Incidence and Prevention of Vaginal Cuff Dehiscence After Laparoscopic and Robotic Hysterectomy in Benign Conditions: An Updated Systematic Review and Meta-Analysis

Abstract

Background and Objectives: Vaginal cuff dehiscence (VCD) represents a rare but relevant complication that occurs following minimally invasive hysterectomy. With the rising frequency of this procedure, it is crucial to continuously evaluate VCD incidence, risk factors, and prevention strategies. This systematic review and meta-analysis aimed to update the evidence on VCD incidence and to assess the role of various surgical techniques and materials adopted for vaginal cuff closure. Materials and Methods: A systematic literature search was conducted in PubMed, Scopus, Web of Science, EMBASE, and the Cochrane Library for studies published up to January 2025. Eligible studies reported VCD rates after laparoscopic or robotic hysterectomy for benign conditions and compared different closure techniques. The primary outcome was the incidence of VCD across closure methods, while secondary outcomes included potential risk factors. A random-effects model estimated pooled VCD rates with 95% confidence intervals (CI), and heterogeneity was assessed using I² tests. Results: Twenty-six studies involving 10,039 patients were analyzed. The overall pooled incidence of VCD was 0.7% (95% CI: 0.4-1.1%), with higher estimates in randomized controlled trials (RCTs) (1.4%) compared to non-RCTs (0.5%). Robotic-assisted hysterectomy had a pooled VCD rate of 1.7%, compared to laparoscopic hysterectomy at 0.7%. Although not statistically significant, transvaginal closure showed a higher VCD risk than laparoscopic closure (2.3% vs. 1.16%; OR 0.97, 95% CI, 0.33-2.82; OR 2.53 (95% CI, 1.10-5.82) when considering only RCTs), and barbed sutures showed a lower VCD incidence (0.35%) than conventional sutures (1.52%) (OR 0.37, 95% CI, 0.13-1.02). Smoking was identified as a significant risk factor for VCD, while the impact of early postoperative sexual activity remains inconclusive. Conclusions: Laparoscopic closure rather than transvaginal cuff closure and barbed sutures were neither significantly associated with reducing VCD risk. Emphasizing smoking cessation preoperatively is essential for VCD prevention. Future studies should investigate the effects of postoperative sexual activity and refine surgical techniques to minimize VCD risk and improve outcomes.

Keywords: hysterectomy techniques; postoperative care; surgical outcomes; vaginal cuff closure.

Figure 1

PRISMA flow diagram of reference selection.

Figure 2

Risk of bias in randomized controlled trials (risk of bias tool for randomized trials) [24,25,32,35,36,38,39,40].

Figure 3

Risk of bias in non-randomized studies (risk of bias in non-randomized studies—of exposures) [17,18,19,20,21,22,23,26,27,28,29,30,31,33,34,37,41].

Figure 4

Forest plot. Transvaginal vs. endoscopic approach to cuff closure (OR for vaginal cuff dehiscence of 0.97 (0.33–2.82) with moderate heterogeneity of I² = 39%) [17,28,30,31,38,40].

Figure 5

Forest plot. Use of barbed sutures non-barbed sutures for cuff closure (OR for vaginal cuff dehiscence of 0.37 (0.13–1.02) with low heterogeneity of I² = 0%) [18,19,20,21,22,23,24,25,27,29,32,33,37,42].

Figure 6

Forest plot. Double-layer vs. single-layer closure for cuff closure (OR for vaginal cuff dehiscence of 0.39 (0.08–1.99) with low heterogeneity of I² = 23%) [34,35,36,41].

Figure 7

Forest plot. Slow-reabsorption vs. fast-reabsorption sutures for cuff closure (OR for vaginal cuff dehiscence of 1.66 (0.15–18.56); I² = NA) [26,39].