Use of uterine manipulators in endometrial cancer surgery: Balancing benefits and uncertainties

Objective: Intrauterine manipulators are commonly used for minimally invasive hysterectomy for endometrial cancer yet concerns regarding tumor spillage and oncologic safety remain debated. This review aims to synthesize comparative evidence regarding their impact on oncologic outcomes. Methods: A comprehensive literature review up to December 2025 identified 15 comparative studies, including randomized trials, meta-analyses, and observational cohorts. The analysis focused on peritoneal cytology, lymphovascular space invasion (LVSI), recurrence patterns, and survival outcomes in patients undergoing hysterectomy for endometrial cancer. Results: Most randomized and matched evidence demonstrated no significant detriment in disease-free or overall survival for early-stage endometrioid disease attributable to manipulator use. However, recent large datasets and meta-analytic subgroups signaled modest increases in positive peritoneal cytology (adjusted OR 1.7) and LVSI among manipulator users. Additionally, specific cohorts reported increased isolated vaginal vault recurrences, although overall operative safety remained comparable. Conclusions: Current evidence suggests that a universal oncologic hazard may not be present for early-stage, low-grade tumors, though the reliance on predominantly retrospective data warrants caution. Until definitive prospective data mature, a selective, technique-conscious approach could be considered.