Objective:

To compare perioperative safety, efficiency and learning curves of MPLH, RASPH and SPLH, and analyze surgical disparities stratified by uterine volume.

Approach:

• Study Design: Single-center retrospective cohort study involving 280 patients who underwent minimally invasive hysterectomy.
• Data Analysis: Multivariable regression and multinomial IPTW weighting were used to correct indication confounding.

Key Findings:

• Unadjusted operative time: MPLH 83.9 min, RASPH 166.0 min, SPLH 102.0 min (P < 0.001).
• Adjusted analysis showed RASPH required longer operating time compared to MPLH and SPLH.
• Unadjusted blood loss: MPLH 126 mL, RASPH 134 mL, SPLH 156 mL (P < 0.001).
• 30-day complication rates were similar across all techniques (P = 0.79).
• CUSUM learning curves indicated MPLH and SPLH reached proficiency faster than RASPH.

Interpretation:

The three techniques shared similar short-term safety, with RASPH having prolonged operative time and SPLH associated with greater intraoperative bleeding.

Limitations:

• Severe baseline imbalance restricts causal subgroup interpretation.
• Limited statistical power in the complex subgroup of RASPH due to small sample size.

Conclusion:

MPLH and SPLH demonstrated equivalent efficiency and faster learning curves, suggesting the need for prospective balanced cohorts for further validation.