Robotic versus conventional laparoscopic total hysterectomy for benign gynecologic disease: an RCT-only, GRADE-assessed systematic review and meta-analysis of operative outcomes and perioperative morbidity.

backgroundRobotic-assisted laparoscopic hysterectomy has gained widespread adoption for benign gynecologic diseases despite its higher cost and ongoing debate over its clinical superiority compared to conventional laparoscopy. Although many comparative studies exist, no meta-analysis has exclusively synthesized randomized controlled trial evidence with a comprehensive GRADE certainty assessment of all clinically relevant, perioperative outcomes.

methodsThis systematic review and meta-analysis was prospectively registered (PROSPERO ID: CRD420251183072). We systematically searched major databases from inception through November 1, 2025, for randomized controlled trials comparing robotic total laparoscopic hysterectomy (R-TLH) with conventional total laparoscopic hysterectomy (C-TLH) for benign indications. Two independent reviewers screened the studies, extracted the data, and assessed the risk of bias using the RoB 2 tool. Random-effects meta-analyses were performed for operative duration, estimated blood loss, conversion to laparotomy, length of hospital stay, and perioperative complications. Heterogeneity was quantified using I² statistics, and comprehensive sensitivity analyses were conducted to assess the robustness of the results. The certainty of the evidence for each outcome was evaluated using the GRADE approach.

resultsFour trials (N = 375 patients) met the inclusion criteria, with 185 and 190 patients in the R-TLH and C-TLH groups, respectively. The total operative time did not differ significantly between the R-TLH and C-TLH groups (mean difference [MD] 11.79 min, 95% CI - 24.59 to 48.17; very low certainty). R-TLH was associated with a significantly shorter hospital stay (MD - 0.64 days, 95% CI - 1.10 to - 0.17; moderate certainty). No significant differences were observed in conversion to laparotomy (OR 0.50, 95% CI 0.10-2.46; low certainty), any postoperative complication (composite as defined by individual trials) (OR 0.58, 95% CI 0.21-1.58; moderate certainty), estimated blood loss (MD - 17.81 mL, 95% CI - 74.31 to 38.68; low certainty), or vaginal cuff hematoma (OR 0.28, 95% CI 0.05-1.62; low certainty). Sensitivity analyses yielded consistent results.

conclusionBased on the highest level of evidence exclusively from randomized trials, robotic and conventional laparoscopic hysterectomy demonstrate comparable operative outcomes for benign disease, with the robotic approach offering modestly shorter hospitalization. Given the substantial cost differences, conventional laparoscopy remains a clinically equivalent option for most patients requiring cholecystectomy.