Background: Transvaginal uterine retrieval after minimally invasive hysterectomy may be technically difficult in patients with uterine enlargement or narrow vaginal and perineal anatomy. Excessive traction during retrieval may cause vaginal or perineal lacerations, while uterine fragmentation is undesirable, particularly in patients with malignancy. Although extending the abdominal incision may facilitate intact specimen retrieval, it compromises some of the benefits of minimally invasive surgery. We describe a simple technique of gradual vaginal and perineal dilation designed to facilitate intact transvaginal uterine retrieval while minimizing vaginal and perineal injury.

Methods: The technique was applied in three Japanese women undergoing minimally invasive hysterectomy: two with endometrial cancer and one with high-grade squamous intraepithelial lesion/cervical intraepithelial neoplasia grade 3. A Sakurai-type self-retaining vaginal speculum was inserted at the beginning of surgery, and the vaginal canal and perineum were gradually dilated throughout the procedure. The extent and pace of dilation were individually adjusted according to tissue compliance and anatomical characteristics. The vaginal incision site was also carefully selected to facilitate specimen retrieval.

Results: In all three cases, the uterus was successfully retrieved transvaginally without manual fragmentation or power morcellation. No vaginal or perineal lacerations requiring suturing occurred; only minor superficial abrasions were observed in one patient. No prolonged vaginal dilation, increased postoperative perineal pain, abnormal bleeding, or other adverse effects attributable to the technique were observed.

Conclusion: Gradual vaginal and perineal dilation initiated at the beginning of minimally invasive hysterectomy, combined with careful selection of the vaginal incision site, may facilitate safer intact transvaginal uterine retrieval while minimizing vaginal and perineal injury. Although further evaluation in larger studies is required, this simple approach may be a practical option when difficult uterine retrieval is anticipated.

Takayuki Nagasawa, M.D., Ph.D., is a gynecologic oncologist in the Department of Obstetrics and Gynecology at Iwate Medical University, Japan. He is a board-certified obstetrician and gynecologist and gynecologic oncologist in Japan, and is also certified in gynecologic laparoscopic surgery and as a cytology specialist. His clinical and academic interests include gynecologic oncology and minimally invasive gynecologic surgery, particularly laparoscopic and robot-assisted surgery. In addition to his medical qualifications, he is also a registered surveyor in Japan.