Uterine Weight and Postoperative Outcomes by Surgical Route in Minimally Invasive Hysterectomy.

OBJECTIVE: To evaluate the association between uterine weight and postoperative outcomes following total laparoscopic hysterectomy (TLH), robotic-assisted laparoscopic hysterectomy (RH) and vaginal hysterectomy (VH) for benign indications. DESIGN: Postoperative outcomes were assessed using multiple complementary parameterizations (quartiles, clinically defined cutoffs, continuous modeling, and Youden-derived thresholds). SETTING: Retrospective cohort study using the U.S.-based ACS NSQIP surgical registry, which includes standardized, prospectively collected data from more than 700 participating hospitals. PARTICIPANTS: Patients who underwent TLH, RH and VH for benign indications between 2022 and 2023. INTERVENTIONS: Uterine weight, analyzed as a continuous variable and by quartiles for each surgical route. Optimal uterine weight cut-off values for predicting complications were identified using the Youden index. Multivariable logistic regression identified outcome-specific associations and uterine weight thresholds. The primary outcome was the occurrence of any postoperative complication within 30 days of surgery. RESULTS: The cohort comprised 27,302 women, including 11,965 who underwent TLH, 12,722 RH, and 2,615 VH. In TLH and RH, postoperative and surgical site complications were lowest in the smallest uterine weight quartile, while conversion to laparotomy was rare (<1%) and increased only in the highest quartile. In VH, outcomes did not vary across uterine weight quartiles. In route-specific multivariable models, uterine weight was associations with postoperative complication. In RH increasing uterine weight was associated with overall complications, surgical site-related complications, and conversion to open surgery, whereas more limited associations were observed in TLH and no consistent associations were identified in VH. For any postoperative complication, Youden Index cutoffs were identified at 90 g in TLH (aOR 1.33), 112 g in RH (aOR 1.32), and 99 g in VH (aOR 1.46). For conversion to open surgery, higher-risk uterine weight thresholds were observed at 232 g in TLH (aOR 9.05) and 380 g in RH (aOR 8.51) however, absolute conversion rates remained low overall. CONCLUSION: Increasing uterine weight was associated with postoperative morbidity in minimally invasive hysterectomy in an outcome-specific and threshold-dependent manner. The most consistent and clinically meaningful associations were observed in RH, and the weakest associations in VH.