Safety of Transvaginal Specimen Retrieval in Total Laparoscopic Hysterectomy for Nulliparous Women: A Retrospective Study

Total laparoscopic hysterectomy (TLH) is a widely accepted minimally invasive procedure for benign gynecologic diseases. Transvaginal retrieval avoids additional abdominal incisions but may be technically challenging in nulliparous women because of narrower vaginal dimensions and less distensible tissues, particularly in cases with a large uterus. We retrospectively analyzed 368 nulliparous patients who underwent TLH at our institution between February 2021 and August 2025. Among them, 267 underwent transvaginal retrieval and 101 underwent transabdominal retrieval, with all cases performed using contained in-bag morcellation. In the high-difficulty subgroup defined as uterine weight ≥500 g (n = 147), 62 underwent transvaginal and 85 underwent transabdominal retrieval. No conversion from transvaginal to transabdominal extraction was required. Compared with the abdominal route, transvaginal retrieval was associated with significantly shorter operative time (median 203.5 vs. 207.0 minutes, p = 0.016) and retrieval time (28.5 vs. 34.0 minutes, p = 0.024), while blood loss did not differ significantly (25 vs. 25 ml, p = 0.142). Retrieval efficiency (uterine weight ÷ retrieval time) tended to be higher in the transabdominal group (median 25.69 vs. 24.14 g/min, p = 0.083), but the difference was not statistically significant. No major complications occurred, and only minor events such as vaginal wall lacerations and vaginal cuff infections were observed (vaginal wall laceration: 1/62 [1.6%] vs. 2/85 [2.4%]; vaginal cuff infection: 1/62 [1.6%] vs. 1/85 [1.2%] in the transvaginal and transabdominal groups, respectively); all were managed conservatively or with simple intraoperative repair. These findings suggest that even in nulliparous women with large uteri, transvaginal retrieval during TLH using contained in-bag morcellation can be considered a safe and effective first-line option for specimen removal when intraoperative conditions permit, potentially providing superior cosmetic results and reducing surgical morbidity without increasing perioperative risks. Prospective, multicenter studies are warranted to validate these results.