**4. Perioperative complications of robotic hysterectomy**

Possible postoperative complications include fever, respiratory failure and pneumonia, postoperative ileus, sepsis, transfusion need, urine retention, and parietal complications [27–31].

*Fever* is the most common secondary complication of hysterectomy. The most common causes are urinary or respiratory tract infections. Most of the time, however, the etiology of fever is unclear; in patients with robotic interventions, it is not associated with increased sepsis, wound infections, or pneumonia. One possible explanation would be that it appears secondary to the atelectasis related to the increased duration of the Trendelenburg position [32].

The leading risk factor for *respiratory complications*, is the generally longer operating times in steep Trendelenburg position in robotic-operated patients [33].

The factors related to *urinary retention* in robotic hysterectomy patients remain unknown [28]. The solution is maintaining an indwelling urinary catheter for at least one day after a hysterectomy, especially in elderly patients.

Intraoperative complications are classified into hemorrhagic, digestive, and urinary tract complications. The occurrence of any of these complications can cause laparoscopic or laparotomic conversion. Most complications occur when inserting the first trocar. The most severe complication is bleeding from damage to large vessels [34, 35].

Intraoperative *hemorrhagic complications* in robotic interventions are rare, with a reduced need for transfusions compared to other types of hysterectomies [27].

*Bladder injuries* can occur during bladder-uterine dissection, being favored by a history of cesarean section. In particular, this type of injury is more common in radical interventions than in standard total hysterectomies because radical hysterectomy involves extensive dissection of periureteral tissue, unroofing of the ureteral tunnel, and the mobilization of the blender, It is essential to recognize them intraoperative. The incidence of bladder injuries during radical hysterectomy is between 0.4 and 3.7%.

Ureteral lesions depend on the complexity of the intervention, with a variable incidence between 0.08 and 4.2%. Most commonly, they occur through thermal injury or radical hysterectomy. The appearance of uterovaginal fistulas follows their non-recognition. The incidence of vesicovaginal and uterovaginal fistulas is between 0.9 and 2.0% [35–37].

*Hysterectomy Matters*
