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Uterine Manipulators

Transvaginal instruments inserted through the cervix into the uterine cavity to provide mobilization, anteversion or retroversion, lateral deviation, and cephalic elevation during gynecologic surgery; some models also delineate the vaginal fornices for colpotomy. Intra-abdominal graspers and myoma screws are alternatives, not transvaginal uterine-manipulator designs. Selection depends on the operation, anatomy and model-specific instructions.[1][2]

Despite their ubiquity, there is no single optimal uterine manipulator that is universally safe, efficient, and cost-effective across all procedures; the surgeon selects the manipulator that best suits the specific case.[1]

Purpose and Rationale​

  • Uterine mobilization: multi-plane movement (anteversion, retroversion, lateral deviation, cephalic elevation) from below, providing dynamic exposure without additional laparoscopic instruments or extra ports.
  • Surgical exposure: placing tension on the broad ligament, uterine vessels, cardinal and uterosacral ligaments, and peritoneal attachments to facilitate identification and dissection.
  • Vaginal-fornix delineation: the cervical (colpotomy) cup delineates the fornices from below; provides a clear landmark for the laparoscopic colpotomy incision; maintains pneumoperitoneum after cuff opening.
  • Ureteral displacement. In a nine-cadaver VCare Plus study, maximal cephalic elevation combined with anteversion or contralateral angulation increased measured separation at specified uterovaginal landmarks; this is an anatomic surrogate, not a demonstrated reduction in ureteral injury and not a universal distance for other devices or patients.[3]
  • Pneumoperitoneum maintenance. Cervical cup or occluding balloon preserves visualization in the final steps of hysterectomy.

Design Components​

ComponentFunction
Intrauterine tip / obturatorRod or cannula through the cervical os into the uterine cavity — transmits manipulation forces. May incorporate a balloon for cavity occlusion / device fixation.
Cervical (colpotomy) cupRigid ring or disc sitting in the fornices; delineates the colpotomy line; available in small / medium / large sizes
Handle / shaftExternal component the assistant holds; ergonomic pistol grips with articulating joints on the most refined designs
Fixation mechanismCervical-cup friction, intrauterine balloon, cervical tenaculum, or threaded cervical fixation

Approach and Classification​

The literature documents at least 10 distinct uterine manipulators.[1] Broadly classified by approach:

ClassExamplesNotes
Vaginal (transvaginal)RUMI + Koh Colpotomizer, VCare / VCare Plus, Hohl, Clermont-Ferrand, Colpo-ProbeThe dominant class for minimally invasive hysterectomy
Intra-abdominal (manipulator-free)Myoma screw, Boztosun technique, tenaculum / grasper on the fundusAvoids transvaginal instrumentation; potentially shorter operative time and lower cost[4][5]

Major Named Systems​

SystemManufacturerDefining feature
RUMI / RUMI II + Koh ColpotomizerCooperSurgical (Hector Advincula design)Hybrid (reusable handle + disposable components); balloon-fixed; pneumoperitoneum maintenance via Koh cup[1][6]
VCare / VCare PlusCONMEDSingle-use; cervical and separate vaginal sealing cups on the documented VCare configuration; VCare Plus was used in the Pan 2025 cadaver study. Check the exact generation's IFU.[3]
HohlKARL STORZ (Michael Hohl)Reusable; tight-fitting cervical cup; shorter insertion time (2 vs 6 min) vs Colpo-Probe (Husslein 2017 RCT)[7]
Clermont-FerrandUniversité Clermont-FerrandReusable European workhorse
Colpo-ProbeCooperSurgicalLoose-fitting; longer insertion time than Hohl in RCT[7]
Multipurpose reusable stainless steelVariousReusable; cross-procedure compatibility for supracervical hysterectomy / sacrocolpopexy / hysteropexy[2]
Myoma screw / Boztosun (intra-abdominal)VariousManipulator-free intra-abdominal approach; shorter operative time[4][5]

Reconstructive-Urology and Urogyn Uses​

The uterine manipulator is in urogyn scope for the laparoscopic or robotic and open pelvic-reconstructive cases that intersect WARWIKI's core operative repertoire:

  • Laparoscopic or robotic sacrocolpopexy with concomitant hysterectomy. Manipulator delineates the vaginal apex for mesh fixation; mobilizes the uterus for the hysterectomy step.[2]
  • Laparoscopic or robotic supracervical hysterectomy. Uterine mobilization without a colpotomy step; select a configuration indicated for this operation and protect the device from dissection energy.[2]
  • Total laparoscopic hysterectomy (TLH) as adjunct to pelvic reconstruction is the canonical use and provides exposure for colpotomy and pneumoperitoneum maintenance.[1][7]
  • Laparoscopic or robotic hysteropexy. Uterine mobilization during a uterine-preserving suspension when trans-cervical placement is appropriate; after hysterectomy, vault prolapse repair instead requires a vaginal or apical delineator, not an intrauterine tip.[2]
  • Endometriosis surgery during urogyn-adjunctive procedures. Exposure of the cul-de-sac, uterosacral ligaments, and rectovaginal septum during excision of deep infiltrating endometriosis encountered during pelvic-reconstructive cases.
  • Laparoscopic myomectomy. Uterine mobilization and exposure of myoma sites; myoma-screw alternative for intra-abdominal manipulation.
  • Total abdominal hysterectomy (TAH) in selected benign cases: a review of four RCTs (n = 340) found shorter operative time, smaller hemoglobin reduction and greater postoperative vaginal length, but the authors noted high risk of bias from lack of blinding; these findings do not establish a universal requirement for a manipulator.[9]

Environmental and Cost — Reusable vs Disposable​

Melnyk 2025 life-cycle assessment over 300 hysterectomies compared four manipulators (reusable stainless steel, two disposable, one hybrid):[8]

  • Reusable stainless steel had the lowest carbon footprint in every environmental category.
  • The two disposable models had global-warming emissions 2.39× and 4.24× higher than the reusable model; the hybrid's estimate depended on reuse assumptions.
  • Higher upfront cost but $16,000–$43,000 institutional savings over 300 uses for the reusable variant.

Practical implication for urogyn programs: a reusable model may reduce cost and modeled environmental impact at the study's use volume; this analysis did not compare clinical performance. Check local processing capacity, instrument life and procedure needs.[8]

The 2026 AUGS sustainability white paper, which shares an author with this analysis, lists reusable devices among suggested operating-room sustainability measures; its abstract names gowns, drapes and specula and does not name manipulators.[22]

The Endometrial-Cancer Manipulator-Safety Debate​

Out of WARWIKI's primary scope (cancer surgery), but mentioned because it has spread to general urogyn awareness:

Concern: the intrauterine balloon or tip may disrupt tumor, forcing malignant cells through the fallopian tubes into the peritoneal cavity or LVSI. Evidence is discordant:

  • No statistically conclusive harm in some analyses: Zorzato 2024 (14 studies, n = 5,019) estimated recurrence HR 1.52 (95% CI 0.99–2.33; p = .05), an imprecise borderline signal, not proof of safety; overall-survival HR 1.07 (95% CI 0.65–1.76). Scutiero 2022 and Uccella 2017 reported different null comparisons.[10][11][12]
  • Possible harm signals: Padilla-Iserte 2021 (n = 2,661): higher recurrence (11.69% versus 7.4%).[13] Nagase 2026 (12 studies, n = 10,805): DFS lower with manipulator (HR 1.18, 95% CI 1.01–1.38, p = 0.04); risk-of-bias caveats.[14]

Current synthesis. Crosbie 2022 Lancet review notes "discordant data" and positive peritoneal cytology of "uncertain clinical significance" since washings are no longer in FIGO staging.[15] D'Indinosante 2026 recommends a "selective, technique-conscious approach" until definitive prospective data mature.[16]

These tumor-dissemination and cancer-survival estimates should not be extrapolated to a benign hysterectomy. An unexpected or suspected malignancy still requires an individualized oncologic plan; benign operative use does not eliminate the separate risks of perforation or bleeding.

Manipulator-Free Techniques​

For surgeons who prefer to avoid manipulators:

  • Manipulator-free TLH. Erdem 2026 retrospective cohort (n = 244 manipulator versus 166 manipulator-free): no significant differences in operative time (79.6 versus 76.6 min), complications, or vaginal-cuff dehiscence. Manipulator-free TLH is safe in expert hands.[17]
  • Myoma screw. Laparoscopic screw into uterine fundus for intra-abdominal manipulation; shorter operative time and lower cost versus vaginal manipulators.[5]
  • Boztosun technique. Intra-abdominal Rein-technique modification; shorter operative and colpotomy times.[4]

Complications​

  • Uterine perforation or bleeding. Assess depth and direction with a separate sound before insertion; for example, the RUMI II handle IFU prohibits use in known or suspected pregnancy, an IUD in place or suspected pelvic infection, and the VCare IFU cautions against use if the cavity sounds under 4 cm or in a large postpartum uterus. These are model-specific instructions, not blanket contraindications for every design.[20][21]
  • Cervical laceration: forceful manipulation or cervical stenosis or atrophy.
  • Vaginal-cuff injury or dehiscence after hysterectomy: a complication of the operation and closure, not a proven device-specific incidence attributable to manipulator selection; take care with colpotomy energy and cuff closure.[7][18][19]
  • False passage through cervical stroma in cervical stenosis.

Technique​

  1. Assess cervical access for the selected model. The RUMI II handle IFU specifies dilation to Hegar or Hank 8; the documented VCare IFU calls for dilation if necessary to admit its 5-mm tube. Do not apply one dilation rule to all devices.[20][21]
  2. Sound the uterus separately to determine cavity direction and depth; choose a tip no longer than the sounded depth for RUMI II, and follow the selected model's insertion and balloon instructions. RUMI II's tip is single-use; VCare's balloon uses 7–10 mL air, not saline. Stop manipulation if the VCare balloon ruptures.[20][21]
  3. Position for the operative landmark. Cephalic elevation with anteversion or contralateral angulation increased measured ureteral separation in the VCare Plus cadaver experiment; visualize the ureter directly when risk warrants rather than treating a cadaveric distance as clinical protection.[3]
  4. Coordinate with assistant. Surgeon at the console directs specific manipulator movements ("antevert," "push cephalad," "deviate left") for each surgical step.
  5. Cup-size selection: by cervical or fornix fit per the chosen IFU; the cadaveric cup-size comparison does not establish that cup size is irrelevant to patient safety.[3][21]
  6. Minimize colpotomy thermal spread. Use the lowest effective energy settings to reduce vaginal-cuff thermal injury and dehiscence risk.[7][19]
  7. Consider manipulator-free in oncologic cases of concern and in surgeons confident with intra-abdominal techniques.[4][5][17]

Limitations​

  • Requires an assistant to control the vaginal handle.
  • No single optimal manipulator for all procedures.[1]
  • Endometrial-cancer oncologic uncertainty (out of WARWIKI scope but relevant to multidisciplinary practice).[10][14]
  • Risk of uterine perforation, cervical laceration, false passage.
  • Disposable-cost and environmental impact: favor reusable systems where operative performance allows.[8]
  • Cervical access limitations. Severe stenosis or absent cervix can preclude trans-cervical insertion; a prior trachelectomy requires anatomy-specific assessment. A vaginal delineator or intra-abdominal alternative may still be usable, depending on the operation and its own instructions.

See also: Heaney Clamp, Heaney Needle Driver, Heaney Retractor, Masterson Pedicle Clamp, Auvard Weighted Speculum.

Videos​

Minimally Invasive Sacrocolpopexy: A Comparison of Vaginal Manipulators (SUFU 2026)
Side-by-side comparison of vaginal manipulator systems for minimally invasive sacrocolpopexy. SUFU Surgical Video Library; embed restricted to sufuorg.com, opens externally.
sufuorg.com · Surgical Video Library

References​

1. van den Haak L, Alleblas C, Nieboer TE, Rhemrev JP, Jansen FW. "Efficacy and safety of uterine manipulators in laparoscopic surgery: a review." Arch Gynecol Obstet. 2015;292(5):1003–11. doi:10.1007/s00404-015-3727-9

2. Schaer GN, Sarlos D, Khan Z. "A multipurpose uterine / vaginal manipulator for laparoscopic urogynecologic procedures." Int Urogynecol J. 2019;30(8):1377–9. doi:10.1007/s00192-019-03940-x

3. Pan ET, Belmonte BM, Wai CY, Balgobin S. "Optimizing use of a uterine manipulator for laparoscopic hysterectomy: a cadaveric study of distances to the pelvic ureter." Am J Obstet Gynecol. 2025;S0002-9378(25)00398–9. doi:10.1016/j.ajog.2025.06.022

4. Çelik İ, Boztosun A, Güner FC. "Comparative analysis of vaginal and abdominal uterine manipulation in laparoscopic hysterectomy: the Boztosun technique." J Clin Med. 2025;14(11):3652. doi:10.3390/jcm14113652

5. Güven CM, Uysal D, Kolsuz Z, Yilmaz B. "Surgical outcomes of intraabdominal versus vaginal approach for uterine manipulation during total laparoscopic hysterectomy." Medicine (Baltimore). 2023;102(22):e33927. doi:10.1097/MD.0000000000033927

6. Keriakos R, Zaklama M. "The RUMI manipulator and Koh Colpotomiser system for total laparoscopic hysterectomy." BJOG. 2000;107(2):274–7. doi:10.1111/j.1471-0528.2000.tb11700.x

7. Husslein H, Frecker H, Shore EM, et al. "Comparing two uterine manipulators during total laparoscopic hysterectomy: a randomized controlled trial." J Minim Invasive Gynecol. 2017;24(5):764–71. doi:10.1016/j.jmig.2017.02.022

8. Melnyk AI, Silva de Souza Lima Cano N, Glass Clark S, Bilec MM, Artsen A. "A comparative carbon footprint and cost analysis of uterine manipulators for hysterectomy." Obstet Gynecol. 2025;146(1):104–12. doi:10.1097/AOG.0000000000005949

9. Baradwan S, Khadawardi K, Himayda S, et al. "Use of uterine manipulators in total abdominal hysterectomy: a systematic review and meta-analysis." J Minim Invasive Gynecol. 2026;33(6):685–693 (online 2025). doi:10.1016/j.jmig.2025.12.033

10. Zorzato PC, Uccella S, Biancotto G, et al. "Intrauterine manipulator during hysterectomy for endometrial cancer: a systematic review and meta-analysis of oncologic outcomes." Am J Obstet Gynecol. 2024;230(2):185–198.e4. doi:10.1016/j.ajog.2023.09.004

11. Scutiero G, Vizzielli G, Taliento C, et al. "Influence of uterine manipulator on oncological outcome in minimally invasive surgery of endometrial cancer: a systematic review and meta-analysis." Eur J Surg Oncol. 2022;48(10):2112–8. doi:10.1016/j.ejso.2022.05.034

12. Uccella S, Bonzini M, Malzoni M, et al. "The effect of a uterine manipulator on the recurrence and mortality of endometrial cancer: a multi-centric study by the Italian Society of Gynecological Endoscopy." Am J Obstet Gynecol. 2017;216(6):592.e1–592.e11. doi:10.1016/j.ajog.2017.01.027

13. Padilla-Iserte P, Lago V, Tauste C, et al. "Impact of uterine manipulator on oncological outcome in endometrial cancer surgery." Am J Obstet Gynecol. 2021;224(1):65.e1–65.e11. doi:10.1016/j.ajog.2020.07.025

14. Nagase Y, Matsuzaki S, Yoshida H, et al. "Survival association of intrauterine manipulator use during minimally invasive hysterectomy for endometrial cancer: a systematic review and meta-analysis." Obstet Gynecol. 2026;147(4):463–77. doi:10.1097/AOG.0000000000006195

15. Crosbie EJ, Kitson SJ, McAlpine JN, et al. "Endometrial cancer." Lancet. 2022;399(10333):1412–28. doi:10.1016/S0140-6736(22)00323-3

16. D'Indinosante M, Bruno M, Napolitano F, et al. "Use of uterine manipulators in endometrial cancer surgery: balancing benefits and uncertainties." Eur J Surg Oncol. 2026;52(6):111810. doi:10.1016/j.ejso.2026.111810

17. Erdem B, Erciyestepe SG. "Manipulator-free versus manipulator-assisted total laparoscopic hysterectomy: are outcomes comparable in experienced hands?" Med Sci Monit. 2026;32:e949649. doi:10.12659/MSM.949649

18. Clarke-Pearson DL, Geller EJ. "Complications of hysterectomy." Obstet Gynecol. 2013;121(3):654–73. doi:10.1097/AOG.0b013e3182841594

19. Nezhat C, Kennedy Burns M, Wood M, et al. "Vaginal cuff dehiscence and evisceration: a review." Obstet Gynecol. 2018;132(4):972–85. doi:10.1097/AOG.0000000000002852

20. CooperSurgical. RUMI II reusable handle UMH650 instructions for use. Device warnings, contraindications, tip sizing and model-specific processing; consult the separate tip IFU before use.

21. CONMED. VCare vaginal-cervical retractor-elevator instructions for use, P/N 17698 Rev A (March 2016), models 60-6085-200A through -203A. Historical VCare generation; obtain the current VCare Plus IFU for a Plus system.

22. Chen CCG, Andiman S, Long J, et al. Health Care Sustainability: Strategies for Operating Rooms and Urogynecologic Procedures. Urogynecology (Phila). 2026;32(6):569-577. doi:10.1097/SPV.0000000000001835