Uterine Fibroids and Hysterectomy Route: Comparative Perioperative Outcomes of Abdominal, Vaginal, Laparoscopic, Robotic, and vNOTES Approaches

Abstract

Background: Uterine fibroids are the most prevalent benign pelvic tumour in women of reproductive age and up to 70% of women are affected by the age of 50. For symptomatic non-responsive fibroids, surgery to remove the uterus (hysterectomy) is the last resort. There are several surgical approaches: total abdominal hysterectomy (TAH), total vaginal hysterectomy (TVH), total laparoscopic hysterectomy (TLH), laparoscopically-assisted vaginal hysterectomy (LAVH), robotic-assisted total laparoscopic hysterectomy (R-TLH), and the increasingly popular transvaginal natural orifice transluminal endoscopic surgery (vNOTES) hysterectomy. Although a lot of literature has been written, the best route selection is still not agreed.
Objectives: To systematically review and meta-analyze operative time, estimated blood loss (EBL), length of hospital stay (LOS), intraoperative and postoperative complication rates and conversion rates for all major hysterectomy approaches for the benign uterine fibroid indication (2022–2026).
Methods: Systematic review and meta-analysis in accordance with the PRISMA 2020 guidelines. Databases: PubMed/MEDLINE, Embase, Cochrane CENTRAL, Scopus and Web of Science (January 2022–June 2026). Random-effects models (DerSimonian-Laird) were used; assessment of heterogeneity using the I² statistic.
Results: Nine studies (total of 1,116,000 patients) of minimally invasive hysterectomy (MIH) showed lower EBL, shorter LOS, and lower overall complication rates compared to TAH in each study. The most common approach was TLH (54.4% in high volume centers). Robotic hysterectomy vs. open: OR 0.42 (0.27–0.66) complications; 6.31-fold risk for transfusion in abdominal. R-TLH vs. C-TLH: similar peri-operative outcomes, with R-TLH having a slightly shorter LOS (MD −0.64 days, 95% CI: −1.10 to −0.17). TLH had a 7.54-fold greater risk of ureteral injury compared to TVH for large uteri (at or above 250 g). The vNOTES hysterectomy was demonstrated to be non-inferior to TLH, and had shorter operative time and better pain scores. Laparoscopic myomectomy demonstrated significantly reduced EBL (105 mL versus 317 mL), shorter operative time, and quicker recovery when compared with open myomectomy.
Conclusion: Hysterectomy is the standard of care for the treatment of uterine fibroids and minimally invasive procedures are the usual treatment. The ‘vaginal-first’ or ‘laparoscopic-first’ algorithm allows for the best possible outcomes while keeping surgical flexibility.A ‘vaginal-first algorithm’ or ‘laparoscopic-first algorithm’ with vNOTES as a teaching tool and safety net. Patient size, surgeon experience, patient comorbidities and fertility status should all be taken into account when developing the route of selection.