Modern Convolutional Design Improves Uterine MRI Segmentation, while nnU-Net Remains Most Robust Across Heterogeneous Datasets

<jats:p>Purpose: To evaluate how segmentation architecture and dataset-adaptive configuration influence uterine MRI segmentation across heterogeneous benign and malignant tasks. Methods: U-Net, Swin-UNETR, and MedNeXt were compared with nnU-Net as a self-configuring reference across T2-weighted MRI datasets: public multiclass UMD anatomy/fibroid segmentation (n=300), institutional endometrial cancer tumor segmentation (n=206), and institutional uterine mass lesion segmentation (n=234). A relabeled external UMD-style cohort (n=12) assessed domain shift. Models used fixed partitions, fold ensembling, Dice, HD95, ASSD, volume error, and paired bootstrap comparisons with Holm correction. Results: MedNeXt was the strongest manually controlled architecture. nnU-Net achieved the highest performance on all internal datasets and external testing. Macro-Dice reached 0.761, 0.746, and 0.814 for nnU-Net on UMD, endometrial cancer, and uterine mass datasets, respectively, versus 0.722, 0.726, and 0.789 for MedNeXt. The nnU-Net-MedNeXt gap was largest for multiclass UMD segmentation and smaller in binary tasks. External testing degraded all models; nnU-Net remained highest (0.542), followed by MedNeXt (0.490), U-Net (0.396), and Swin-UNETR (0.287). Conclusions: Uterine MRI segmentation performance depended on task, architecture, and evaluation domain. MedNeXt supported modern convolutional design as a strong manual baseline, but nnU-Net remained the most robust overall, emphasizing the importance of dataset-adaptive configuration and external validation.</jats:p>