to laparotomy 3 (0.1%) Women requiring blood transfusion 23 (1.1%) Ureteral injury 1 (0.05%) Bladder injury 4 (0.2%) TLH = total laparoscopic hysterectomy. Postoperative outcomes are summarized in Table 4 . The mean hospital stay was 1.2 days (range 1–8), with 51 patients (2.4%) remaining hospitalized for more than two days. Causes for extended hospitalization included pyrexia (22 cases), delayed catheter removal (nine cases), wound infection (six cases). Concerning the vaginal vault, we had 2 cases of vault hematoma (0.1%) and 10 cases of vault dehiscence (0.5%). Nine patients (0.4%) required readmission for surgical treatment of vaginal complications. Table 4 Postoperative complications (n = 2162) Pyrexia > 37.5°C 22 (1%) Urinary tract infection 8 (0.4%) Deep vein thrombosis 0 Pulmonary embolism 0 Mean catheter duration (range) 1 (1–7) days Patients with catheter > 2 days 9 (0.4%) Mean hospital stay (range) 1.2 (1–8) days Patients hospitalized > 2 days 51 (2.4%) Wound infection 6 (0.3%) Vault hematoma 2 (0.1%) Vault dehiscence 10 (0.5%) Readmission after surgery 9 (0.4%) Discussion This updated multicenter, multinational case series of 2,162 consecutive TLH without a uterine manipulator represents, to our knowledge, the largest cohort reported to date. Following our previous report of 1,023 cases [ 13 ], the present study confirms the reproducibility, safety and efficacy of this technique across a wider patient population and with longer follow-up. Our data show that TLH without a manipulator can be consistently performed with low complication rates, short operative time, and minimal blood loss, even in challenging cases such as women with high BMI, prior laparotomy or caesarean section, or large uteri. Importantly, there were only 3 cases of conversion to laparotomy and complications, including ureter injury, were rare. These outcomes suggest that performing TLH without a uterine manipulator does not compromise surgical safety, provided that standardized techniques and appropriate intra-abdominal handling are employed by well trained and experienced surgeons. Intraoperative outcomes compare favorably with published series of TLH with a uterine manipulator [ 14 ] as our mean operative time of 78 minutes and estimated blood loss of 59 mL are at least equivalent, and often superior, to values reported in studies using uterine manipulators [ 15 ]. Similarly, the low incidence of ureteral injury (0.05%) in our study shows that adequate protection of the ureter can be achieved even without manipulator use, relying instead on careful anatomical dissection and strategic use of laparoscopic instruments to manipulate intra abdominally the uterus. The extremely low incidence of ureteral injury (0.05%) in our series compares favorably with rates reported in other studies with traditional manipulators, which range between 0.2% and 1.0% [ 16 – 18 ]. Importantly, the only case of ureteral injury was in a patient with a large intraligamentary fibroid, underscoring that patient-specific pathology, rather than the absence of a manipulator, was the decisive risk factor. Furthermore, rate of bladder (0.2%) injuries remained within or below the ranges reported in other large-scale laparoscopic hysterectomy studies [ 15 , 19 ]. These findings strongly support the notion that careful surgical technique and appropriate use of laparoscopic instruments can effectively mitigate the theoretical risks associated with abandoning a manipulator. Early postoperative complications such as urinary tract infection (0.4%), pyrexia (1.0%) and wound infection (0.3%) were rare and comparable to or below published rates in laparoscopic hysterectomy. Importantly, there was no case of deep vein thrombosis or pulmonary embolism. Moreover, the median hospital stay was short (1.2 days), with only 2.3% of patients requiring hospitalization beyond two days, primarily for non-surgical reasons or patients’ preference. These results further support the efficiency of TLH without a manipulator in enabling rapid recovery and minimal morbidity. A particular strength of our technique lies in the preservation of vaginal integrity and vascularization, as we perform colpotomy with scissors, limiting the use of bipolar energy to hemostasis only and no monopolar energy is used. Avoiding extensive thermal damage appears to contribute to more robust healing of the vaginal cuff as the incidence of vault dehiscence (0.5%) in our cohort was lower than many reported series, where rates between 1–3% are described [ 20 ]. The technical feasibility of TLH without a manipulator must also be considered in the context of surgical training. As highlighted in our earlier report, this approach is inherently more demanding, requiring more precise instrument handling and spatial orientation to maintain a safe distance from the ureter during uterine artery ligation. In our expanded series, all procedures were performed by the same experienced surgical team following standardized steps, which likely contributed to the consistently low complication rates. Nevertheless, we acknowledge that the learning curve may be longer for surgeons new to this approach. We continue to advocate for structured mentorship when adopting TLH without a uterine manipulator. Based on our cumulative experience of more than 2,000 cases, we estimate that at least 30 supervised procedures are necessary before a surgeon can perform the technique independently. While this threshold is comparable to other advanced laparoscopic procedures, the absence of a manipulator demands additional emphasis on mastering intra-abdominal uterine mobilization using ancillary instruments. Once this skill set is acquired, operative times plateau, complication rates decrease and the technique becomes reproducible across different case complexities. Furthermore, we believe that this technique serves as an essential foundation for more complex operations, such as laparoscopic nerve-sparing radical hysterectomy. The LACC trial renewed scrutiny of manipulator use in oncological settings and our data further support the notion that TLH without a manipulator is feasible not only in benign cases but also for radical hysterectomy with excellent oncological outcome [ 12 ]. Thus, establishing competence in this technique during benign hysterectomy may provide a safer transition for surgeons undertaking advanced laparoscopic surgeries such as radical hysterectomy and laparoscopic sacrocolpopexy [ 21 ]. The strengths of this study include its large sample size, standardized surgical technique and consecutive patient inclusion, which reduce selection bias. All procedures were performed by the same experienced team, enhancing consistency and reproducibility. However, the retrospective design and lack of a comparison group limit direct conclusions regarding superiority. Prospective randomized studies remain necessary to confirm these findings. Conclusion This expanded multicenter, multinational study of 2,162 patients confirm that hysterectomy without a uterine manipulator is feasible, safe and reproducible with low rates of intra- and postoperative complications and short hospital stay. Our study shows that the major concern of ureter injury during a laparoscopic hysterectomy can be avoided even by performing hysterectomy without a manipulator, resulting in better vaginal vault healing in acceptable operative time. Of course, it is crucial that the surgery is performed by an experienced, well-trained laparoscopic surgeon that has undergone an adequate learning curve. Declarations Funding The author(s) received no financial support for the research and authorship. Author Contribution D Z: Conceptualization Writing – original draft, Responsible SurgeonA G: Data curation, Formal analysis, Writing – review and editingP P: Data curation, Formal analysis, Writing – review and editingA S: Formal analysis, EditingA S: Data curation, Formal analysis, Writing – review and editingA E: Data curation, Formal analysis, Writing – review and editingD G: Data curation, Review A K: Conceptualization, Writing – original draft, Responsible Surgeon Data Availability Data cannot be shared openly but are available on request from authors References Pickett, C.M., et al., Surgical approach to hysterectomy for benign gynaecological disease . Cochrane Database Syst Rev, 2023. 8(8): p. CD003677. Reich, H., New techniques in advanced laparoscopic surgery . Baillieres Clin Obstet Gynaecol, 1989. 3(3): p. 655–81. Rademaker, D., et al., Vaginal or laparoscopic hysterectomy: Do perioperative outcomes differ? A propensity score-matched analysis . Acta Obstet Gynecol Scand, 2019. 98(8): p. 1040–1045. Karaman, Y., B. Bingol, and Z. Gunenc, Prevention of complications in laparoscopic hysterectomy: experience with 1,120 cases performed by a single surgeon . J Minim Invasive Gynecol , 2007. 14(1): p. 78–84. Giorgi, M., et al., Prevention and treatment of intraoperative complications during gynecological laparoscopic surgery: Practical tips and tricks - A narrative review. Adv Ther, 2025. 42(5): p. 2089–2117. Wong, J.M.K., et al., Urinary tract injury in gynecologic laparoscopy for benign indication: A systematic review . Obstet Gynecol, 2018. 131(1): p. 100–108. Ramirez, P.T., et al., Minimally invasive versus abdominal radical hysterectomy for cervical cancer . N Engl J Med, 2018. 379(20): p. 1895–1904. Ramirez, P.T., et al., LACC trial: Final analysis on overall survival comparing open versus minimally invasive radical hysterectomy for early-stage cervical cancer . J Clin Oncol, 2024. 42(23): p. 2741–2746. Chiva, L., et al., SUCCOR study: An international European cohort observational study comparing minimally invasive surgery versus open abdominal radical hysterectomy in patients with stage IB1 cervical cancer . Int J Gynecol Cancer, 2020. 30(9): p. 1269–1277. Kohler, C., et al., The basic principles of oncologic surgery during minimally invasive radical hysterectomy . J Gynecol Oncol, 2020. 31(1): p. e33. Kavallaris, A., et al., Total laparoscopic hysterectomy without uterine manipulator: description of a new technique and its outcome . Arch Gynecol Obstet, 2011. 283(5): p. 1053–7. Kavallaris, A., et al., Laparoscopic nerve-sparing radical hysterectomy without uterine manipulator for cervical cancer stage IB: Description of the technique, our experience and results after the era of LACC trial . Arch Gynecol Obstet, 2021. 303(4): p. 1039–1047. Zygouris, D., et al., Total laparoscopic hysterectomy without uterine manipulator. A retrospective study of 1,023 cases . Eur J Obstet Gynecol Reprod Biol, 2020. 253: p. 254–258. Wattiez, A., et al., The learning curve of total laparoscopic hysterectomy: comparative analysis of 1,647 cases . J Am Assoc Gynecol Laparosc, 2002. 9(3): p. 339–45. Choudhary, A., P.A. Palaskar, and V. Bhivsane, Complications of total laparoscopic hysterectomy: A retrospective study of cases performed by a single surgeon . J Minim Access Surg, 2023. 19(4): p. 473–477. Donnez, O., et al., A series of 3,190 laparoscopic hysterectomies for benign disease from 1990 to 2006: Evaluation of complications compared with vaginal and abdominal procedures. BJOG, 2009. 116(4): p. 492–500. Adelman, M.R., T.R. Bardsley, and H.T. Sharp, Urinary tract injuries in laparoscopic hysterectomy: A systematic review . J Minim Invasive Gynecol, 2014. 21(4): p. 558–66. Leonard, F., et al., Ureteral complications from laparoscopic hysterectomy indicated for benign uterine pathologies: A 13-year experience in a continuous series of 1,300 patients. Hum Reprod, 2007. 22(7): p. 2006–11. Brummer, T.H., et al., FINHYST, a prospective study of 5,279 hysterectomies: Complications and their risk factors . Hum Reprod, 2011. 26(7): p. 1741–51. Mikhail, E., et al., Does laparoscopic hysterectomy increase the risk of vaginal cuff dehiscence? An analysis of outcomes from multiple academic centers and a review of the literature . Surg Technol Int, 2015. 27: p. 157–62. Kavallaris, A. and D. Zygouris, Laparoscopic sacrocolpopexy comparing polypropylene mesh with polyvinylidene fluoride mesh for pelvic organ prolapse: Technique description and long-term outcomes . Neurourol Urodyn, 2020. 39(8): p. 2264–2271. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 15 Sep, 2026 Reviewers agreed at journal 08 Sep, 2026 Reviewers invited by journal 08 Sep, 2026 Editor assigned by journal 26 Aug, 2026 Submission checks completed at journal 22 Aug, 2026 First submitted to journal 21 Aug, 2026 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 In Review Editorial Policies 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-10773840","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":717206608,"identity":"fab6715c-88d3-4d5f-9207-4a10e44329ba","order_by":0,"name":"Dimitrios Zygouris","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4UlEQVRIiWNgGAWjYDCCAxCKh4G9B8LgI14Lzxkwh4eNWC0MDBI5EA5BLXznzxi/+Nh2T0Z+5tuDjz/m2MmwMTA/fHQDjxbJA2fMLGe2FfMY3M5LNji4LRnoMDZj4xw8WgwO9pgZ87Yl8BhI55hJHNzGDNTCwyaNV8thHogW+ZlnQFrqidByjMf4MUgLww0ekJbDhLVInmErY5xxDuiwMznGBme3HedhYybgF77zhzd/+FCWYC/ffsbwQeW2ant+9uaHj/FpYWDgMJNAFWDGqxwE2B9/IKhmFIyCUTAKRjYAAOkNRlLjqcEjAAAAAElFTkSuQmCC","orcid":"","institution":"St Luke’s Hospital","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Dimitrios","middleName":"","lastName":"Zygouris","suffix":""},{"id":717206609,"identity":"d1cb20d7-7ea4-45f3-8a8c-7b3ab19dee45","order_by":1,"name":"Antonios Gkoutzioulis","email":"","orcid":"","institution":"St Luke’s Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Antonios","middleName":"","lastName":"Gkoutzioulis","suffix":""},{"id":717206611,"identity":"93c13e73-52ed-480b-b32b-07cec95db83c","order_by":2,"name":"Panagiotis Papandreou","email":"","orcid":"","institution":"St Luke’s Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Panagiotis","middleName":"","lastName":"Papandreou","suffix":""},{"id":717206612,"identity":"f1751949-f233-4c2d-9d5b-c448ad8a8f75","order_by":3,"name":"Anna Sachpekidou","email":"","orcid":"","institution":"St Luke’s Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Anna","middleName":"","lastName":"Sachpekidou","suffix":""},{"id":717206616,"identity":"aefa3938-7991-4b3f-a427-cdfc4a46840c","order_by":4,"name":"Andrea Shaelou","email":"","orcid":"","institution":"Mother and Child Medical Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Andrea","middleName":"","lastName":"Shaelou","suffix":""},{"id":717206621,"identity":"9d125bc8-0e42-449c-93d8-a9436cf11d23","order_by":5,"name":"Afroditi Elisseou","email":"","orcid":"","institution":"Mother and Child Medical Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Afroditi","middleName":"","lastName":"Elisseou","suffix":""},{"id":717206623,"identity":"fb7bb43e-4b3e-4bf3-b94a-d253006eb12f","order_by":6,"name":"Dimitrios Grigoriou","email":"","orcid":"","institution":"Mother and Child Medical Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Dimitrios","middleName":"","lastName":"Grigoriou","suffix":""},{"id":717206624,"identity":"2c9ed29c-1ba8-4a40-b78b-22f9e9dcfc60","order_by":7,"name":"Andreas Kavallaris","email":"","orcid":"","institution":"St Luke’s Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Andreas","middleName":"","lastName":"Kavallaris","suffix":""}],"badges":[],"createdAt":"2026-08-21 08:10:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-10773840/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-10773840/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":120301677,"identity":"6813ff26-6e35-4c07-9250-23eddbcb8c72","added_by":"auto","created_at":"2026-09-16 09:47:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":186349,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-10773840/v1/cedbac69-d8d3-48be-8940-e1425253db56.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Total Laparoscopic Hysterectomy Without a Uterine Manipulator in more than 2000 Consecutive Patients: Updated Insights from a Large Retrospective, multicenter, multinational Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHysterectomy remains the most frequently performed gynecological surgery and can be conducted via abdominal, vaginal, laparoscopic, or robotic approaches, each with various technical modifications [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The laparoscopic technique was first introduced approximately three decades ago [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] and since then laparoscopy has progressively evolved into the preferred route for hysterectomy as it revealed reduced blood loss, shorter hospital stay, faster recovery and improved postoperative outcomes compared to open surgery, while continuous refinements in laparoscopic instruments and surgical techniques have further contributed to its widespread adoption [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA uterine manipulator is used to mobilize the uterus, improve exposure, define colpotomy point, and reduce intraoperative risks\u0026mdash;especially bladder and ureter injury [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. However, the publication of the Laparoscopic Approach to Cervical Cancer (LACC) trial [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] brought renewed scrutiny to the use of uterine manipulators, raising questions about their potential impact on oncologic and surgical outcomes [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNotably, we had already highlighted similar concerns nearly a decade earlier, when we published our technique for total laparoscopic hysterectomy (TLH) performed without a uterine manipulator [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. This method was later extended to laparoscopic nerve-sparing radical hysterectomy, particularly in studies conducted in the wake of the LACC trial findings [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn 2020, we reported outcomes from 1,023 TLH cases performed in two hospitals by the same surgical team, without the use of a uterine manipulator, demonstrating the safety and efficiency of this approach [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In the following years, we expanded our series to 2,162 consecutive TLH cases performed without a uterine manipulator, representing one of the largest cohorts worldwide. The present study aims to validate our previous results in a larger population and to evaluate the reproducibility, perioperative outcomes, and long-term safety of TLH without a uterine manipulator.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eStudy design and population\u003c/p\u003e \u003cp\u003eThis is a retrospective study of 2,162 consecutive patients undergoing TLH without a uterine manipulator between January 2011 and January 2026 at St. Luke\u0026rsquo;s Hospital in Thessaloniki, Greece, and at the Mother and Child Medical Center in Nicosia, Cyprus. All data were retrospectively collected and analyzed after obtaining approval from the hospitals\u0026rsquo; ethics committees. Prior to surgery, all patients provided written informed consent following a comprehensive explanation of the procedure. Each operation was documented using the ENDOBASE digital recording system (Olympus, Hamburg, Germany).\u003c/p\u003e \u003cp\u003ePatients\u003c/p\u003e \u003cp\u003ePatient demographic data, including age, weight, body mass index (BMI) and surgical history, were retrospectively retrieved from hospitals\u0026rsquo; medical records. Information regarding the indications for hysterectomy, surgical parameters, and intra- and postoperative complications was also collected.\u003c/p\u003e \u003cp\u003eAll hysterectomies were performed for benign indications. Exclusion criteria included suspected or confirmed malignancy of the endometrium, cervix, or ovary, as well as patients with Stage III\u0026ndash;IV pelvic organ prolapse, who were scheduled for laparoscopic sacrocolpopexy.\u003c/p\u003e \u003cp\u003ePreoperative evaluation included a detailed clinical history, physical examination and transvaginal ultrasound. All patients underwent routine laboratory testing (complete blood count, liver, and kidney function tests) and had nothing by mouth for eight hours before surgery and no additional bowel preparation was performed.\u003c/p\u003e \u003cp\u003eIntraoperatively, a single dose of prophylactic antibiotics (cefuroxime 1.5 g) was administered intravenously. Antithrombotic prophylaxis was initiated eight hours postoperatively and continued until hospital discharge. Patients were mobilized within 6\u0026ndash;10 hours of surgery and a follow-up complete blood count was performed at 24 hours. The transurethral catheter was removed once the patient was fully mobilized and no drainage was not routinely used.\u003c/p\u003e \u003cp\u003eEstimated blood loss was calculated from the change in hemoglobin levels between the preoperative and 24-hour postoperative measurements. Operative time was defined as the interval from the first umbilical incision to skin closure at the final incision site.\u003c/p\u003e \u003cp\u003eAll procedures were carried out by the same surgical team (AK and DZ) using a previously described technique [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], without the use of a uterine manipulator.\u003c/p\u003e \u003cp\u003eSurgical technique\u003c/p\u003e \u003cp\u003eThe standardized technique was consistent with our previously described protocol. The patient is placed in modified lithotomy position and after pneumoperitoneum, four trocars were inserted. The uterus is mobilized using grasping forceps and laparoscopic instruments. For the colpotomy the surgeon, standing on the patient\u0026rsquo;s right side, introduced the left index finger vaginally to identify the dissection plane, after which the anterior wall was incised with laparoscopic scissors. The assistant then grasped the vaginal wall, a compress was inserted to maintain pneumoperitoneum, and the surgeon continued after changing gloves. The cervix was mobilized cephalad and dissected circumferentially close to its margin to preserve cervical length and avoid uterosacral ligament transection, facilitating future vault suspension. Thermal energy use during colpotomy was minimized, and the vagina was closed laparoscopically with interrupted O-Vicryl sutures using intracorporeal knotting.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 2,162 patients met the inclusion criteria and underwent TLH for benign indications. Patients\u0026rsquo; characteristics, including age, BMI, menopausal status and history of previous laparotomy or caesarean section, are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The mean age was 52.9 years (range 37\u0026ndash;86) and the mean BMI was 27.9 kg/m\u0026sup2; (range 19.8\u0026ndash;48.6). A total of 670 women (31.0%) were postmenopausal and 1,227 patients (56.7%) underwent TLH with adnexectomy.\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\u003ePatient demographic characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTLH\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2162\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ndash; TLH without adnexectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e935 (43.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ndash; TLH with adnexectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1227 (56.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMenopausal status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e670 (31%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious laparotomy or caesarean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1232 (57%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52.9 (37\u0026ndash;86)*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (kg/m\u0026sup2;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27.9 (19.8\u0026ndash;48.6)*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003e*Values are presented as mean (range).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eTLH\u0026thinsp;=\u0026thinsp;total laparoscopic hysterectomy; CS\u0026thinsp;=\u0026thinsp;caesarean section; BMI\u0026thinsp;=\u0026thinsp;body mass index.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e outlines the indications for hysterectomy. The common indication was fibroids (1,230; 56.9%) and adenomyosis (260; 12%), while endometrial hyperplasia accounted for 237 cases (11.0%). We also included 241 (11%) cases of Menorrhagia / DUB and 118 (5.5%) cases of CIN that after detailed consultation TLH was decided.\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\u003eIndications for Hysterectomy\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFibroids\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;2162\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1230 (56.9%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdenomyosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e260 (12%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEndometrial hyperplasia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e237 (11%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCIN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e118 (5.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMenorrhagia / DUB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e241(11%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76 (3.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eCIN\u0026thinsp;=\u0026thinsp;cervical intraepithelial neoplasia; DUB\u0026thinsp;=\u0026thinsp;dysfunctional uterine bleeding.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIntraoperative data are shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The mean operative time was 76 minutes (range 41\u0026ndash;182), including 73 minutes (range 41\u0026ndash;149) in cases of TLH without adnexectomy or opportunistic salpingectomy and 81 minutes (range 20\u0026ndash;182) for TLH with adnexectomy. The mean estimated blood loss was 54 mL (range 20\u0026ndash;390) and the mean uterine weight was 269 g (range 40\u0026ndash;1,730). There were 3 cases of conversion to laparotomy due to major bleeding and blood transfusion was required in 23 patients (1.1%). Intraoperative complications included one ureteral injury (0.05%), four bladder injuries (0.2%). All complications were recognized intraoperatively and managed laparoscopically.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIntraoperative outcomes (n\u0026thinsp;=\u0026thinsp;2162)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperating time, all cases (range)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76 (41\u0026ndash;182) min\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, TLH (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e73 (41\u0026ndash;149) min\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperating time, TLH\u0026thinsp;+\u0026thinsp;adnexectomy (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e81 (20\u0026ndash;182) min\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEstimated blood loss (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54 (20\u0026ndash;390) mL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUterine weight (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e269 (40\u0026ndash;11730) g\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConversion to laparotomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (0.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWomen requiring blood transfusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (1.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUreteral injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.05%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBladder injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (0.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eTLH\u0026thinsp;=\u0026thinsp;total laparoscopic hysterectomy.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePostoperative outcomes are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. The mean hospital stay was 1.2 days (range 1\u0026ndash;8), with 51 patients (2.4%) remaining hospitalized for more than two days. Causes for extended hospitalization included pyrexia (22 cases), delayed catheter removal (nine cases), wound infection (six cases). Concerning the vaginal vault, we had 2 cases of vault hematoma (0.1%) and 10 cases of vault dehiscence (0.5%). Nine patients (0.4%) required readmission for surgical treatment of vaginal complications.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePostoperative complications (n\u0026thinsp;=\u0026thinsp;2162)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePyrexia\u0026thinsp;\u0026gt;\u0026thinsp;37.5\u0026deg;C\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (1%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrinary tract infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (0.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDeep vein thrombosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePulmonary embolism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean catheter duration (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1\u0026ndash;7) days\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatients with catheter\u0026thinsp;\u0026gt;\u0026thinsp;2 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (0.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean hospital stay (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.2 (1\u0026ndash;8) days\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatients hospitalized\u0026thinsp;\u0026gt;\u0026thinsp;2 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51 (2.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWound infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (0.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVault hematoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (0.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVault dehiscence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (0.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReadmission after surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (0.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis updated multicenter, multinational case series of 2,162 consecutive TLH without a uterine manipulator represents, to our knowledge, the largest cohort reported to date. Following our previous report of 1,023 cases [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], the present study confirms the reproducibility, safety and efficacy of this technique across a wider patient population and with longer follow-up.\u003c/p\u003e \u003cp\u003eOur data show that TLH without a manipulator can be consistently performed with low complication rates, short operative time, and minimal blood loss, even in challenging cases such as women with high BMI, prior laparotomy or caesarean section, or large uteri. Importantly, there were only 3 cases of conversion to laparotomy and complications, including ureter injury, were rare. These outcomes suggest that performing TLH without a uterine manipulator does not compromise surgical safety, provided that standardized techniques and appropriate intra-abdominal handling are employed by well trained and experienced surgeons.\u003c/p\u003e \u003cp\u003eIntraoperative outcomes compare favorably with published series of TLH with a uterine manipulator [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] as our mean operative time of 78 minutes and estimated blood loss of 59 mL are at least equivalent, and often superior, to values reported in studies using uterine manipulators [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSimilarly, the low incidence of ureteral injury (0.05%) in our study shows that adequate protection of the ureter can be achieved even without manipulator use, relying instead on careful anatomical dissection and strategic use of laparoscopic instruments to manipulate intra abdominally the uterus. The extremely low incidence of ureteral injury (0.05%) in our series compares favorably with rates reported in other studies with traditional manipulators, which range between 0.2% and 1.0% [\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Importantly, the only case of ureteral injury was in a patient with a large intraligamentary fibroid, underscoring that patient-specific pathology, rather than the absence of a manipulator, was the decisive risk factor.\u003c/p\u003e \u003cp\u003eFurthermore, rate of bladder (0.2%) injuries remained within or below the ranges reported in other large-scale laparoscopic hysterectomy studies [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. These findings strongly support the notion that careful surgical technique and appropriate use of laparoscopic instruments can effectively mitigate the theoretical risks associated with abandoning a manipulator.\u003c/p\u003e \u003cp\u003eEarly postoperative complications such as urinary tract infection (0.4%), pyrexia (1.0%) and wound infection (0.3%) were rare and comparable to or below published rates in laparoscopic hysterectomy. Importantly, there was no case of deep vein thrombosis or pulmonary embolism. Moreover, the median hospital stay was short (1.2 days), with only 2.3% of patients requiring hospitalization beyond two days, primarily for non-surgical reasons or patients\u0026rsquo; preference. These results further support the efficiency of TLH without a manipulator in enabling rapid recovery and minimal morbidity.\u003c/p\u003e \u003cp\u003eA particular strength of our technique lies in the preservation of vaginal integrity and vascularization, as we perform colpotomy with scissors, limiting the use of bipolar energy to hemostasis only and no monopolar energy is used. Avoiding extensive thermal damage appears to contribute to more robust healing of the vaginal cuff as the incidence of vault dehiscence (0.5%) in our cohort was lower than many reported series, where rates between 1\u0026ndash;3% are described [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe technical feasibility of TLH without a manipulator must also be considered in the context of surgical training. As highlighted in our earlier report, this approach is inherently more demanding, requiring more precise instrument handling and spatial orientation to maintain a safe distance from the ureter during uterine artery ligation. In our expanded series, all procedures were performed by the same experienced surgical team following standardized steps, which likely contributed to the consistently low complication rates. Nevertheless, we acknowledge that the learning curve may be longer for surgeons new to this approach.\u003c/p\u003e \u003cp\u003eWe continue to advocate for structured mentorship when adopting TLH without a uterine manipulator. Based on our cumulative experience of more than 2,000 cases, we estimate that at least 30 supervised procedures are necessary before a surgeon can perform the technique independently. While this threshold is comparable to other advanced laparoscopic procedures, the absence of a manipulator demands additional emphasis on mastering intra-abdominal uterine mobilization using ancillary instruments. Once this skill set is acquired, operative times plateau, complication rates decrease and the technique becomes reproducible across different case complexities.\u003c/p\u003e \u003cp\u003eFurthermore, we believe that this technique serves as an essential foundation for more complex operations, such as laparoscopic nerve-sparing radical hysterectomy. The LACC trial renewed scrutiny of manipulator use in oncological settings and our data further support the notion that TLH without a manipulator is feasible not only in benign cases but also for radical hysterectomy with excellent oncological outcome [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Thus, establishing competence in this technique during benign hysterectomy may provide a safer transition for surgeons undertaking advanced laparoscopic surgeries such as radical hysterectomy and laparoscopic sacrocolpopexy [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe strengths of this study include its large sample size, standardized surgical technique and consecutive patient inclusion, which reduce selection bias. All procedures were performed by the same experienced team, enhancing consistency and reproducibility. However, the retrospective design and lack of a comparison group limit direct conclusions regarding superiority. Prospective randomized studies remain necessary to confirm these findings.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis expanded multicenter, multinational study of 2,162 patients confirm that hysterectomy without a uterine manipulator is feasible, safe and reproducible with low rates of intra- and postoperative complications and short hospital stay. Our study shows that the major concern of ureter injury during a laparoscopic hysterectomy can be avoided even by performing hysterectomy without a manipulator, resulting in better vaginal vault healing in acceptable operative time. Of course, it is crucial that the surgery is performed by an experienced, well-trained laparoscopic surgeon that has undergone an adequate learning curve.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThe author(s) received no financial support for the research and authorship.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eD Z: Conceptualization Writing \u0026ndash; original draft, Responsible SurgeonA G: Data curation, Formal analysis, Writing \u0026ndash; review and editingP P: Data curation, Formal analysis, Writing \u0026ndash; review and editingA S: Formal analysis, EditingA S: Data curation, Formal analysis, Writing \u0026ndash; review and editingA E: Data curation, Formal analysis, Writing \u0026ndash; review and editingD G: Data curation, Review A K: Conceptualization, Writing \u0026ndash; original draft, Responsible Surgeon\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData cannot be shared openly but are available on request from authors\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePickett, C.M., et al., \u003cem\u003eSurgical approach to hysterectomy for benign gynaecological disease\u003c/em\u003e. Cochrane Database Syst Rev, 2023. 8(8): p. CD003677.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReich, H., \u003cem\u003eNew techniques in advanced laparoscopic surgery\u003c/em\u003e. Baillieres Clin Obstet Gynaecol, 1989. 3(3): p. 655\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRademaker, D., et al., \u003cem\u003eVaginal or laparoscopic hysterectomy: Do perioperative outcomes differ? A propensity score-matched analysis\u003c/em\u003e. Acta Obstet Gynecol Scand, 2019. 98(8): p. 1040\u0026ndash;1045.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaraman, Y., B. Bingol, and Z. Gunenc, \u003cem\u003ePrevention of complications in laparoscopic hysterectomy: experience with 1,120 cases performed by a single surgeon\u003c/em\u003e. \u003cem\u003eJ Minim Invasive Gynecol\u003c/em\u003e, 2007. 14(1): p. 78\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGiorgi, M., et al., \u003cem\u003ePrevention and treatment of intraoperative complications during gynecological laparoscopic surgery: Practical tips and tricks - A narrative review.\u003c/em\u003e Adv Ther, 2025. 42(5): p. 2089\u0026ndash;2117.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWong, J.M.K., et al., \u003cem\u003eUrinary tract injury in gynecologic laparoscopy for benign indication: A systematic review\u003c/em\u003e. Obstet Gynecol, 2018. 131(1): p. 100\u0026ndash;108.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRamirez, P.T., et al., \u003cem\u003eMinimally invasive versus abdominal radical hysterectomy for cervical cancer\u003c/em\u003e. N Engl J Med, 2018. 379(20): p. 1895\u0026ndash;1904.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRamirez, P.T., et al., \u003cem\u003eLACC trial: Final analysis on overall survival comparing open versus minimally invasive radical hysterectomy for early-stage cervical cancer\u003c/em\u003e. J Clin Oncol, 2024. 42(23): p. 2741\u0026ndash;2746.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChiva, L., et al., \u003cem\u003eSUCCOR study: An international European cohort observational study comparing minimally invasive surgery versus open abdominal radical hysterectomy in patients with stage IB1 cervical cancer\u003c/em\u003e. Int J Gynecol Cancer, 2020. 30(9): p. 1269\u0026ndash;1277.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKohler, C., et al., \u003cem\u003eThe basic principles of oncologic surgery during minimally invasive radical hysterectomy\u003c/em\u003e. J Gynecol Oncol, 2020. 31(1): p. e33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKavallaris, A., et al., \u003cem\u003eTotal laparoscopic hysterectomy without uterine manipulator: description of a new technique and its outcome\u003c/em\u003e. Arch Gynecol Obstet, 2011. 283(5): p. 1053\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKavallaris, A., et al., \u003cem\u003eLaparoscopic nerve-sparing radical hysterectomy without uterine manipulator for cervical cancer stage IB: Description of the technique, our experience and results after the era of LACC trial\u003c/em\u003e. Arch Gynecol Obstet, 2021. 303(4): p. 1039\u0026ndash;1047.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZygouris, D., et al., \u003cem\u003eTotal laparoscopic hysterectomy without uterine manipulator. A retrospective study of 1,023 cases\u003c/em\u003e. Eur J Obstet Gynecol Reprod Biol, 2020. 253: p. 254\u0026ndash;258.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWattiez, A., et al., \u003cem\u003eThe learning curve of total laparoscopic hysterectomy: comparative analysis of 1,647 cases\u003c/em\u003e. J Am Assoc Gynecol Laparosc, 2002. 9(3): p. 339\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChoudhary, A., P.A. Palaskar, and V. Bhivsane, \u003cem\u003eComplications of total laparoscopic hysterectomy: A retrospective study of cases performed by a single surgeon\u003c/em\u003e. J Minim Access Surg, 2023. 19(4): p. 473\u0026ndash;477.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDonnez, O., et al., \u003cem\u003eA series of 3,190 laparoscopic hysterectomies for benign disease from 1990 to 2006: Evaluation of complications compared with vaginal and abdominal procedures.\u003c/em\u003e BJOG, 2009. 116(4): p. 492\u0026ndash;500.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdelman, M.R., T.R. Bardsley, and H.T. Sharp, \u003cem\u003eUrinary tract injuries in laparoscopic hysterectomy: A systematic review\u003c/em\u003e. J Minim Invasive Gynecol, 2014. 21(4): p. 558\u0026ndash;66.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLeonard, F., et al., \u003cem\u003eUreteral complications from laparoscopic hysterectomy indicated for benign uterine pathologies: A 13-year experience in a continuous series of 1,300 patients.\u003c/em\u003e Hum Reprod, 2007. 22(7): p. 2006\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrummer, T.H., et al., \u003cem\u003eFINHYST, a prospective study of 5,279 hysterectomies: Complications and their risk factors\u003c/em\u003e. Hum Reprod, 2011. 26(7): p. 1741\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMikhail, E., et al., \u003cem\u003eDoes laparoscopic hysterectomy increase the risk of vaginal cuff dehiscence? An analysis of outcomes from multiple academic centers and a review of the literature\u003c/em\u003e. Surg Technol Int, 2015. 27: p. 157\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKavallaris, A. and D. Zygouris, \u003cem\u003eLaparoscopic sacrocolpopexy comparing polypropylene mesh with polyvinylidene fluoride mesh for pelvic organ prolapse: Technique description and long-term outcomes\u003c/em\u003e. Neurourol Urodyn, 2020. 39(8): p. 2264\u0026ndash;2271.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"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":"archives-of-gynecology-and-obstetrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"arch","sideBox":"Learn more about [Archives of Gynecology and Obstetrics](https://www.springer.com/journal/404)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/arch/default.aspx","title":"Archives of Gynecology and Obstetrics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Total laparoscopic Hysterectomy, Uterine manipulator, Complication rate, Ureter injury, Vaginal vault complications","lastPublishedDoi":"10.21203/rs.3.rs-10773840/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-10773840/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn 2020, we reported the outcomes of 1,023 TLH procedures performed withouta uterine manipulator. In this study we present updated data on 2,162 cases, providing the largest multi-center experience to date, aiming to evaluate the safety and outcomes in a large patient cohort.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003cbr\u003e\nWe retrospectively reviewed 2,162 consecutive patients who underwent TLH for benign indications, between 1/2011 and 1/2026.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003cbr\u003e\nThe mean patient age was 52.9 years \u0026nbsp;and the mean body mass index was 27.9 kg/m². The most common indication was fibroid 56%, adenomyosis uteri 12%, followed by endometrial hyperplasia 11.0% and cervical intraepithelial neoplasia 5.5%.\u003c/p\u003e\n\u003cp\u003eThe mean operative time was 76 minutes, with an estimated mean blood loss of 54 ml. In three cases conversion to laparotomy was needed due to major bleeding and blood transfusion was necessary in 23 patients (1.1%). Intraoperative complications included one ureteral injury (0.05%), four bladder injuries (0.2%).\u003c/p\u003e\n\u003cp\u003eThe mean hospital stay was 1.2 days, with 51 patients requiring hospitalization for more than two days. Postoperative complications included vault hematoma in two and vault dehiscence in ten.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003cbr\u003e\nThis expanded multicenter, multinational series of 2,162 patients confirm our previous findings that TLH without a uterine manipulator is feasible, safe, and reproducible technique with low rates of intra- and postoperative complications and short hospital stay. With appropriate surgical expertise, this technique shortens operative time and may serve as a first step in the training of gynecologists for performing advanced laparoscopic surgeries, such as radical hysterectomy.\u003c/p\u003e","manuscriptTitle":"Total Laparoscopic Hysterectomy Without a Uterine Manipulator in more than 2000 Consecutive Patients: Updated Insights from a Large Retrospective, multicenter, multinational Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-09-16 09:47:20","doi":"10.21203/rs.3.rs-10773840/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"30420596317152015892954812877050331995","date":"2026-09-15T11:38:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"165606402634714058730249610314582663241","date":"2026-09-08T11:37:02+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-09-08T11:21:34+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-08-26T20:09:29+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-08-22T09:49:21+00:00","index":"","fulltext":""},{"type":"submitted","content":"Archives of Gynecology and Obstetrics","date":"2026-08-21T07:51:57+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"archives-of-gynecology-and-obstetrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"arch","sideBox":"Learn more about [Archives of Gynecology and Obstetrics](https://www.springer.com/journal/404)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/arch/default.aspx","title":"Archives of Gynecology and Obstetrics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"6d881680-acb2-4192-9a5f-c8d45b0fb11b","owner":[],"postedDate":"September 16th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"30420596317152015892954812877050331995","date":"2026-09-15T11:38:35+00:00","index":19,"fulltext":""},{"type":"reviewerAgreed","content":"165606402634714058730249610314582663241","date":"2026-09-08T11:37:02+00:00","index":12,"fulltext":""},{"type":"reviewersInvited","content":"7","date":"2026-09-08T11:21:34+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-09-16T09:47:21+00:00","versionOfRecord":[],"versionCreatedAt":"2026-09-16 09:47:20","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-10773840","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-10773840","identity":"rs-10773840","version":["v1"]},"buildId":"pf3fE39SIOqb-0xH_OWvX","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}