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Uterine Manipulators

Transvaginal (or intra-abdominal) instruments inserted into the uterine cavity and / or cervical canal to provide mobilization, anteversion / retroversion, lateral deviation, cephalic elevation, and vaginal-fornix delineation of the uterus during laparoscopic, robotic, and open gynecologic surgery — the essential tool for optimizing surgical exposure during minimally invasive hysterectomy, sacrocolpopexy, and adjunctive procedures.[1][2]

Despite their ubiquity, there is no single "optimal" uterine manipulator that is universally safe, efficient, and cost-effective across all procedures — the surgeon selects the manipulator that best suits the specific case.[1]

Purpose and Rationale​

  • Uterine mobilization — multi-plane movement (anteversion, retroversion, lateral deviation, cephalic elevation) from below, providing dynamic exposure without additional laparoscopic instruments or extra ports.
  • Surgical exposure — placing tension on the broad ligament, uterine vessels, cardinal and uterosacral ligaments, and peritoneal attachments to facilitate identification and dissection.
  • Vaginal-fornix delineation — the cervical (colpotomy) cup delineates the fornices from below; provides a clear landmark for the laparoscopic colpotomy incision; maintains pneumoperitoneum after cuff opening.
  • Ureteral displacement — cadaveric data: maximal cephalic elevation + anteversion or contralateral angulation increases the ureter-to-uterus/vagina distance from 1.4–1.9 cm (no manipulator) to 2.2–6.2 cm (with manipulator).[3]
  • Pneumoperitoneum maintenance — cervical cup or occluding balloon preserves visualization in the critical final steps of hysterectomy.

Design Components​

ComponentFunction
Intrauterine tip / obturatorRod or cannula through the cervical os into the uterine cavity — transmits manipulation forces. May incorporate a balloon for cavity occlusion / device fixation.
Cervical (colpotomy) cupRigid ring or disc sitting in the fornices; delineates the colpotomy line; available in small / medium / large sizes
Handle / shaftExternal component the assistant holds; ergonomic pistol grips with articulating joints on the most refined designs
Fixation mechanismCervical-cup friction, intrauterine balloon, cervical tenaculum, or threaded cervical fixation

Approach and Classification​

The literature documents at least 10 distinct uterine manipulators.[1] Broadly classified by approach:

ClassExamplesNotes
Vaginal (transvaginal)RUMI + Koh Colpotomizer, VCare / VCare Plus, Hohl, Clermont-Ferrand, Colpo-ProbeThe dominant class for minimally invasive hysterectomy
Intra-abdominal (manipulator-free)Myoma screw, Boztosun technique, tenaculum / grasper on the fundusAvoids transvaginal instrumentation; potentially shorter operative time and lower cost[4][5]

Major Named Systems​

SystemManufacturerDefining feature
RUMI / RUMI II + Koh ColpotomizerCooperSurgical (Hector Advincula design)Hybrid (reusable handle + disposable components); balloon-fixed; pneumoperitoneum maintenance via Koh cup[1][6]
VCare / VCare PlusConMedFully disposable; integrated cervical cup; the system used in the Pan 2025 ureteral-distance study[3]
HohlKARL STORZ (Michael Hohl)Reusable; tight-fitting cervical cup; shorter insertion time (2 vs 6 min) vs Colpo-Probe (Husslein 2017 RCT)[7]
Clermont-FerrandUniversité Clermont-FerrandReusable European workhorse
Colpo-ProbeCooperSurgicalLoose-fitting; longer insertion time than Hohl in RCT[7]
Multipurpose reusable stainless steelVariousReusable; cross-procedure compatibility for supracervical hysterectomy / sacrocolpopexy / hysteropexy[2]
Myoma screw / Boztosun (intra-abdominal)VariousManipulator-free intra-abdominal approach; shorter operative time[4][5]

Reconstructive-Urology and Urogyn Uses​

The uterine manipulator is squarely in urogyn scope — essential for the laparoscopic / robotic and open pelvic-reconstructive cases that intersect WARWIKI's core operative repertoire:

  • Laparoscopic / robotic sacrocolpopexy with concomitant hysterectomy — manipulator delineates the vaginal apex for mesh fixation; mobilizes the uterus for the hysterectomy step.[2]
  • Laparoscopic / robotic supracervical hysterectomy — uterine mobilization without cervical-cup delineation (no colpotomy step).[2]
  • Total laparoscopic hysterectomy (TLH) as adjunct to pelvic reconstruction — the canonical use; provides exposure for colpotomy and pneumoperitoneum maintenance.[1][7]
  • Laparoscopic / robotic hysteropexy and vaginal-vault prolapse repair — apex delineation for suspension or mesh placement.[2]
  • Endometriosis surgery during urogyn-adjunctive procedures — exposure of the cul-de-sac, uterosacral ligaments, and rectovaginal septum during excision of deep infiltrating endometriosis encountered during pelvic-reconstructive cases.
  • Laparoscopic myomectomy — uterine mobilization and exposure of myoma sites; myoma-screw alternative for intra-abdominal manipulation.
  • Total abdominal hysterectomy (TAH) as adjunct to pelvic reconstruction — manipulator use in TAH significantly reduces operative time and hemoglobin drop, and preserves vaginal length (Baradwan 2025 systematic review and meta-analysis of 4 RCTs, n = 340).[9]

Environmental and Cost — Reusable vs Disposable​

Melnyk 2025 life-cycle assessment over 300 hysterectomies compared four manipulators (reusable stainless steel, two disposable, one hybrid):[8]

  • Reusable stainless steel had the lowest carbon footprint in every environmental category.
  • Disposable manipulators had global-warming emissions 2.4–4.2× higher than the reusable device.
  • Higher upfront cost but $16,000–$43,000 institutional savings over 300 uses for the reusable variant.

Practical implication for urogyn programs: reusable manipulators are the cost- and environment-preferred choice for high-volume centers, with the operative-performance trade-offs against disposable / hybrid systems generally minor.

The Endometrial-Cancer Manipulator-Safety Debate​

Out of WARWIKI's primary scope (cancer surgery), but mentioned because it has spread to general urogyn awareness:

Concern: the intrauterine balloon / tip may disrupt tumor, forcing malignant cells through the fallopian tubes into the peritoneal cavity or LVSI. Evidence is discordant:

  • No significant harm signals: Zorzato 2024 meta-analysis (14 studies, n = 5,019) — pooled HR recurrence 1.52 (95% CI 0.99–2.33, p = 0.05, borderline); HR OS 1.07 (NS).[10] Scutiero 2022 (18 studies) — no difference in LVSI, recurrence, or peritoneal cytology.[11] Uccella 2017 SIGE multicenter (n = 951) — no recurrence-risk effect.[12]
  • Possible harm signals: Padilla-Iserte 2021 (n = 2,661) — higher recurrence (11.69% vs 7.4%).[13] Nagase 2026 (12 studies, n = 10,805) — DFS lower with manipulator (HR 1.18, 95% CI 1.01–1.38, p = 0.04); risk-of-bias caveats.[14]

Current synthesis: Crosbie 2022 Lancet review notes "discordant data" and positive peritoneal cytology of "uncertain clinical significance" since washings are no longer in FIGO staging.[15] D'Indinosante 2026 recommends a "selective, technique-conscious approach" until definitive prospective data mature.[16]

For the urogyn surgeon performing adjunctive hysterectomy in a benign context (sacrocolpopexy + hysterectomy, vault prolapse, etc.), the manipulator-safety question is not directly relevant — these cases do not involve a tumor-bearing uterus. The debate matters only when adjunctive hysterectomy is performed for a known endometrial malignancy (a gyn-oncology decision domain, not urogyn).

Manipulator-Free Techniques​

For surgeons who prefer to avoid manipulators:

  • Manipulator-free TLH — Erdem 2026 retrospective cohort (n = 244 manipulator vs 166 manipulator-free): no significant differences in operative time (79.6 vs 76.6 min), complications, or vaginal-cuff dehiscence. Manipulator-free TLH is safe in expert hands.[17]
  • Myoma screw — laparoscopic screw into uterine fundus for intra-abdominal manipulation; shorter operative time and lower cost vs vaginal manipulators.[5]
  • Boztosun technique — intra-abdominal Rein-technique modification; shorter operative and colpotomy times.[4]

Complications​

  • Uterine perforation — thin myometrium (postmenopausal atrophy, recent pregnancy, prior surgery).
  • Cervical laceration — forceful manipulation or cervical stenosis / atrophy.
  • Vaginal-cuff dehiscence after TLH — ~ 1.35% (vs TAH 0.15%, TVH 0.08%); thermal damage at colpotomy contributes (range 32–5232 μm regardless of manipulator type in Husslein 2017 RCT).[7][18][19]
  • False passage through cervical stroma in cervical stenosis.

Technique​

  1. Cervical dilation to Hegar 8–10 before inserting most manipulators.
  2. Sound the uterus to determine cavity depth; adjust intrauterine-tip length accordingly to avoid perforation.
  3. Optimize manipulator position — maximal cephalic elevation + anteversion or contralateral angulation maximizes ureteral protection (1.4 → 6.2 cm).[3]
  4. Coordinate with assistant — surgeon at the console directs specific manipulator movements ("antevert," "push cephalad," "deviate left") for each surgical step.
  5. Cup-size selection by vaginal caliber; cup size does not significantly affect ureteral distances.[3]
  6. Minimize colpotomy thermal spread — use the lowest effective energy settings to reduce vaginal-cuff thermal injury and dehiscence risk.[7][19]
  7. Consider manipulator-free in oncologic cases of concern and in surgeons confident with intra-abdominal techniques.[4][5][17]

Limitations​

  • Requires an assistant to control the vaginal handle.
  • No single optimal manipulator for all procedures.[1]
  • Endometrial-cancer oncologic uncertainty (out of WARWIKI scope but relevant to multidisciplinary practice).[10][14]
  • Risk of uterine perforation, cervical laceration, false passage.
  • Disposable-cost and environmental impact — favor reusable systems where operative performance allows.[8]
  • Cannot be used in patients with cervical stenosis, prior trachelectomy, or absent cervix.

See also: Koh Colpotomizer, Heaney Clamp, Heaney Needle Driver, Heaney Retractor, Masterson Pedicle Clamp, Auvard Weighted Speculum.

References​

1. van den Haak L, Alleblas C, Nieboer TE, Rhemrev JP, Jansen FW. "Efficacy and safety of uterine manipulators in laparoscopic surgery: a review." Arch Gynecol Obstet. 2015;292(5):1003–11. doi:10.1007/s00404-015-3727-9

2. Schaer GN, Sarlos D, Khan Z. "A multipurpose uterine / vaginal manipulator for laparoscopic urogynecologic procedures." Int Urogynecol J. 2019;30(8):1377–9. doi:10.1007/s00192-019-03940-x

3. Pan ET, Belmonte BM, Wai CY, Balgobin S. "Optimizing use of a uterine manipulator for laparoscopic hysterectomy: a cadaveric study of distances to the pelvic ureter." Am J Obstet Gynecol. 2025;S0002-9378(25)00398–9. doi:10.1016/j.ajog.2025.06.022

4. Çelik İ, Boztosun A, Güner FC. "Comparative analysis of vaginal and abdominal uterine manipulation in laparoscopic hysterectomy: the Boztosun technique." J Clin Med. 2025;14(11):3652. doi:10.3390/jcm14113652

5. Güven CM, Uysal D, Kolsuz Z, Yilmaz B. "Surgical outcomes of intraabdominal versus vaginal approach for uterine manipulation during total laparoscopic hysterectomy." Medicine (Baltimore). 2023;102(22):e33927. doi:10.1097/MD.0000000000033927

6. Keriakos R, Zaklama M. "The RUMI manipulator and Koh Colpotomiser system for total laparoscopic hysterectomy." BJOG. 2000;107(2):274–7. doi:10.1111/j.1471-0528.2000.tb11700.x

7. Husslein H, Frecker H, Shore EM, et al. "Comparing two uterine manipulators during total laparoscopic hysterectomy: a randomized controlled trial." J Minim Invasive Gynecol. 2017;24(5):764–71. doi:10.1016/j.jmig.2017.02.022

8. Melnyk AI, Silva de Souza Lima Cano N, Glass Clark S, Bilec MM, Artsen A. "A comparative carbon footprint and cost analysis of uterine manipulators for hysterectomy." Obstet Gynecol. 2025;146(1):104–12. doi:10.1097/AOG.0000000000005949

9. Baradwan S, Khadawardi K, Himayda S, et al. "Use of uterine manipulators in total abdominal hysterectomy: a systematic review and meta-analysis." J Minim Invasive Gynecol. 2025;S1553-4650(25)01020–9. doi:10.1016/j.jmig.2025.12.033

10. Zorzato PC, Uccella S, Biancotto G, et al. "Intrauterine manipulator during hysterectomy for endometrial cancer: a systematic review and meta-analysis of oncologic outcomes." Am J Obstet Gynecol. 2024;230(2):185–198.e4. doi:10.1016/j.ajog.2023.09.004

11. Scutiero G, Vizzielli G, Taliento C, et al. "Influence of uterine manipulator on oncological outcome in minimally invasive surgery of endometrial cancer: a systematic review and meta-analysis." Eur J Surg Oncol. 2022;48(10):2112–8. doi:10.1016/j.ejso.2022.05.034

12. Uccella S, Bonzini M, Malzoni M, et al. "The effect of a uterine manipulator on the recurrence and mortality of endometrial cancer: a multi-centric study by the Italian Society of Gynecological Endoscopy." Am J Obstet Gynecol. 2017;216(6):592.e1–592.e11. doi:10.1016/j.ajog.2017.01.027

13. Padilla-Iserte P, Lago V, Tauste C, et al. "Impact of uterine manipulator on oncological outcome in endometrial cancer surgery." Am J Obstet Gynecol. 2021;224(1):65.e1–65.e11. doi:10.1016/j.ajog.2020.07.025

14. Nagase Y, Matsuzaki S, Yoshida H, et al. "Survival association of intrauterine manipulator use during minimally invasive hysterectomy for endometrial cancer: a systematic review and meta-analysis." Obstet Gynecol. 2026;147(4):463–77. doi:10.1097/AOG.0000000000006195

15. Crosbie EJ, Kitson SJ, McAlpine JN, et al. "Endometrial cancer." Lancet. 2022;399(10333):1412–28. doi:10.1016/S0140-6736(22)00323-3

16. D'Indinosante M, Bruno M, Napolitano F, et al. "Use of uterine manipulators in endometrial cancer surgery: balancing benefits and uncertainties." Eur J Surg Oncol. 2026;52(6):111810. doi:10.1016/j.ejso.2026.111810

17. Erdem B, Erciyestepe SG. "Manipulator-free versus manipulator-assisted total laparoscopic hysterectomy: are outcomes comparable in experienced hands?" Med Sci Monit. 2026;32:e949649. doi:10.12659/MSM.949649

18. Clarke-Pearson DL, Geller EJ. "Complications of hysterectomy." Obstet Gynecol. 2013;121(3):654–73. doi:10.1097/AOG.0b013e3182841594

19. Nezhat C, Kennedy Burns M, Wood M, et al. "Vaginal cuff dehiscence and evisceration: a review." Obstet Gynecol. 2018;132(4):972–85. doi:10.1097/AOG.0000000000002852