Vaginally applied (vcare uterine manipulator) with abdominally applied boztosun method for uterine manipulation in laparoscopic hysterectomy comparing manipulation

Objective: The aim of this study was to compare the Boztosun method (Modified Rein technique) with the Vcare uterine manipulator used in our clinic in cases undergoing hysterectomy for benign reasons and to determine the effectiveness of these two groups and to determine the laboratory and clinical results of the operated patients. Materials and Methods: Between March 19, 2022 and March 19, 2024, demographic characteristics, uterine manipulator insertion times, operative times, discharge times, colpotomy time, intraoperative and postoperative laboratory values of 15 patients who underwent laparoscopic hysterectomy for benign causes using Boztosun method (Modified Rein method) and 15 patients who underwent surgery with Vcare uterine manipulator in our Gynecology and Obstetrics clinic at Akdeniz University Medical Faculty Hospital, These two methods were compared and evaluated in terms of whether the operation could be completed laparoscopically (transition to laparotomy), for which indications the operation was performed, whether any complications developed during or after the operation, whether oophorectomy was added to the operation, whether an intraoperative drain was placed, whether the patient had previous abdominal surgery, pathology results of hysterectomy materials and uterine weights. Results: In the study, 15 patients aged between 42 and 63 years with a mean age of 49.4 years and 15 patients aged between 39 and 72 years with a mean age of 49.4 years who underwent laparoscopic hysterectomy at Akdeniz University Medical Faculty Hospital between March 19, 2022 and March 19, 2024 and in whom the Boztosun method was used during the operation were evaluated in two groups. While 9 patients (30%) were in menopause, 15 patients (50%) had a history of previous abdominal surgery. The most common indications were myoma uteri (43.3%), treatment-resistant menometrorrhagia (16.6%), postmenopausal bleeding (13.3%), endometrial intraepithelial hyperplasia (13.3%), and chronic pelvic pain (3.3%). The operation time was significantly longer in the Vcare uterine manipulator group (109 minutes) than in the Boztosun method (81.67 minutes) and this difference was statistically significant. The hospital stay was also longer in the Vcare uterine manipulator group (3.53 days) than in the Boztosun method (2.13 days) and this difference was statistically significant. Colpotomy time was longer in the Vcare uterine manipulator group (8.87 minutes) than in the Boztosun method (4.13 minutes) and this difference was statistically significant. Uterine manipulator insertion time was also longer and statistically significant in the Vcare uterine manipulator group (8.07 minutes) compared to Boztosun method (0.81 minutes). Uterine weight and the amount of hemoglobin decrease were also higher in the Vcare uterine manipulator group, respectively, but these differences were not statistically significant. The duration of colpotomy showed low correlation with uterine weight, whereas there were significant strong positive correlations between colpotomy duration and uterine manipulator insertion time (r=0.806, p<0.001). Certain measurements were compared between groups with and without abdominal surgery. The operation time was shorter in the group without previous abdominal surgery (mean 87 minutes) and this difference was statistically significant. None of the patients had bladder injury, ureteral injury, intestinal and vascular injury, or the need for preop - intraop and postop blood transfusion. Bladder catheter was withdrawn in 100% of the patients on the first postop day. All patients received prophylactic antibiotics and no complications such as postop incision site infection and urinary tract infection were observed in any patient. In 30 patients (80%) the pathology result was benign, in (20%) the result was premalignant and in none of the patients the result was malignant. Conclusion: The Boztosun method (Modified Rein technique), which we developed inspired by the classical Rein technique, provided us great convenience in the manipulation of the uterus, manipulator placement, operation time and colpotomy. The most difficult situation in the classical Rein technique was the attachment of the cotton tape to the uterus and its removal from the uterus. Thanks to this method we have developed, the cotton tape is attached to the uterus much faster and easier and reattaching it in case of possible dislodgement has been made simpler. In this way, the applicability of the method has become easier. When the operation time, colpotomy time, manipulator placement time, postoperative hemogram drop, discharge time, complications and success of the method were compared, the results were found to be significant compared to the Vcare uterine manipulator and many studies in the literature. Since the cases in the study were performed by residents with little laparoscopic experience and trained in our clinic, we believe that prospective, randomized studies with larger case series by surgeons with more laparoscopic experience and familiar with the method are needed to support and improve our findings. Key Words: Laparoscopy, Manipulator, Boztosun, Vcare, Hysterectomy, Gynecology, Colpotomy, Rein