This review evaluates the effectiveness and safety of different surgical approaches to hysterectomy for benign gynecological conditions. The four main approaches are abdominal hysterectomy (AH), vaginal hysterectomy (VH), laparoscopic hysterectomy (LH), and robotic-assisted hysterectomy (RH). The review includes 47 studies with 5102 women, focusing on outcomes such as return to normal activities, satisfaction, quality of life, intraoperative visceral injury, and major long-term complications. Key findings include: - **VH vs. AH**: VH results in a shorter return to normal activities (mean difference -9.5 days, 95% CI -12.6 to -6.4), but no significant differences in other primary outcomes. - **LH vs. AH**: LH also results in a shorter return to normal activities (mean difference -13.6 days, 95% CI -15.4 to -11.8), but has a higher risk of urinary tract injuries (odds ratio 2.4, 95% CI 1.2 to 4.8). - **LH vs. VH**: No significant differences in any primary outcomes between LH and VH. - **RH vs. LH**: No significant differences in any primary outcomes between RH and LH. Overall, the evidence is of low or moderate quality, with limitations including poor reporting and imprecision. The review concludes that VH should be preferred over AH when technically feasible due to faster recovery and fewer postoperative complications. When VH is not possible, LH has some advantages over AH, but these are offset by longer operation times. Single-port laparoscopic hysterectomy and robotic-assisted hysterectomy should be further evaluated or abandoned due to lack of evidence of benefits. The choice of surgical approach should be discussed and decided based on the relative benefits and hazards, considering the surgeon's expertise.This review evaluates the effectiveness and safety of different surgical approaches to hysterectomy for benign gynecological conditions. The four main approaches are abdominal hysterectomy (AH), vaginal hysterectomy (VH), laparoscopic hysterectomy (LH), and robotic-assisted hysterectomy (RH). The review includes 47 studies with 5102 women, focusing on outcomes such as return to normal activities, satisfaction, quality of life, intraoperative visceral injury, and major long-term complications. Key findings include: - **VH vs. AH**: VH results in a shorter return to normal activities (mean difference -9.5 days, 95% CI -12.6 to -6.4), but no significant differences in other primary outcomes. - **LH vs. AH**: LH also results in a shorter return to normal activities (mean difference -13.6 days, 95% CI -15.4 to -11.8), but has a higher risk of urinary tract injuries (odds ratio 2.4, 95% CI 1.2 to 4.8). - **LH vs. VH**: No significant differences in any primary outcomes between LH and VH. - **RH vs. LH**: No significant differences in any primary outcomes between RH and LH. Overall, the evidence is of low or moderate quality, with limitations including poor reporting and imprecision. The review concludes that VH should be preferred over AH when technically feasible due to faster recovery and fewer postoperative complications. When VH is not possible, LH has some advantages over AH, but these are offset by longer operation times. Single-port laparoscopic hysterectomy and robotic-assisted hysterectomy should be further evaluated or abandoned due to lack of evidence of benefits. The choice of surgical approach should be discussed and decided based on the relative benefits and hazards, considering the surgeon's expertise.