Impact of different hysterectomy techniques on postoperative clinical and sexual outcomes: A retrospective analysis in a tertiary center

Hysterectomy is the most commonly performed pelvic surgical procedure in gynecology [ 1 ]. While the most frequent indication is uterine leiomyoma, other benign or malignant gynecological conditions such as abnormal uterine bleeding, adenomyosis, endometriosis, malignancies, and pelvic organ prolapse may also necessitate hysterectomy [ 2 ]. Today, hysterectomy can be performed using several surgical approaches, including abdominal, vaginal, laparoscopic, robotic-assisted, and transvaginal natural orifice transluminal endoscopic surgery techniques [ 3 , 4 ]. The selection of surgical route is influenced by multiple patient-, disease-, surgeon-, and institution-related factors, including the indication for surgery, uterine size, pelvic anatomy, presence of prolapse, previous surgery, comorbidities, patient preference, available technology, and surgeon experience [ 5 ]. Therefore, comparisons among hysterectomy techniques in retrospective observational studies should be interpreted with caution because surgical approach is not randomly assigned and may reflect underlying differences in case complexity and patient selection. Laparoscopic hysterectomy has gained widespread acceptance as a minimally invasive alternative to abdominal and vaginal approaches. It is associated with several well-documented advantages over abdominal surgery, including shorter hospital stay, reduced postoperative pain, faster return to normal activities, lower incidence of wound infections, and decreased blood loss [ 6 , 7 ]. Although comparisons between abdominal and minimally invasive methods are often complicated by differences in patient selection, uterine size, surgical indication, and surgical expertise, current evidence generally suggests higher complication rates in open abdominal approaches [ 8 ]. Consequently, the use of laparoscopic techniques has significantly increased, especially in cases where vaginal hysterectomy is not feasible [ 7 , 9 , 10 ]. In parallel, robotic-assisted hysterectomy has increasingly been adopted in contemporary gynecologic practice; however, its use remains dependent on institutional resources, cost, availability of robotic platforms, and surgeon training. As robotic hysterectomy was not routinely performed at our center during the study period, it was not included in the present analysis. Beyond perioperative outcomes, postoperative anatomical and functional outcomes are important components of recovery after hysterectomy. Vaginal length may differ according to surgical technique, cuff closure, extent of vaginal tissue excision, and indication for surgery. However, the relationship between postoperative vaginal anatomy and sexual function remains complex. Sexual function after hysterectomy may be influenced not only by anatomical changes, but also by preoperative symptoms, relief of bleeding or pain, hormonal status, psychological factors, relationship dynamics, and sociocultural context. Therefore, anatomical differences between surgical techniques may not necessarily translate into clinically meaningful differences in postoperative sexual function. In this study, we aimed to retrospectively analyze total hysterectomy procedures performed for benign indications over a three-and-a-half-year period at a tertiary care center. While previous studies have largely focused on perioperative parameters such as blood loss, complications, and hospital stay, fewer studies have evaluated postoperative vaginal length together with female and partner sexual function across different hysterectomy techniques. We further examined demographic and clinical predictors of transfusion and complications, thereby providing a comprehensive assessment that bridges surgical outcomes with functional and quality-of-life measures. Given the retrospective design and non-random allocation of surgical approach, the findings should be interpreted as associations rather than evidence of causal superiority of one surgical technique over another.

Descriptive characteristics of the study population are summarized in Table 1 . A total of 466 patients were included in the analysis. The mean age was 48.74 ± 7.20 years range, 31–75. Mean height and weight were 159.32 ± 5.82 cm and 78.13 ± 13.80 kg, corresponding to a mean body mass index BMI of 30.43 ± 5.38 kg/m². The mean numbers of pregnancies and births were 4.40 ± 2.41 and 3.32 ± 2.03, respectively. Comorbid conditions were present in 64.8% of patients, and 77.5% had a history of previous surgery. The mean hysterectomy indication score was 9.33 ± 2.77. Uterine size measurements were available for 244 patients 52.4%, with a mean uterine size of 9.96 ± 2.19 cm, while uterine size was not recorded in 222 patients 47.6%. Missing uterine size values were not imputed. Abbreviations: SD = standard deviation; BMI = body mass index; FSFI = Female Sexual Function Index; IIEF-5 = International Index of Erectile Function-5. *Uterine size data were available for 244 patients. The mean operative time was 151.71 ± 42.19 minutes. Mean preoperative hemoglobin and hematocrit levels were 12.22 ± 1.79 g/dL and 38.06 ± 4.78%, respectively, and decreased postoperatively to 10.62 ± 1.80 g/dL and 33.15 ± 4.61%. Blood transfusion was required in 12.0% of patients 95% CI, 9.4–15.3, and postoperative complications occurred in 8.2% 95% CI, 6.0–11.0. Mean vaginal length decreased from 8.52 ± 0.75 cm preoperatively 95% CI, 8.45–8.59 to 7.86 ± 0.79 cm postoperatively 95% CI, 7.79–7.93. Female sexual function, assessed using the Female Sexual Function Index FSFI, showed minimal overall change from preoperative to postoperative evaluation 23.52 ± 4.46 vs. 23.64 ± 3.59. Among male partners with available data n = 297, mean International Index of Erectile Function-5 IIEF-5 scores declined from 14.87 ± 3.31 preoperatively to 14.10 ± 2.23 postoperatively; this partner-related finding was considered exploratory because partner data were available only for a subset of the cohort. Changes in vaginal length and female sexual function according to hysterectomy technique are presented in Table 2 . Patients were grouped as total abdominal hysterectomy TAH, n = 124, total laparoscopic hysterectomy TLH, n = 177, and total vaginal hysterectomy TVH, n = 165. Preoperative vaginal length and preoperative FSFI scores were comparable among the groups p = 0.954 and p = 0.995, respectively. Postoperative vaginal length differed significantly according to surgical technique, with the shortest postoperative vaginal length observed in the TLH group p < 0.001. The greatest reduction in vaginal length occurred following TLH −1.08 ± 0.64 cm, followed by TAH −0.49 ± 0.61 cm, whereas a modest increase in vaginal length was observed after TVH + 0.34 ± 0.58 cm. Postoperative FSFI scores did not differ significantly among the groups p = 0.508, and changes in FSFI scores ΔFSFI were also similar across surgical techniques p = 0.267. Male partner IIEF-5 scores showed a statistically significant postoperative decline across surgical groups p < 0.001; however, this result should be interpreted as an exploratory partner-related outcome rather than as a definitive indicator of clinically meaningful deterioration. Data are presented as mean ± standard deviation. One-way ANOVA was used for between-group comparisons. Superscript letters indicate statistically significant differences between groups based on Tukey’s HSD post-hoc test (p < 0.05). Δ indicates postoperative minus preoperative values. Variables associated with postoperative complications in univariate analyses are shown in Table 3 . When patients with complications n = 38 were compared with those without complications n = 428, no statistically significant differences were observed in age, BMI, uterine size, operative time, or postoperative vaginal length in univariate comparisons all p > 0.05. The distribution of hysterectomy techniques was also similar between patients with and without postoperative complications p = 0.980. Complication rates were 8.1% for TAH, 7.9% for TLH, and 8.5% for TVH. These univariate findings suggest that postoperative complications were not clearly associated with surgical route in crude comparisons. Data are presented as mean ± SD or n (%). Independent samples t-test was used for continuous variables; chi-square or Fisher’s exact test for categorical variables. TAH = Total Abdominal Hysterectomy; TLH = Total Laparoscopic Hysterectomy; TVH = Total Vaginal Hysterectomy; BMI = Body Mass Index. Multivariable linear regression analysis identifying factors associated with postoperative vaginal length is presented in Table 4 . The model was statistically significant p < 0.001. Preoperative vaginal length was the strongest predictor of postoperative vaginal length B = 0.742; 95% CI, 0.69–0.80; p < 0.001. After adjustment for age, BMI, uterine size, operative time, and preoperative vaginal length, surgical technique remained associated with postoperative vaginal length. Compared with TAH, TLH was associated with a shorter postoperative vaginal length B = −0.506; 95% CI, −0.66 to −0.36; p < 0.001, whereas TVH was associated with a longer postoperative vaginal length B = 0.268; 95% CI, 0.03–0.51; p = 0.029. Age, BMI, uterine size, and operative time were not significantly associated with postoperative vaginal length in this model. Because uterine size data were not available for all patients, findings involving this covariate should be interpreted with caution. Data were analyzed using multivariate linear regression. Dependent variable: postoperative vaginal length. Independent variables: age, BMI, surgical type, uterine size, operative time, and preoperative vaginal length. TAH = Total Abdominal Hysterectomy; TLH = Total Laparoscopic Hysterectomy; TVH = Total Vaginal Hysterectomy; BMI = Body Mass Index. Statistically significant results are shown in bold (p < 0.05). Factors associated with postoperative female sexual function are summarized in Table 5 . The multivariable linear regression model was statistically significant p < 0.001. Preoperative FSFI score was the only significant predictor of postoperative FSFI score B = 0.671; 95% CI, 0.63–0.71; p < 0.001. After adjustment for age, BMI, surgical type, postoperative complications, and preoperative FSFI score, hysterectomy technique was not significantly associated with postoperative FSFI score. Age, BMI, and postoperative complications were also not significantly associated with postoperative FSFI outcomes in this model. These findings suggest that baseline female sexual function was more strongly related to early postoperative FSFI scores than surgical route in the present cohort. Data were analyzed using multivariate linear regression. Dependent variable: postoperative Female Sexual Function Index (FSFI) score. Independent variables: age, BMI, surgical type, presence of postoperative complication, and preoperative FSFI score. TAH = Total Abdominal Hysterectomy; TLH = Total Laparoscopic Hysterectomy; TVH = Total Vaginal Hysterectomy; BMI = Body Mass Index. Statistically significant results are shown in bold (p < 0.05). Multivariable logistic regression analysis of factors associated with blood transfusion is presented in Table 6 . After adjustment for operative time, preoperative hemoglobin, and preoperative hematocrit levels, lower preoperative hemoglobin was significantly associated with a higher likelihood of blood transfusion (OR = 0.39; 95% CI, 0.26–0.60; p < 0.001). Operative time showed a borderline association with transfusion requirement (p = 0.055), whereas preoperative hematocrit was not significantly associated with transfusion in this model. Because preoperative hemoglobin and hematocrit are closely related hematologic parameters, the nonsignificant result for hematocrit should be interpreted in the context of adjustment for hemoglobin. Estimated intraoperative blood loss was not available in the retrospective database and therefore could not be included in the transfusion model. Multivariate binary logistic regression with blood transfusion (yes/no) as the dependent variable. OR = odds ratio; CI = confidence interval. Multivariable logistic regression analysis examining factors associated with postoperative complications is shown in Table 7 . Longer operative time was significantly associated with a higher likelihood of postoperative complications in the multivariable model (OR per minute = 1.02; 95% CI, 1.01–1.03; p < 0.001). Age, BMI, and uterine size were not significantly associated with postoperative complications. Given the observational design, operative time should be interpreted as a marker that may reflect surgical complexity or intraoperative difficulty rather than as a direct causal factor. Multivariate binary logistic regression with postoperative complication (yes/no) as the dependent variable. OR = odds ratio; CI = confidence interval.

In this retrospective cohort study, hysterectomy technique was associated with postoperative vaginal length, with the greatest reduction observed after laparoscopic hysterectomy and the greatest preservation observed after vaginal hysterectomy. However, these anatomical differences did not translate into significant differences in early postoperative female sexual function, supporting the view that postoperative sexual health is multifactorial and not determined by vaginal length alone. Lower preoperative hemoglobin was associated with a higher likelihood of blood transfusion, whereas operative time was associated with postoperative complications, likely reflecting surgical complexity rather than a direct causal effect of procedure duration. Because estimated intraoperative blood loss and emergency or acute bleeding status were not consistently available, the transfusion findings should be interpreted cautiously. Male partner IIEF-5 scores showed a statistically significant postoperative decline; however, this partner-related result was exploratory, based on a subset of patients, and its clinical significance remains uncertain. Future prospective, multicenter studies with longer follow-up, detailed surgical complexity variables, estimated blood loss data, and both patient- and partner-reported outcomes are needed to better clarify the anatomical, functional, and couple-centered effects of different hysterectomy techniques.

This retrospective observational cohort study was conducted at the Department of Obstetrics and Gynecology, Van Training and Research Hospital, a tertiary referral center in eastern Türkiye. The study period spanned from January 2020 to June 2023. The study included patients who underwent total hysterectomy for benign gynecological indications using one of the three conventional surgical approaches routinely performed at our institution during the study period: total abdominal hysterectomy, total laparoscopic hysterectomy, or total vaginal hysterectomy. Robotic-assisted hysterectomy was not routinely performed at our center during the study period and was therefore not included in the analysis. The study was reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. The study included women aged 18–75 years who underwent total hysterectomy for benign gynecological indications during the study period. Surgical approach was determined in routine clinical practice according to surgical indication, uterine size, pelvic anatomy, presence of prolapse, previous surgery, comorbidities, surgeon judgment, and institutional practice, rather than by random allocation. Patients were excluded if they had incomplete demographic or clinical records, inadequate compliance with clinical examination, missing sexual function assessment data, or insufficient perioperative documentation for the outcomes of interest. Patients undergoing hysterectomy for malignant indications, obstetric indications, or emergency life-threatening hemorrhage were not included. After application of these criteria, 466 patients were included in the final analysis. Patient-level data included demographic characteristics age, height, weight, body mass index, gravida, parity, comorbidities, and history of previous surgery; surgical variables including indication score, uterine size, operative time, and type of hysterectomy; and clinical outcomes including preoperative and postoperative hemoglobin and hematocrit levels, blood transfusion requirement, postoperative complications, vaginal length, and sexual function scores. Estimated intraoperative blood loss was not consistently recorded in the retrospective surgical records and therefore could not be included as a study variable or incorporated into the transfusion models. Postoperative complications were defined as any adverse medical or surgical event occurring within 30 days after hysterectomy, including bleeding requiring reoperation; wound-related complications such as infection, hematoma, or dehiscence; febrile morbidity defined as a body temperature ≥38°C on two or more consecutive postoperative days excluding the first 24 hours; urinary tract infection or urinary tract injury confirmed by laboratory, imaging, or operative findings; and readmission or reintervention related to postoperative events. Minor and self-limiting conditions such as transient nausea, mild ileus, or short-term fever were not classified as complications. The primary outcome was the change in vaginal length from preoperative to postoperative assessment. Secondary outcomes included postoperative female sexual function assessed by the Female Sexual Function Index (FSFI), male partner sexual function assessed by the International Index of Erectile Function-5 (IIEF-5), postoperative complication rates, and blood transfusion requirement. Analyses of male partner sexual function were considered exploratory because partner data were available for a subset of 297 cases. Analyses involving partner outcomes were restricted to these patients, and missing partner data were excluded by listwise deletion. Clinical and perioperative data were extracted retrospectively from electronic hospital records. Operative time was defined as the interval from skin incision to completion of the surgical procedure. All hysterectomies were performed by gynecologic surgeons at a tertiary referral center according to standard institutional surgical practice. The choice of surgical route was based on clinical indication, pelvic anatomy, uterine size when available, presence of prolapse, previous surgical history, comorbidities, and surgeon judgment. Vaginal length was measured intraoperatively using a hysterometer immediately before hysterectomy and at the completion of the procedure, ensuring a standardized assessment across surgical techniques. Hemoglobin and hematocrit levels were obtained from routine laboratory tests performed preoperatively and during the early postoperative period as part of standard clinical care. Estimated intraoperative blood loss was not consistently documented in the electronic surgical records and therefore could not be analyzed. Female and male sexual function were evaluated using validated instruments, namely the Female Sexual Function Index and the International Index of Erectile Function-5, respectively [ 11 , 12 ], based on documented preoperative and postoperative assessments recorded in patient files. Postoperative sexual function assessments were conducted at routine follow-up visits, typically around 8 weeks after surgery, with an acceptable window of 6–12 weeks. When multiple postoperative assessments were available, the measurement closest to 8 weeks was used for analysis. Therefore, sexual function outcomes in this study should be interpreted as early postoperative functional assessments rather than long-term sexual function outcomes. The study data were accessed for research purposes between 01/05/2023 and 15/06/2023 in accordance with institutional regulations. The final sample size reflected all eligible patients who met the inclusion criteria during the study period. No a priori sample size calculation was performed because of the retrospective design. Therefore, the analyses were exploratory and based on the available cohort. The study protocol was approved by the Non-Interventional Clinical Research Ethics Committee of Van Regional Training and Research Hospital approval date: 26/04/2023; protocol no: 2023/09–04. The study was conducted in accordance with the Declaration of Helsinki. Due to the retrospective design and the use of de-identified routinely collected clinical data, the requirement for informed consent was waived by the ethics committee. The minimal anonymized dataset underlying this study is restricted due to patient privacy and institutional regulations. Qualified researchers may request access to the data by contacting the Non-Interventional Clinical Research Ethics Committee of Van Regional Training and Research Hospital (Contact Email: [email protected], Phone: + 90 432 222 00 10). The study data were accessed and extracted for research purposes after ethics approval, between 01/05/2023 and 15/06/2023, in accordance with institutional regulations. Clinical trial registration was not applicable because this was a retrospective observational study. Statistical analyses were performed using IBM SPSS Statistics version 20.0 IBM Corp., Armonk, NY, USA. The distribution of continuous variables was assessed visually using histograms and Q–Q plots and analytically using the Kolmogorov–Smirnov test. Continuous variables were summarized as mean ± standard deviation or median interquartile range, as appropriate, while categorical variables were presented as number and percentage. Comparisons among surgical groups were performed using one-way analysis of variance with Tukey’s post-hoc test for normally distributed continuous variables. Paired sample t-tests were used for within-group preoperative and postoperative comparisons. Categorical variables were compared using Pearson’s chi-square test or Fisher’s exact test, as appropriate. Multivariable analyses included linear regression models for postoperative vaginal length and postoperative FSFI scores, and binary logistic regression models for postoperative complications and blood transfusion requirement. Candidate variables were selected based on clinical relevance and availability in the retrospective database. For postoperative vaginal length, the model included preoperative vaginal length, surgical type, age, body mass index, uterine size, and operative time. For postoperative FSFI score, the model included preoperative FSFI score, surgical type, age, body mass index, and postoperative complications. For blood transfusion, the model included operative time, preoperative hemoglobin, and preoperative hematocrit. For postoperative complications, the model included age, body mass index, operative time, and uterine size. Because preoperative hemoglobin and hematocrit are biologically related parameters, multicollinearity was assessed using variance inflation factors before interpretation of the transfusion model. Estimated intraoperative blood loss could not be included in the transfusion model because it was not consistently available in the retrospective surgical records. Uterine size was included in models when available; missing uterine size data were not imputed. Analyses involving male partner IIEF-5 scores were restricted to patients with available partner data and were considered exploratory. Model diagnostics included assessment of multicollinearity using variance inflation factors, goodness-of-fit using Nagelkerke R² for logistic regression models, and calibration using the Hosmer–Lemeshow test. All analyses were exploratory in nature. A two-sided p-value <0.05 was considered statistically significant, without adjustment for multiple comparisons.

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