Bibliography on Assisted Reproductive Technology and Gynecological Surgery

This platform serves as a structured resource for clinicians and researchers specializing in assisted reproductive technology (ART) and gynecologic surgery. It has been developed in response to the increasing complexity and rapid evolution of these intersecting fields. The result of collaborative work by gynecologic surgeons highly engaged in both disciplines, each review offers a clear and accessible synthesis of recent studies.

As an innovative alternative to classic abstracts and the often time-consuming reading of full-text scientific papers, this hybrid tool —bridging the gap between conventional abstracts and full-text article reviews— enables rapid identification of high-impact publications while guiding users toward those that warrant deeper exploration.

In addition to bibliographic content, the site offers a range of complementary educational tools, including: Frequently Asked Questions, Podcasts, Structured course outlines derived from the source articles, PowerPoint slide decks for educational use.

Regular updates will reflect major developments in the covered areas, ensuring the content remains relevant and practice-oriented.

vNotes Surgical Technique

Dr Anne Dupont

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Dr François Durand

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Overview

  • Access Route vNOTES utilizes the vaginal canal as the primary access route to the abdominal cavity, eliminating the need for visible abdominal incisions. This contrasts with traditional laparoscopy which uses abdominal wall incisions.
  • Instrumentation A single-port platform, such as the vNOTES port (e.g., Surgaid Medical or Gelpoint vPath), is inserted through an incision in the vaginal mucosa (either bilateral in the lateral vaginal fornix or via a single anterior midline incision), allowing standard laparoscopic instruments and a 30-degree endoscope to access the abdominal cavity and perform complex procedures. Pneumoperitoneum is established through CO2 insufflation, typically maintaining maximum intraperitoneal pressure at 10 mmHg.
  • Scarless Surgery A key benefit of vNOTES is that it is a scarless approach, enhancing cosmetic satisfaction for patients.

vNOTES has been successfully applied in a variety of gynecological surgeries, including:

  • Hysterectomy for benign uterine conditions like cervical intraepithelial neoplasia (CIN), uterine fibroids, adenomyosis, menometrorrhagia, ovarian cysts, and pelvic organ prolapse.
  • Adnexal surgery (e.g., salpingo-oophorectomy, ovarian cystectomy).
  • Myomectomy.
  • Rectal prolapse repair.
  • Sentinel lymph node dissection for endometrial cancer staging, particularly using a retroperitoneal approach. This technique allows exploration of the lymphatic system along its natural distribution from caudally to cranially.
  •  

Studies comparing vNOTES hysterectomy (vNOTEH) with laparoscopic hysterectomy (LH) and conventional vaginal hysterectomy (VH) highlight several potential advantages:

  • Faster Recovery and Shorter Hospital Stay:
    • Remarkably decreased time to first anal exhaust (median 48.0 h for vNOTEH vs. 69.0 h for LH, P < 0.001).
    • Significantly earlier return-to-work (RTW) time (median 2.0 months for vNOTEH vs. 3.0 months for LH, P = 0.011). This represents a 30% reduction in workforce reintegration time.
    • Shorter postoperative hospitalization compared to LH (e.g., median 5 days vs. 8 days in one study and 2.2 days vs. 2.5 days in another), or similar to VH. Some patients can even be discharged the same day.
  • Reduced Pain and Enhanced Cosmetic Outcomes:
    • Lower postoperative pain scores (e.g., lowest 6th-hour pain score of 1.53 for vNOTEH compared to 2.19 for VH and 4.51 for TLH).
    • Superior cosmetic satisfaction due to the absence of abdominal incisions.
  • Surgical Efficiency and Safety Profiles:
    • In some studies, vNOTEH demonstrated significantly shorter operation time compared to LH (e.g., median 90.0 min vs. 110.0 min, or 85.0 min vs. 110.0 min), although other studies found similar operative times between vNOTES and LH, or even longer for vNOTES compared to VH in some contexts.
    • Comparable safety profiles with LH and VH regarding intervention-requiring complications.
    • Total blood loss can be similar to LH or higher than LH in some studies, but generally comparable to VH. Blood transfusion rates are low.
  • Improved Sexual Quality of Life (sQoL):
    • Patients undergoing vNOTES hysterectomy showed significantly improved scores in arousal, orgasm, and overall sexual satisfaction compared to those undergoing conventional laparoscopic hysterectomy. This was particularly noted in patients with adenomyosis.
  • Broader Applicability:
    • vNOTES integrates the benefits of vaginal surgery with enhanced endoscopic visualization, making it applicable even in cases with challenging anatomical conditions such as large uteri (> 280g or > 538.8g in some reports), obesity, or previous abdominal surgery. It offers better visualization of adnexa compared to conventional VH.
    • The retroperitoneal vNOTES approach for sentinel lymph node dissection offers anesthetic advantages, as it can be performed without the need for the Trendelenburg position, which facilitates ventilation in obese patients.
  • Cost-Effectiveness:
    • VH is generally the least costly, but vNOTES hysterectomy has been reported to be significantly less costly than TLH.

Despite the promising findings, current studies on vNOTES have limitations, including:

  • Non-randomized or retrospective designs.
  • Single-center data and focus on specific patient subgroups, which may limit generalizability.
  • Lack of comprehensive assessment of factors like social support, postoperative care protocols (e.g., ERAS implementation), and detailed cost-effectiveness analyses.
  • The procedure is relatively new, and there is a learning curve involved. Further large-scale, prospective, randomized controlled trials are needed to confirm these findings and establish the long-term safety and broader societal impacts of vNOTES.

FAQ

Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) is an innovative, minimally invasive surgical procedure that uses the vaginal canal as the primary access route to the abdominal cavity. It is considered a promising third-generation surgical procedure, combining the principles of traditional vaginal surgery with endoscopic visualization. This approach aims to eliminate visible abdominal incisions, resulting in a scarless outcome.

In vNOTES hysterectomy (vNOTEH), an incision is made in the vaginal mucosa, which can be either bilateral in the lateral vaginal fornix or via a single anterior midline incision. A single-port platform, such as the vNOTES port (e.g., Surgaid Medical or Gelpoint vPath), is then inserted through this incision. This platform allows standard laparoscopic instruments and a 30-degree endoscope to access the abdominal cavity for the procedure. Pneumoperitoneum is established through CO2 insufflation, typically maintaining maximum intraperitoneal pressure at 8-10 mmHg. The dissection is generally conducted from caudal (vaginal access) to cranial (towards the adnexa).

vNOTES has been successfully applied in various gynecological surgeries for benign conditions, including hysterectomy for cervical intraepithelial neoplasia (CIN), uterine fibroids, adenomyosis, menometrorrhagia, ovarian cysts, and pelvic organ prolapse. It is also explored for gynecologic malignancies, particularly for sentinel lymph node dissection for endometrial cancer staging.

vNOTES hysterectomy (vNOTEH) is associated with faster recovery outcomes compared to laparoscopic hysterectomy (LH). Patients undergoing vNOTEH have shown a significantly decreased time to first anal exhaust (median 48.0 hours vs. 69.0 hours for LH), representing an acceleration of 21 hours in bowel function recovery. They also experience an earlier return-to-work (RTW) time (median 2.0 months vs. 3.0 months for LH).

Yes, studies indicate that vNOTES hysterectomy results in lower postoperative pain scores. One study reported the lowest 6th-hour pain score of 1.53 for vNOTES, compared to 2.19 for vaginal hysterectomy (VH) and 4.51 for total laparoscopic hysterectomy (TLH). Median visual analog scale (VAS) pain scores were as low as 1 out of 10 at 24 hours postoperatively in some cases of vNOTES retroperitoneal sentinel lymph node dissection.

vNOTES leads to significantly shorter postoperative hospitalization compared to LH. The median hospital stay for vNOTEH was 5 days compared to 8 days for LH in one study, and 2.2 days for vNOTES versus 2.5 days for TLH in another comparison of vNOTES, VH, and TLH. For sexually active patients, vNOTES led to earlier discharge (1.8 days vs. 2.6 days for TLH). Some patients undergoing vNOTES retroperitoneal sentinel lymph node dissection were even discharged the same day (30%), with a median hospital stay of 2 days for others.

Yes, vNOTES is a scarless approach due to the absence of abdominal incisions. This contributes to superior cosmetic satisfaction for patients, with vNOTEH groups showing remarkably higher cosmetic satisfaction scores (median 9 points) compared to LH groups (median 8 points). This cosmetic benefit is particularly valued by younger patients.

Yes, vNOTES expands its applicability to patients with challenging anatomical conditions, including large uteri (e.g., >280g or >538.8g in some reports), obesity, or a history of previous abdominal surgery. It offers better visualization of adnexa compared to conventional vaginal hysterectomy. The retroperitoneal vNOTES approach for sentinel lymph node dissection can also be performed without the need for the Trendelenburg position, which facilitates ventilation in obese patients.

Patients undergoing vNOTES hysterectomy have shown significantly improved scores in arousal, orgasm, and overall sexual satisfaction compared to those undergoing conventional laparoscopic hysterectomy. The total sQoL score in the vNOTES group was significantly better (median 28.97) than in the TLH group (median 24.99). This improvement was particularly noted in patients with adenomyosis, where arousal and orgasm scores improved post-operatively.

Operation times for vNOTES hysterectomy vary across studies. One study reported a significantly shorter operation time for vNOTEH (median 90.0 minutes) compared to LH (median 110.0 minutes). However, another study found vNOTES hysterectomy to have the highest mean operation time (108 ± 41 minutes) compared to VH (85 ± 29 minutes) and TLH (100 ± 42 minutes) at their center, attributing this to the procedure being newer there. A meta-analysis comparing vNOTES with VH found no statistically significant difference in operative time.

vNOTES has shown comparable safety profiles with LH and VH regarding intervention-requiring complications. In one study, intraoperative complications for vNOTES were 1.6% (one bladder perforation), compared to 4.8% for VH (two bladder perforations, one bleeding) and 0% for TLH. For vNOTES retroperitoneal sentinel lymph node dissection, bladder injury was reported in 5% of cases, with most managed conservatively. One case of postoperative bleeding requiring reintervention and one case of adductor muscle paresis were also noted. Overall, there were no significant differences in intraoperative or postoperative complications between vNOTES and VH in a meta-analysis.

Yes, vNOTES is being used for gynecologic malignancies, specifically for sentinel lymph node dissection for endometrial cancer staging. This is achieved via a retroperitoneal vNOTES approach, where the paravesical space is entered through a vaginal incision, a vNOTES port is placed, and the retroperitoneum is insufflated with CO2. Sentinel lymph nodes are then identified using near-infrared light and removed endoscopically.

While both are vaginal approaches, vNOTES offers better visualization of the adnexa and a clearer view for the surgeon, which can facilitate hysterectomy in patients without uterine descensus. A meta-analysis found no statistically significant difference between vNOTES hysterectomy and conventional VH in estimated blood loss, duration of operation, length of hospital stay, pain scores, or intraoperative and postoperative complications. However, one study noted that vNOTES was preferred more often than VH in patients with a history of previous cesarean section and/or pelvic surgery due to a wider field of view for intra-abdominal adhesions.

vNOTES generally shows advantages over TLH in shorter operation time, reduced postoperative hospitalization, and superior cosmetic outcomes. Patients also experience faster recovery of intestinal function (time to first anal exhaust) and earlier return to work. In terms of sexual quality of life, vNOTES groups showed significantly higher scores in arousal, orgasm, and overall satisfaction compared to TLH groups. While total blood loss can be similar, some studies noted higher blood loss in vNOTES in sexually active subgroups, but this was not linked to increased transfusion rates.

One study found that vaginal hysterectomy (VH) was the least costly operation, but vNOTES hysterectomy was significantly less costly than TLH.

vNOTES is a relatively new technique that requires surgeons to have expertise in both vaginal and laparoscopic surgery. There is a significant learning curve involved, which can impact initial results such as operative times and complication rates. One study noted that approximately 30 cases are needed to reach a learning curve plateau in vNOTES. Experienced laparoscopic surgeons may have a rapid learning curve for vNOTES.

Current research often faces limitations such as non-randomized or retrospective designs, which introduce potential bias and limit generalizability. Studies often focus on specific patient subgroups (e.g., high-grade CIN), which might not apply to other populations or healthcare settings. There’s also a lack of comprehensive assessment of factors like social support, detailed postoperative care protocols (e.g., ERAS implementation), and cost-effectiveness analyses. The heterogeneity in study designs and patient indications can also affect surgical and postoperative outcomes.

Yes, large-scale, prospective, randomized controlled trials (RCTs) are needed to confirm initial findings and establish long-term safety and broader societal impacts. The VaNoLaH trial (Baekelandt et al., 2024) is a multinational RCT designed to compare vNOTES with both VH and LH. This trial aims to recruit 1000 women and generate generalizable results in real-life settings, assessing outcomes like hospital discharge within 12 hours, conversion rates, and complications.

vNOTES is a safe, reliable, and effective alternative for hysterectomy in benign gynecological conditions, particularly adenomyosis. It offers advantages such as earlier recovery of intestinal function, faster return to work, shorter hospital stays, lower pain scores, and superior cosmetic results compared to laparoscopic hysterectomy. It also offers better visualization of the adnexa and can be used safely in patients with large uteri or a history of previous intra-abdominal surgery, where VH might be more challenging.

Bibliography

  • Comparison of rapid recovery outcomes between vNOTES hysterectomy and laparoscopic hysterectomy: a prospective study
    Ying Tang, Chun-ling Fang, Jun-rong Huang, Xiao-mei Chen, Xin Cai, Jia Wu, Hui-quan Hu, Jun Li et Yue-xi Luo. BMC Surgery (2025) 25 189 DOI :1186/s12893-025-02906-9
  • vNOTES retroperitoneal sentinel lymph node dissection for endometrial cancer staging: First multicenter, prospective case series
    Jan Baekelandt, Astrid Jespers, Daniela Huber, Levon Badiglian- Filho, Andrea Stuart, Linus Chuang, Oudai Ali, Alexander Burnett. Acta Obstetricia et Gynecologica Scandinavica (2024) 103 1311-1317 DOI :1111/aogs.14843
  • Sexual quality of life after hysterectomy performed by conventional laparoscopy versus Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) in benign gynaecology
    Marie Timmermans, Hripsime Hovsepyan, Panayiotis Tanos, Michelle Nisolle, Stavros Karampelas. Facts Views Vis Obgyn (2025) 17 1 68-74 DOI :52054/FVVO.2024.13784

  • VaNoLaH trial: a study protocol—a multinational randomised controlled trial including two identical substudies comparing vaginal versus vNOTES (vaginal natural orifice transluminal surgery) hysterectomy or laparoscopic versus vNOTES hysterectomy
    Jan Filip Baekelandt, Andrea Stuart, Johanna Wagenius, Annouschka Laenen, Ben W Mol, Jan Deprest, Jan J A Bosteels. BMJ Open (2024) 14 e081979 DOI :1136/bmjopen-2023-081979
  • Systematic review and meta-analysis of vaginal natural orifice transluminal endoscopic surgery hysterectomy versus vaginal hysterectomy for benign indications
    Greg J. Marchand, Hollie Ulibarri, Amanda Arroyo, Madison Blanco, Daniela Gonzalez Herrera, Brooke Hamilton, Kate Ruffley, Ali Azadi. AJOG Global Reports (2024) DOI :1016/j.xagr.2024.100355
  • A single center retrospective study of vNOTES hysterectomy, laparoscopic hysterectomy and vaginal hysterectomy operations
    Fatmanur Mollahüseyinoğlu Küllaç, Ayşe Zehra Özdemir, Çağlanur Yıldız. Medicine® (2024) 103 50 e40881 DOI :1097/MD.0000000000040881

Background and Rationale: Hysterectomy is a common surgical intervention for female patients diagnosed with high-grade cervical intraepithelial neoplasia (CIN II-III), especially when concurrent uterine fibroids or adenomyosis are present. These patients, often younger and actively involved in societal roles, require rapid postoperative recovery to minimize daily life disruptions. Key recovery indicators include the time to first anal exhaust (reflecting gastrointestinal recovery) and return-to-work (RTW) time (linked to social and mental well-being). While laparoscopic surgery has become mainstream for benign gynecological diseases, vaginal natural orifice transluminal endoscopic surgery (vNOTES) has emerged as a promising, minimally invasive, third-generation procedure. Unlike traditional laparoscopy, vNOTES utilizes the vaginal canal to insert a single-port platform, allowing instruments to access the abdominal cavity for complex procedures. This approach has been applied in various gynecological surgeries, offering a minimally invasive, painless, and scarless alternative. Although vNOTES hysterectomy was first deemed feasible and safe in 2012 and shown to be comparable to laparoscopy, its specific impact on recovery outcomes like time to first anal exhaust and RTW time, particularly in high-grade CIN patients, remained unclear.

Methods: This was a prospective cohort study conducted from September 2022 to December 2023. It enrolled 330 patients, with 92 in the vNOTEH group and 238 in the LH group, based on surgical procedure. The study focused on women diagnosed with CIN II-III, with or without uterine fibroids or adenomyosis. Patients were included if they were employed, willing to undergo follow-up, and met specific pathological and clinical criteria. Exclusions included those scheduled for laparotomy, unemployed patients, or those with various pelvic inflammatory diseases or malignancies. The primary outcome was time to first anal exhaust, and the secondary outcome was RTW time. Statistical analyses included linear regression to identify factors affecting anal exhaust time and multivariate Cox proportional hazards regression for RTW time.

Results: The study found that the vNOTEH group demonstrated significantly faster recovery outcomes compared to the LH group.

  • Operation Time: The vNOTEH group had a remarkably shorter median operation time (90.0 minutes) compared to the LH group (110.0 minutes).
  • Time to First Anal Exhaust: The vNOTEH group showed a shorter median time to first anal exhaust (48.0 hours) compared to the LH group (69.0 hours), a statistically significant difference (P < 0.001). Linear regression analysis confirmed that the vNOTES approach was significantly associated with a shorter time to first anal exhaust.
  • Postoperative Hospitalization: vNOTEH patients had shorter postoperative hospitalization (median 5 days) compared to LH patients (median 8 days).
  • Return-to-Work (RTW) Time: The median RTW time significantly decreased in the vNOTEH subgroup (2.0 months) compared to the LH subgroup (3.0 months, P = 0.011). By 4 months postoperatively, 81.8% of vNOTEH patients had returned to employment, versus 68.4% in the LH group, with all vNOTEH patients achieving complete workforce reintegration by 6 months. Multivariate Cox logistic regression revealed that surgical approach (vNOTES) and shorter postoperative hospitalization were significantly related to earlier RTW time.
  • Cosmetic Outcomes: Cosmetic satisfaction scores were remarkably higher in the vNOTEH group (median 9 points) compared to the LH group (median 8 points, P < 0.001).
  • Complications: There were no significant differences in surgical complications requiring clinical intervention or postoperative dyspareunia between the two groups. No cases required conversion to an alternative surgical approach, and no readmission was observed in either group.

Conclusions and Relevance: The study concluded that vNOTES in women might be advantageous in facilitating earlier recovery of intestinal function and an earlier return to work after hysterectomy compared with laparoscopy. These findings indicate that vNOTEH offers a shorter operation time, reduced postoperative hospitalization, and superior cosmetic outcomes without increasing surgical complications. The benefits are consistent with enhanced recovery after surgery (ERAS) principles, and the absence of abdominal incisions eliminates wound healing concerns and enhances cosmetic satisfaction. The socioeconomic significance of vNOTES’s advantages is highlighted, suggesting it may alleviate both physiological stress and socioeconomic strain, including productivity losses.

Limitations: The authors acknowledged several limitations, including the non-randomized design, which could introduce bias due to patient preference, surgeon expertise, and instrument availability. The study was single-center and focused on a specific subgroup (high-grade CIN patients), which may limit the generalizability of the results. Factors like social support and specific postoperative care protocols were not assessed, potentially biasing recovery time comparisons. Lastly, the study lacked cost-effectiveness analyses and comprehensive quality-of-life measures beyond cosmetic satisfaction, leaving broader societal impacts unverified.

Background and Rationale Endometrial carcinoma stands as the most frequently diagnosed gynecological cancer in high-income countries, with its incidence on the rise, largely attributed to increasing rates of obesity. Accurate surgical staging is paramount for guiding subsequent adjuvant treatments such as radiation and chemotherapy. Historically, this has involved extensive lymphadenectomy, which can lead to significant complications like lymphedema and lymphocyst formation. Sentinel lymph node (SLN) analysis has emerged as a highly accurate and sensitive alternative, proving effective in detecting metastases, including micrometastases and isolated tumor cells not always found by conventional pathological examination, thereby becoming a standard practice.

However, standard laparoscopic SLN dissection can be technically challenging, particularly in the obese patient population, which constitutes a significant proportion of endometrial cancer patients. Vaginal natural orifice transluminal endoscopic surgery (vNOTES) offers a promising evolution in minimally invasive gynecological surgery. It utilizes the vaginal canal as a natural orifice to access the abdominal cavity, thereby eliminating the need for external abdominal incisions and offering a “scarless” outcome. The first vNOTES hysterectomy was performed in 2012, and subsequent studies have demonstrated its safety and feasibility for benign gynecological conditions, showing advantages such as shorter operative times, reduced postoperative pain, and shorter hospital stays compared to conventional laparoscopy. Notably, vNOTES has shown particular benefit in obese patients where traditional laparoscopic access might be more difficult.

While initial transperitoneal vNOTES approaches for SLN dissection faced limitations in visualizing the caudal pelvic retroperitoneum, a new retroperitoneal vNOTES approach was developed to provide superior exposure of the entire pelvic area, including the caudal part of the obturator space, iliac arteries, and sacral plexus. This study represents the first publication of prospective data applying this specific retroperitoneal vNOTES technique for endometrial cancer staging.

Methods The study enrolled 64 women diagnosed with histologically proven early-stage endometrial carcinoma or complex atypical hyperplasia, all deemed suitable for surgical staging that included SLN removal. Data was collected prospectively from March 2016 to May 2023. All surgical procedures were co-led by four experienced gynecologic surgeons from the international NOTES societies gynecologic oncology special interest group.

The surgical technique for vNOTES retroperitoneal sentinel lymph node dissection involved:

  • Placing the patient in a dorsal lithotomy position.
  • Administering prophylactic antibiotics and inserting a Foley catheter.
  • Injecting indocyanine green into the cervix to facilitate SLN identification.
  • Creating a vaginal mucosa incision, either bilateral in the lateral vaginal fornix or a single anterior midline incision, based on surgeon preference.
  • Accessing the obturator fossa paravesically through blunt and sharp dissection.
  • Inserting a vNOTES port (Gelpoint vPath mini or small) to establish a sealed retroperitoneal space and insufflate CO2.
  • Inserting standard endoscopic instruments transvaginally to identify anatomical landmarks such as the ureter, iliac bifurcation, iliac arteries/veins, and the obturator nerve.
  • Developing the retroperitoneal space further and identifying SLNs using fluorescence imaging.
  • Resecting and removing the identified SLNs transvaginally.
  • Repeating the procedure on the contralateral side. The entire procedure was performed transvaginally without any abdominal incisions. Following SLN removal, all patients underwent a vaginally assisted NOTES hysterectomy (VANH) with bilateral salpingo-oophorectomy, where the initial steps mirrored conventional vaginal hysterectomy but the rest of the hysterectomy was performed endoscopically. Patients were followed clinically for at least 6 weeks post-surgery.

Results The study reported several key outcomes:

  • Patient Demographics: The median age of patients was 69.5 years, with a median BMI of 26 kg/m2. Notably, 18 patients were obese (BMI ≥30 kg/m2) and 4 were morbidly obese (BMI >40 kg/m2).
  • Surgical Time: The median total operative time was 126 minutes.
  • Blood Loss: The median estimated blood loss was 80 mL.
  • Sentinel Lymph Node Identification:
    • Bilateral sentinel nodes were successfully identified in 97% of cases (62 out of 64 patients).
    • Only unilateral identification occurred in two cases.
    • On average, three nodes were resected per patient.
    • Positive sentinel nodes were found in 4 patients (6%), with three cases showing isolated tumor cells and one with macrometastasis.
  • Hospital Stay: 19 patients (30%) were discharged on the same day of surgery. For the remaining patients, the median hospital stay was 2 days.
  • Pain Score: The median Visual Analog Scale (VAS) pain score at 24 hours postoperatively for hospitalized patients was 1 out of 10, indicating low pain levels.
  • Complications: A total of 10 perioperative or short-term postoperative complications were observed.
    • Bladder injury occurred in 3 cases (5%), two of which were managed conservatively with a Foley catheter, and one required suture repair. All bladder injuries recovered completely without sequelae.
    • One patient required surgical reintervention (laparoscopy for coagulation) 48 hours post-surgery due to bleeding.
    • Other complications included one case of obturator nerve neuropraxy (adductor paresis) with spontaneous recovery, one obturator vein laceration repaired during surgery, and one femoral deep vein thrombosis leading to a vaginal vault hematoma, managed conservatively.
    • There was one conversion to laparoscopy (1.5%) due to bleeding not manageable via vNOTES, but no conversions to laparotomy.
    • No complications resulted in the postponement of adjuvant therapy.

Conclusions and Relevance The study concludes that vNOTES retroperitoneal sentinel node resection with hysterectomy is a feasible and safe alternative for staging early-stage endometrial cancer. The high bilateral SLN identification rate of 97% suggests that this technique is at least as efficacious as the currently established standards for SLN detection.

The authors highlight several theoretical and observed advantages of this vNOTES approach:

  • It is less invasive, being performed entirely transvaginally without abdominal incisions, which enhances cosmetic outcomes and aligns with enhanced recovery after surgery (ERAS) principles.
  • It eliminates the need for a Trendelenburg position during SLN dissection, offering an anesthetic advantage, especially for obese patients where ventilation can be challenging.
  • The technique follows the natural lymph node trajectory from caudally to cranially, which may reduce the risk of inadvertently missing the primary sentinel node.
  • The vaginal approach provides a shorter distance to the sentinel nodes, making it potentially less challenging in the presence of abdominal adiposity.
  • The findings of shorter hospitalization and less postoperative pain observed in studies comparing vNOTES hysterectomy to laparoscopy for benign indications can be extrapolated to patients with endometrial carcinoma.

While acknowledging that the 5% bladder injury rate in this study is higher than reported for general laparoscopic hysterectomies, the authors attribute this to the developmental phase of this relatively new technique and anticipate that complication rates and operative times will decline as surgeons gain more experience. The study represents the first prospective data on this specific procedure and adheres to the IDEAL framework for surgical innovation at Stage 2A (development).

Limitations The authors noted several limitations to the study:

  • The small and early cohort size limits the generalizability of the findings and calls for larger scale investigations.
  • The study lacked a direct comparison with current gold standard techniques, such as traditional laparoscopic or robotic SLN dissection.
  • The retrospective nature and single-center focus of similar studies (not this one which is prospective multi-center) can introduce bias, though this specific study addresses some of these by being multi-center and prospective.
  • Long-term safety outcomes and comprehensive quality-of-life measures beyond cosmetic satisfaction were not fully assessed, leaving broader societal impacts unverified.

In conclusion, for patients with early-stage endometrial cancer, vNOTES retroperitoneal sentinel lymph node dissection, when performed by experienced surgeons, appears to be a safe, reproducible, and less invasive alternative to standard laparoscopic staging, offering benefits related to patient recovery and comfort, and supporting the ongoing development of this promising surgical approach. Further larger-scale studies are warranted to confirm these benefits and assess long-term safety.

Background and Rationale Hysterectomy is a highly common gynecological surgical procedure, performed through various approaches including abdominal, vaginal, and laparoscopic techniques. For benign conditions such as fibroids, adenomyosis, menometrorrhagia, uterine prolapse, or chronic pelvic pain, the vaginal route is generally preferred. This preference stems from its association with shorter operative times, faster recovery, reduced pain, fewer incisional hernias, and improved aesthetic outcomes. However, conventional vaginal hysterectomy can be limited by factors such as large uterine size, restricted vaginal access, or a history of abdominopelvic adhesions. In such cases, a laparoscopic approach may become necessary, although it carries an increased risk of injury to the urinary or digestive tracts.

vNOTES has emerged as a promising, minimally invasive third-generation surgical procedure that combines the advantages of vaginal access with endoscopic visualization and laparoscopic instrumentation. First described for cholecystectomy in 2007 and then for hysterectomy in 2012, vNOTES allows surgeons to access the abdominal cavity via the natural vaginal orifice, resulting in a scarless abdomen and potentially improved recovery. While previous studies have shown vNOTES to be feasible and safe for benign uterine conditions, demonstrating benefits like shorter operative times, less postoperative pain, and shorter hospital stays compared to traditional laparoscopy, there has been a notable lack of data concerning its impact on specific recovery outcomes such as return-to-work time or sexual quality of life. This study sought to address this gap by focusing on sQoL and recovery metrics.

Methods This was a single-center, retrospective observational study conducted at Brugmann University Hospital in Belgium between September 2020 and October 2022. The study included 127 patients who underwent hysterectomy for benign indications, specifically drug-resistant menometrorrhagia, polyfibromatous uterus, or adenomyosis. Of these, 91 patients underwent TLH and 36 underwent vNOTES hysterectomy. All surgical procedures, whether vNOTES or TLH, were performed by the same surgical team, which was experienced in laparoscopic surgery.

The vNOTES surgical technique involved placing the patient in a gynecological position under general anesthesia. A circular pericervical colpotomy was performed, followed by dissection of the bladder and opening of the pouch of Douglas. The uterosacral ligaments were sectioned, ligated, and reattached. A vNOTES port (Gel pointTM platform) was then installed via anterior colpotomy, establishing a pneumoperitoneum at a low pressure of 8 mmHg, and the hysterectomy was performed endoscopically. The TLH procedure adhered to standard practices validated by the European Society of Gynaecological Endoscopy. Both groups received paracetamol and non-steroidal anti-inflammatory drugs for 48 hours postoperatively.

The primary objective was to evaluate sQoL at least 3 months post-surgery. This was assessed using the Female Sexual Function Index (FSFI) questionnaire, a multidimensional self-report instrument covering six domains: desire, subjective arousal, lubrication, orgasm, satisfaction, and pain. A total FSFI score below or equal to 26.55 indicated female sexual dysfunction. Secondary objectives included assessing improvement in sQoL for patients with adenomyosis. Data on patient characteristics and intra- and post-operative outcomes were extracted from medical records. Statistical analysis was performed using R software, with a P-value < 0.05 considered statistically significant.

Results Of the 127 patients, baseline characteristics like age and BMI were comparable between the vNOTES and TLH groups. However, the vNOTES group had significantly higher gravidity and parity compared to the TLH group.

Regarding surgical characteristics for the total cohort:

  • There were no significant differences in operative time (median vNOTES: 152.6 min; TLH: 174.2 min) or haemoglobin drop.
  • The vNOTES group experienced significantly greater total blood loss (median 286.4 mL vs 166.1 mL for TLH; P=0.007), which the authors attributed to the vaginal access through a highly vascularized area, but notably, no blood transfusions were required.
  • The vNOTES group had significantly smaller uterine weights (median 305.3 g vs 445.1 g for TLH; P=0.022), which the authors acknowledge as a selection bias where their team preferred not to propose vNOTES for larger uteri.
  • No significant differences were found in the overall rate of complications.

A key focus was on the sexually active sub-population (n=66):

  • A significantly higher proportion of vNOTES patients (75.0%) were sexually active post-operatively compared to TLH patients (42.9%; P<0.01).
  • For these sexually active patients, vNOTES demonstrated significantly shorter hospital stays (median 1.8 days vs 2.6 days for TLH; P=0.011).
  • Patients who underwent vNOTES had significantly higher FSFI scores in the areas of arousal (P=0.014), orgasm (P=0.003), and overall sexual satisfaction (P=0.002) compared to those who underwent TLH.
  • The overall FSFI global score was significantly better for the vNOTES group (28.97) than for the TLH group (24.99; P=0.003). Crucially, the vNOTES group’s average score was above the predefined threshold of 26.55, indicating satisfaction with sQoL, while the TLH group’s average fell below this threshold.
  • Furthermore, 75% of vNOTES patients restarted sexual activities within 3 months postoperatively, compared to only 42.9% of TLH patients.

When analyzing the adenomyosis sub-population (n=27):

  • Arousal and orgasm scores were improved post-operatively in patients suffering from adenomyosis, irrespective of the surgical technique used (P=0.04 for arousal, P=0.016 for orgasm).
  • The FSFI global score was also above the threshold for sexual dysfunction in adenomyosis patients. However, within the adenomyosis group, no significant difference in FSFI results was observed between vNOTES and TLH specifically.

Conclusions and Relevance The study concludes that vNOTES is a plausible operative method for total hysterectomy in patients with benign gynecological conditions, particularly adenomyosis. It offers distinct advantages such as shorter hospital stays and a faster re-introduction to sexual life. In the absence of contraindications, vNOTES can be considered a first-line management option in benign gynecological surgery.

The authors emphasize that the study’s findings on earlier discharge and improved sQoL align with the understanding that faster physical recovery leads to earlier re-engagement in daily and social activities, including sexual life. While acknowledging a higher observed blood loss in vNOTES due to vaginal access, no transfusions were needed, underscoring its safety. The overall superior sQoL outcomes with vNOTES, despite the vaginal suture, highlight its potential benefits for patient well-being beyond mere physical recovery. The observed improvement in sexual function for adenomyosis patients suggests that successful treatment of the underlying condition contributes to enhanced sQoL, a vital aspect for patients’ overall quality of life.

Limitations The study acknowledges several limitations:

  • Its retrospective design and single-center nature introduce potential for bias and limit the generalizability of the findings.
  • A selection bias was evident, as vNOTES was primarily offered to patients with smaller uterine weights.
  • The lack of baseline preoperative FSFI scores meant that changes in sQoL could not be directly measured against a pre-surgical baseline.
  • The results include the surgical team’s learning curve for vNOTES, though the main operating surgeon remained consistent.
  • The study also did not include cost-effectiveness analyses or broader quality-of-life measures beyond cosmetic satisfaction.

Despite these limitations, this study provides valuable insights into the benefits of vNOTES hysterectomy, particularly concerning sexual quality of life, which is often under-researched. The findings support the continued development and adoption of vNOTES as a safe, effective, and patient-centric minimally invasive surgical option. Further large-scale, prospective, randomized multicentric studies are needed to validate these findings and overcome the inherent biases of a retrospective design.

Background and Rationale Hysterectomy remains one of the most frequently performed gynecological surgical procedures worldwide. Over the past three decades, advancements in surgical techniques have led to a rise in minimally invasive methods, including vaginal hysterectomy (VH), laparoscopic hysterectomy (LH), robot-assisted laparoscopic hysterectomy (RH), and the more recent vaginal natural orifice transluminal endoscopic surgery (vNOTES). These minimally invasive approaches are favored as they have demonstrated a reduction in surgical morbidity compared to traditional abdominal hysterectomy. While VH is generally considered the most minimally invasive, offering advantages such as fewer complications, shorter surgical times, and faster postoperative recovery, its global incidence has been decreasing in favor of laparoscopic techniques.

vNOTES represents a cutting-edge development in gynecological surgery, ingeniously combining the benefits of a conventional vaginal approach with advanced endoscopic visualization through a transvaginal GelPort. This innovative technique aims to provide a scarless abdominal outcome while maintaining a comprehensive endoscopic view of the surgical field. Earlier, smaller-scale studies have hinted at the promising advantages of vNOTES. For instance, the single-center HALON trial, a 1:1 RCT involving 70 participants, suggested that vNOTES was not inferior to conventional laparoscopy for successful benign hysterectomy, correlating with more same-day discharges, reduced surgical time, less postoperative pain, and fewer complications. A subsequent systematic review and meta-analysis published in 2020, which incorporated the HALON trial and five observational studies, further supported these findings. It reported that vNOTES, when compared to total laparoscopic hysterectomy (TLH), was associated with significantly shorter operation times (a mean difference of 16.73 minutes), reduced length of hospital stay (a mean difference of 0.58 days), and less estimated blood loss (a mean difference of 98.87 mL). Crucially, this review found no significant differences in intraoperative or postoperative complications, readmission rates, 24-hour postoperative pain scores, or hemoglobin drop on day 1 postoperatively.

Despite these encouraging preliminary results, a significant limitation of previous research, including the HALON trial, has been the restricted generalizability of their findings due to small sample sizes and their single-center nature. Furthermore, a notable criticism of the HALON trial was its omission of a direct comparison between vNOTES and conventional VH. The VaNoLaH trial protocol directly addresses these gaps, emphasizing the urgent need for larger, multi-center, pragmatic RCTs to provide robust, generalizable evidence.

Study Design and Methodology The VaNoLaH trial is designed as a multicenter, non-blinded, pragmatic RCT. Its primary objective is to evaluate hysterectomy for benign disease across different surgical approaches, aiming to recruit 1000 women aged 18-75 years. To achieve a comprehensive comparison while maintaining ethical considerations, the trial is structured into two identical substudies (Group A and Group B):

  • Group A (VH vs. vNOTES): If the surgeon determines that a conventional VH is both safe and technically feasible, eligible patients will be randomized to either VH or vNOTES hysterectomy.
  • Group B (LH vs. vNOTES): If a conventional VH is not considered safe or feasible by the surgeon, patients will be randomized to either LH or vNOTES hysterectomy.

This innovative two-step randomization strategy is deliberately implemented to prevent ethical dilemmas that could arise from randomizing patients to a VH when the surgeon perceives it as technically challenging (e.g., due to large uterine size), which might otherwise lead to increased complications. For instance, larger uteri are more likely to be channeled into the LH group, where 50% will then be randomized to vNOTES. Patients are excluded if their hysterectomy is for Stage II+ prolapse (as part of a prolapse repair), endometriosis, or if they have clinically relevant comorbidities requiring extended inpatient postoperative care, a history of rectal surgery, suspected rectovaginal endometriosis or malignancy, suspected obliterated pouch of Douglas (due to severe pelvic inflammatory disease or other causes), active lower genital tract infection, or pregnancy.

Randomization will be performed using permuted blocks via REDCap software and will be stratified based on key patient characteristics: uterus size (longitudinal length over or under 15 cm), history of previous cesarean section (yes/no), and body mass index (BMI over or under 35). The surgeons performing the procedures will not be blinded to the allocated technique. A critical aspect of the trial is the requirement that all participating surgeons are beyond their learning curves for all three surgical techniques (VH, LH, and vNOTES). Specifically, they must have a minimum of three years of experience as independent vaginal and laparoscopic surgeons and have performed at least 50 vNOTES cases. Surgeries will commence before 12:00 to facilitate assessment of same-day discharge. Patient recruitment began in 2024 and is expected to conclude in 2026, with participation from 10 to 20 centers across multiple countries.

Outcomes Measured The primary outcome of the VaNoLaH trial is the proportion of women who are discharged from the hospital within 12 hours after surgery. This is contingent on the patient’s preference, adherence to local hospital discharge criteria, and the absence of complications.

Secondary outcomes will encompass a comprehensive range of clinical and patient-reported measures, including:

  • Total duration of hospitalization.
  • Rates of conversion to an alternative surgical approach.
  • The total duration of the surgical procedure.
  • The incidence of intraoperative complications, such as visceral injuries (e.g., to the bladder, ureter, bowel, or vessels).
  • The incidence and severity (classified according to the Clavien-Dindo system) of postoperative complications occurring within the first six weeks following surgery.
  • Rates of readmission requiring hospitalization for any adverse event causally related to the gynecological intervention within six weeks post-surgery.
  • Patient-reported outcome measures, specifically focusing on sexual function, which will be assessed using the validated Short Female Sexual Function Index questionnaire sent to patients via email three months postoperatively.

Statistical Analysis and Generalizability Statistical analysis for the primary and binary secondary outcomes will employ a two-sided Cochran-Mantel-Haenszel test, stratified by uterus size, prior cesarean section, and BMI. A 5% significance level will be adopted. Continuous secondary outcomes will be analyzed using analysis of variance. The analysis will primarily follow an “intention-to-treat” principle, with “per protocol” and sensitivity analyses also performed to ensure robustness. No interim analyses are planned for this multicenter pragmatic trial.

Strengths and Limitations The study’s strengths lie in its pragmatic, non-blinded, multicenter RCT design, which is expected to yield generalizable results reflective of real-life clinical settings. By integrating multiple centers and countries, the trial accounts for variations in local practices and healthcare systems, enhancing the applicability of its findings. Furthermore, the study rigorously adheres to the IDEAL framework for surgical innovation, positioning it as a Stage 3 (Assessment) trial aimed at validating promising earlier results in a larger, diverse context. This structured evaluation is vital for the evidence-based introduction of new surgical procedures.

However, the protocol also acknowledges certain limitations: a cost-effectiveness analysis will not be performed due to the inherent differences in healthcare systems across participating countries. Additionally, the study will not include a robotic arm comparison, primarily due to the limited number of surgeons proficient in all four minimally invasive hysterectomy techniques. A potential source of bias is recognized in the experience levels of participating surgeons, as many may have more extensive experience with VH or LH compared to the relatively newer vNOTES, which could subtly favor the outcomes of the more established techniques.

Ethics and Dissemination The VaNoLaH trial protocol has received ethical approval from the main center, Imelda Hospital in Belgium, and from the ethical boards in other participating countries such as Sweden, Croatia, Switzerland, and Israel. All procedures involving human participants are conducted in accordance with the 1963 Helsinki Declaration. The trial is registered under the number NCT05971875, and its results will be submitted for publication in peer-reviewed international journals.

In conclusion, the VaNoLaH trial represents a crucial, meticulously designed multi-center RCT poised to provide high-quality, generalizable evidence on the comparative advantages of vNOTES hysterectomy against conventional vaginal and laparoscopic approaches for benign gynecological conditions, with a particular focus on patient recovery and sexual quality of life.

Background and Rationale Hysterectomy stands as the second most common surgical procedure performed on women in the United States, typically indicated for benign gynecological disorders in over 90% of cases globally. Over time, surgical techniques have evolved from traditional laparotomy to various minimally invasive approaches, including conventional vaginal hysterectomy (VH), laparoscopic hysterectomy (LH), robot-assisted laparoscopic hysterectomy, and the more recent vaginal natural orifice transluminal endoscopic surgery (vNOTES).

Conventional VH has historically been lauded for its benefits, such as shorter hospital stays, lower infection rates, reduced costs, and a quicker return to normal activities. It also avoids trocar access complications and offers a scarless outcome. However, its applicability can be limited by factors like surgeon expertise, technical complexity for certain uterine conditions (e.g., large uterine size), and inherent poor visualization of the anatomy, particularly the adnexa.

vNOTES has emerged as a promising “third-generation” minimally invasive technique, leveraging the vaginal canal to access the abdominal cavity with endoscopic visualization and laparoscopic instrumentation. First documented for hysterectomy in 2012, vNOTES aims to overcome the limitations of conventional VH while retaining the advantages of laparoscopic visualization and easier instrument manipulation, leading to improved recovery and a scar-free abdomen. Previous research has suggested vNOTES offers advantages over laparoscopic hysterectomy in terms of operation time, hospital stay, estimated blood loss, and cosmetic outcomes. Despite the growing popularity of vNOTES, the specific comparison between vNOTES hysterectomy and conventional VH had a notable lack of systematic review and meta-analysis, prompting this study.

Study Objectives The primary objective of this systematic review and meta-analysis was to evaluate the safety and effectiveness of hysterectomy by vNOTES compared to conventional vaginal hysterectomy for various benign indications.

Methodology The study utilized the PRISMA guidelines for conducting systematic reviews and meta-analyses. Researchers conducted a comprehensive search across multiple electronic databases, including Scopus, Medline, PubMed, ClinicalTrials.Gov, and the Cochrane Library, from their inception until September 1, 2023.

Studies eligible for inclusion were those comparing vNOTES hysterectomy versus conventional VH for any benign indications and reporting at least one of the pre-selected outcomes. Excluded were single-arm studies, articles not including the specified outcomes, and secondary research like other systematic reviews or meta-analyses. Data extraction was performed manually and independently by two authors, with conflicts resolved by a third.

The main outcomes collected included:

  • Estimated blood loss (mL).
  • Operation time (min).
  • Length of hospital stay (days).
  • Visual Analogue Scale (VAS) pain score at Day 1.
  • Intraoperative complications.
  • Postoperative complications.

Given that all four included studies were observational, the ROBINS-I tool was used to assess the risk of bias. Statistical analysis employed RevMan 5.4.1 for continuous outcomes (mean difference with 95% confidence intervals) and Open Meta Analyst software for dichotomous outcomes (odds ratios with 95% confidence intervals). Heterogeneity among studies was assessed using the Chi-square test and I² test, with subgroup analysis performed to address inconsistency.

Results The search yielded 741 unique records, ultimately leading to the inclusion of four eligible observational studies in the meta-analysis, involving a total of 373 patients. Of these, 160 women underwent hysterectomy by the vNOTES technique, and 213 by conventional VH.

Risk of Bias: The overall risk of bias was found to be moderate in three studies and serious in one (Lee et al. 2018).

Key Findings on Outcomes: The meta-analysis generally revealed no statistically significant differences between vNOTES hysterectomy and conventional VH across most studied outcomes.

  • Operative Time: The overall operation time for conventional VH was comparable to that of vNOTES hysterectomy (MD=0.64 minutes, 95% CI [-26.18, 27.47]; P=.96). While one case-control subgroup (Aharoni et al.) showed a decreased operation time for vNOTES (MD=-24.10 minutes), the overall pooled analysis indicated no significant difference.
  • Estimated Blood Loss: Overall, surgeon-declared estimated blood loss was similar in both procedures (MD=-44.70 mL, 95% CI [-99.97, 10.57]; P=.11). Although Aharoni et al. reported a decrease in blood loss for vNOTES (MD=-85.00 mL).
  • Length of Hospital Stay: The overall duration of hospitalization was also comparable between the two groups (MD=-0.16 days, 95% CI [-1.62, 1.30]; P=.83).
  • VAS Pain Scores at Day 1: The overall measured VAS score at day 1 post-surgery was comparable (MD=-0.01, 95% CI [-0.54, 0.52]; P=.96).
  • Intraoperative Complications: No significant variation was found in the incidence of intraoperative complications between both cohorts (OR=0.376, 95% CI [0.127, 1.113]; P=.077).
  • Postoperative Complications: The incidence of postoperative complications was also similar in both techniques (OR=0.35, 95% CI [0.11, 1.08]; P=.07).

Despite the overall non-significant differences, the study noted that vNOTES may provide more advantages such as better visualization of the adnexa, better cosmesis (scar-free abdomen), and less tissue trauma compared to traditional vaginal hysterectomy. It may also facilitate access to hard-to-reach adnexa and offer a clearer view, which is often a challenge for VH. Furthermore, vNOTES could provide more comfortable ergonomics for the surgeon.

Discussion and Comparison with Existing Literature The study highlights that the choice of hysterectomy procedure often depends on factors such as uterine size, surgical indication, surgeon’s experience, and patient comorbidities. While this meta-analysis found no statistically significant differences in key recovery outcomes between vNOTES and VH, previous studies, including a systematic review by Chaccour et al., have favored vNOTES over laparoscopic hysterectomy for outcomes like operation time, recovery time, postoperative pain, and complications.

The authors acknowledge that the heterogeneity observed in some outcomes may be attributed to the lack of surgical standardization due to the novelty of vNOTES and its recent adaptation by gynecologic surgeons. They also note that additional procedures like salpingectomy, important for reducing future ovarian malignancy risk, can be challenging during conventional VH but may be easier with vNOTES due to better visualization.

Strengths and Limitations The primary strength of this study is its position as the first systematic review and meta-analysis to statistically compare vaginal and vNOTES hysterectomy. The overall low risk of bias in the included studies is also a strength.

However, the study acknowledges several limitations:

  • The search did not retrieve randomized controlled trials (RCTs) with a low risk of bias, limiting the overall evidence level.
  • The retrospective nature of the included studies introduces potential for measurement bias.
  • The possibility of publication bias cannot be excluded due to the lack of relevant RCTs.
  • The small sample size and observed heterogeneity in some outcomes further limit the generalizability.
  • Differences in hysterectomy indications among included studies could affect outcomes.
  • The inclusion of studies that also performed other procedures (e.g., prolapse repair) alongside hysterectomy might have influenced the overall data.

Conclusion and Future Directions In conclusion, the systematic review and meta-analysis suggest that hysterectomy by vNOTES appears to be a reliable, safe, and effective alternative to conventional vaginal hysterectomy, with no significant differences observed in surgical and postoperative outcomes. While not demonstrating statistical superiority in core recovery metrics, vNOTES may offer additional advantages related to improved visualization, better cosmesis (scar-free abdomen), and potentially less tissue trauma.

The authors emphasize the crucial need for additional high-evidence randomized clinical trials to definitively establish the effective role of the vNOTES technique and determine its superiority or non-inferiority against established procedures for benign gynecological conditions. Such studies would help overcome the limitations of current observational data and contribute to more standardized surgical practices.

Background and Rationale Hysterectomy remains a very common surgical procedure in gynecology, primarily indicated for benign conditions such as abnormal uterine bleeding, uterine fibroids (myoma uteri), ovarian cysts, pelvic organ prolapse, and cervical pathologies. Over time, surgical approaches have evolved from traditional laparotomy to various minimally invasive techniques, including VH, TLH, robot-assisted laparoscopy, and the more recently developed vNOTES.

Historically, conventional vaginal hysterectomy (VH) has been considered the gold standard due to its benefits such as being cost-effective, leading to faster healing, and providing the best cosmetic results by avoiding abdominal scars. It also avoids complications associated with trocar access. However, VH has limitations, including difficulty with large uterine volumes, challenges in cases without uterine descensus, the presence of intra-abdominal adhesions from prior surgeries or conditions like endometriosis and pelvic inflammatory diseases, and limited access to the adnexa.

Laparoscopic hysterectomy (TLH) gained prominence by offering improved visualization and easier access to the adnexa, which VH often lacked. However, TLH involves abdominal incisions and can be technically challenging in certain patient populations, such as obese individuals, due to issues like omentum fatty tissue blocking the view or difficulty reaching the deep pelvis with instruments.

vNOTES hysterectomy emerged as a “new method” aiming to combine the advantages of a vaginal, scarless approach with endoscopic visualization and laparoscopic instrumentation, allowing complex procedures through the natural vaginal orifice. It was first documented for hysterectomy in 2012. This study sought to evaluate vNOTES in direct comparison to both VH and TLH to assess its safety and efficacy across various outcomes.

Methodology This was a single-center, retrospective observational study conducted at Ondokuz Mayıs University Faculty of Medicine between January 2021 and December 2022.

  • Patient Cohort: The study included a total of 186 hysterectomy cases for benign indications, equally divided into three groups: 62 vNOTES hysterectomies, 62 VH, and 62 TLH. To minimize selection bias in the VH and TLH groups, the latest 62 operations performed in each were included.
  • Surgeon Experience: All operations were performed by three different board-certified gynecologic surgeons, each performing over one hundred hysterectomies annually, ensuring a high level of surgical expertise. The choice of surgical technique was left to the surgeon’s preference.
  • Inclusion/Exclusion Criteria: Patients were diagnosed with high-grade cervical intraepithelial neoplasia (CIN II-III) with or without uterine fibroids or adenomyosis. Patients with malignancy or endometriosis were excluded, and all pathology results were confirmed benign. History of cesarean section and/or pelvic surgery was not considered a contraindication for any of the three techniques.
  • Data Collection: Demographic characteristics (age, BMI, parity, history of cesarean section, history of pelvic surgery, indications) and surgical results were collected from hospital records. Surgical outcomes included blood loss (measured by Hb difference), operating time, uterine weight, operating cost, complications (intraoperative and postoperative), additional surgical procedures, and conversion rates. Postoperative pain was assessed using a Numerical Rating Scale (NRS) at the 6th postoperative hour, with scores obtained directly from patients.
  • Surgical Techniques: Detailed descriptions of each procedure were provided, highlighting how vNOTES initially mirrored VH steps (e.g., cervical incision, bladder/rectum detachment) before transitioning to endoscopic visualization and laparoscopic instrumentation using an Alexis retractor for pneumoperitoneum.
  • Statistical Analysis: Standard statistical methods were used, including One Way ANOVA, Kruskal-Wallis, Mann-Whitney U test, and Independent samples t-test. A P-value < 0.05 was considered statistically significant. The study received ethical approval from Ondokuz Mayıs University.

Results The study’s findings offered several key comparisons across the three surgical techniques:

  • Demographic Characteristics:
    • There were significant differences in age and BMI among the groups. Specifically, the vNOTES hysterectomy group had a significantly higher BMI compared to the TLH group (P=.005).
    • Indications for hysterectomy varied: pelvic organ prolapse was the most common indication for VH (75.8%), while abnormal uterine bleeding was most common for vNOTES and TLH.
    • A history of cesarean section was significantly related to the surgical technique chosen (P=.01).
  • Operative Time:
    • The VH group had the shortest mean operation time (85 ± 29 minutes).
    • The vNOTES hysterectomy group had the longest mean operation time (108 ± 41 minutes).
    • There was a significant difference in operation time between vNOTES hysterectomy and VH (P=.005), with vNOTES being longer. However, no significant difference was found between vNOTES and TLH (P=.57). The authors attributed the longer vNOTES time to its relative novelty at their center.
  • Estimated Blood Loss (Hb Decline):
    • The vNOTES hysterectomy group experienced the highest Hb decrease (1.2 ± 0.9).
    • There was a significant difference in Hb decline between vNOTES and VH (P=.009), but no significant difference compared to TLH (P=.133).
  • Length of Hospital Stay (Discharge Time):
    • The vNOTES hysterectomy group had the shortest mean discharge time (2.2 ± 0.8 days).
    • The TLH group had the longest postoperative hospital stay (2.5 ± 0.8 days).
    • vNOTES hysterectomy patients were discharged significantly faster than TLH patients (P=.022). No significant difference was observed between vNOTES and VH in terms of discharge time (P=1.00).
  • Postoperative Pain Score (NRS at 6h):
    • The vNOTES hysterectomy group reported the lowest average pain score (1.53, range 0–9).
    • There was a significant difference in postoperative pain scores among the three techniques (P<.05).
  • Cost:
    • VH was the least costly operation.
    • TLH was the most costly operation.
    • vNOTES hysterectomy was significantly less costly than TLH (P=.01) but more costly than VH (P=.003).
  • Complications and Conversions:
    • No postoperative complications were observed for any of the three surgical techniques.
    • Intraoperative complications were few, with one bladder perforation in vNOTES hysterectomy and three complications in the VH group (two bladder perforations, one bleeding). No complications were observed in the TLH group. No significant difference in intraoperative complications was found between techniques.
    • Conversion to laparoscopy or laparotomy was rare: 3 patients in the vNOTES group required conversion (bladder perforation, bleeding, adhesions), and 1 patient in the VH group converted due to bleeding. No TLH cases required conversion.
  • Additional Surgical Procedures:
    • The VH group had the highest rate of additional surgical procedures (75.8%), primarily for pelvic organ prolapse repair. There was a significant difference in additional procedures among the groups.
  • Adnexal Surgery:
    • The rates of salpingectomy and oophorectomy were highest in the TLH group.
    • vNOTES hysterectomy showed higher rates of adnexal surgery than VH.

Discussion and Implications This study makes a significant contribution by being one of the few to directly compare vNOTES hysterectomy with both VH and TLH within a single study, providing a more comprehensive understanding of their relative merits.

The findings highlight several advantages of vNOTES hysterectomy:

  • Faster Recovery: vNOTES demonstrated shorter discharge times and significantly lower 6th-hour pain scores compared to TLH, and comparable discharge times and lower pain scores compared to VH.
  • Access and Visualization: The study confirmed that vNOTES provides superior access and a clearer view of the adnexa compared to VH, facilitating procedures like salpingectomy and oophorectomy, which are often challenging in conventional VH. This also extends to cases without uterine descensus and patients with a history of previous cesarean section or pelvic surgery, where vNOTES offers a wider field of view for adhesions.
  • Obese Patients: Despite vNOTES patients having a higher BMI than TLH patients, the vaginal route (vNOTES and VH) was suggested to be superior to the laparoscopic route for obese patients due to technical difficulties with TLH.
  • Cost and Aesthetics: vNOTES hysterectomy was found to be significantly less costly than TLH and offers the advantage of a scarless, more aesthetic outcome compared to abdominal approaches.

The study also acknowledged its limitations, including its retrospective, single-center design, which could introduce selection bias. The observed longer operative time for vNOTES at their center compared to some other studies was attributed to it being a newly adopted procedure, indicating a learning curve. However, the consistent surgical team with experienced surgeons might mitigate some of these biases. The absence of postoperative complications across all groups is notable, though the intraoperative complication rates were low and not significantly different.

Conclusion In conclusion, this single-center retrospective study suggests that vNOTES hysterectomy is a safe and effective surgical alternative to both total laparoscopic hysterectomy (TLH) and conventional vaginal hysterectomy (VH) for benign indications. While VH remains the most cost-effective option, vNOTES offers distinct advantages such as shorter hospital stays, reduced postoperative pain, enhanced visualization for adnexal procedures, and superior cosmetic outcomes compared to TLH, while overcoming some of the anatomical limitations of VH. Despite the noted learning curve and slightly longer operative times compared to VH, vNOTES is deemed a viable and increasingly preferred minimally invasive option, especially for patients requiring adnexal access, those with higher BMIs, or a history of previous abdominal surgeries where VH might be challenging.

PODCAST

course outline 

Advanced Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES): Techniques and Applications

  • A. What is vNOTES? (1 min)
    • vNOTES, or Vaginal Natural Orifice Transluminal Endoscopic Surgery, has emerged as a promising third-generation surgical procedure.
    • It is built on the principles of minimally invasive surgery.
    • The technique was first suggested to be feasible and safe for hysterectomy in 2012.
    • Consensus has been reached on its safe implementation in gynecologic practice.
  • B. Core Principles of vNOTES (2 min)
    • Unlike traditional laparoscopy, vNOTES utilizes the vaginal canal to insert a single-port platform, allowing laparoscopic instruments to access the abdominal cavity and perform complex procedures.
    • It combines the benefits of a traditional vaginal approach with endoscopic overview of the surgical field.
    • A key advantage is the elimination of visible abdominal incisions, making it a “scarless approach”.
    • This innovative approach leads to improved recovery and enhanced cosmesis.
  • C. Evolution in Minimally Invasive Gynecologic Surgery (2 min)
    • vNOTES has broadened the scope of minimally invasive surgery.
    • It overcomes limitations of conventional vaginal hysterectomy (VH), such as challenges with large uterine size, narrow vaginal access, nulliparity, or a history of cesarean section, by integrating enhanced endoscopic visualization.
    • It also offers better visualization and easier access to the adnexa compared to conventional VH.
  • General vNOTES Hysterectomy (vNOTEH) (7 min)
    • Patient Positioning and Setup: Patients are placed in the high lithotomy position under general anesthesia. A Foley catheter is inserted for bladder emptying.
    • Vaginal Access and Peritoneal Entry: The process begins with cervical cold-knife circumcision after ropivacaine-adrenaline solution infiltration for hydrodissection and local anesthesia. Anterior and posterior colpotomies are performed with cold scissors.
    • Port Placement and Pneumoperitoneum: The vNOTES port (e.g., Surgaid Medical, Gelpoint vPath mini or small) is placed via anterior colpotomy, and pneumoperitoneum is established through CO2 insufflation, maintaining maximum intraperitoneal pressure at 10 mmHg. A 30-degree endoscope is then inserted.
    • Uterine Dissection: Uterine dissection is conducted from caudal to cranial using standard endoscopic instruments (cold grasping forceps, bipolar grasping forceps, sealing device).
    • Adnexal Procedures and Closure: Prophylactic salpingectomy is routinely performed to reduce ovarian cancer risk. The vaginal cuff is then closed directly using running Vicryl 1 suture, with uterosacral ligament attachment.
  • B. Advanced Technique: Retroperitoneal vNOTES for Sentinel Lymph Node Dissection (8 min)
    • Purpose: This approach is specifically designed for surgical staging of endometrial cancer with sentinel lymph node removal. Systematic surgical staging is crucial for guiding adjuvant therapy.
    • Unique Access: The paravesical space is entered through a vaginal incision after injecting the cervix with indocyanine green. Incisions can be bilateral in the lateral vaginal fornix or a single anterior midline incision.
    • No Trendelenburg Position: A significant advantage is that the entire sentinel dissection is performed without the need for Trendelenburg position. This offers an anesthetic advantage, especially for obese patients, by facilitating easier ventilation. [Note: While general vNOTEH may utilize Trendelenburg tilt, the retroperitoneal vNOTES technique specifically avoids it.]
    • Lymph Node Identification: Sentinel lymph nodes are identified bilaterally using near-infrared light (after indocyanine green injection). The retroperitoneal approach allows for better exposure of the entire pelvic area, including the caudal part of the obturator space, iliac arteries, and sacral plexus.
    • Dissection and Removal: Sentinel nodes are identified, isolated by careful dissection, and resected and removed entirely transvaginally using endoscopic instruments like bipolar graspers, disposable scissors, and sealing devices. This method follows the natural lymph node trajectory from caudally to cranially, which may reduce the risk of missing the sentinel node.
  • Benign Gynecologic Conditions (8 min)
    • Common Indications: vNOTES hysterectomy is a plausible operative method for benign gynecological conditions such as high-grade cervical intraepithelial neoplasia (CIN II-III) with or without uterine fibroids or adenomyosis, leiomyomas, menometrorrhagia, uterine prolapse, and chronic pelvic pain.
    • Challenging Anatomies:
      • Large Uteri: vNOTES has demonstrated advantages over laparoscopy in cases involving large uteri (> 280 g), achieving a success rate of 99%. Studies show it can be used safely even in patients with large uterine weights.
      • Obesity: vNOTES offers benefits in the obese population where standard laparoscopic access can be technically challenging. It can be safely performed in obese patients.
      • Previous Abdominal Surgery/Nulliparity: A history of cesarean section or pelvic surgery is not a contraindication.
    • Other Procedures: This innovative approach has been successfully applied in various gynecological surgeries, including adnexal surgery, myomectomy, and rectal prolapse repair. It can also facilitate access to hard-to-reach adnexa with a clearer view than VH.
  • B. Gynecologic Oncology (7 min)
    • Endometrial Cancer Staging: vNOTES retroperitoneal sentinel lymph node dissection is a significant application, allowing for safe and successful identification and removal of sentinel lymph nodes in women with early-stage endometrial carcinoma.
    • Advantages in Oncology:
      • High Detection Rate: Bilateral sentinel nodes could be identified in 97% of cases in a multicenter prospective case series, which is comparable to laparoscopic sentinel node resection trials.
      • Less Invasive: It is a less invasive alternative to standard laparoscopic staging.
      • Obesity Benefit: The approach is particularly advantageous in obese patients with endometrial cancer as it avoids the need for Trendelenburg position, simplifying anesthesia.
      • Natural Lymphatic Trajectory: It follows the natural lymph distribution from caudally to cranially, potentially reducing the risk of missing nodes.
    • Current Evidence Status: This technique is currently in IDEAL stage 2A (development), with prospective multicenter data demonstrating its feasibility for endometrial cancer staging. Further large-scale studies are needed for long-term safety assessment.
  • Enhanced Recovery Metrics (7 min)
    • Faster Intestinal Function Recovery: The time to first anal exhaust is significantly shorter with vNOTEH compared to laparoscopic hysterectomy (LH). The median time was 48.0 hours for vNOTEH vs. 69.0 hours for LH.
    • Earlier Return to Work (RTW): vNOTES leads to a remarkably decreased median RTW time. The median RTW time for vNOTEH was 2.0 months vs. 3.0 months for LH. By 4 months postoperatively, 81.8% of vNOTEH patients returned to employment, compared to 68.4% in the LH group.
    • Shorter Postoperative Hospitalization: The vNOTES group demonstrated significantly shorter postoperative hospitalization compared to LH (median 5 days vs. 8 days). In some studies, vNOTES showed comparable hospital stay to VH. The sexually active vNOTES group was discharged earlier than the TLH group (1.8 days vs. 2.6 days).
  • B. Patient-Reported Outcomes (8 min)
    • Reduced Postoperative Pain: vNOTES is associated with lower postoperative pain scores. The average pain score at 6 hours post-op was 1.53 for vNOTES, which was the lowest among vNOTES, VH, and TLH.
    • Enhanced Cosmetic Satisfaction: The absence of abdominal incisions in vNOTES eliminates concerns of wound healing and enhances cosmetic satisfaction, particularly valued by younger patients. Cosmetic satisfaction scores were remarkably higher for vNOTEH compared to LH (median 9 points vs. 8 points).
    • Improved Sexual Quality of Life (sQoL): Patients undergoing vNOTES hysterectomy for benign conditions showed significantly improved scores in arousal, orgasm, and overall sexual satisfaction compared to conventional laparoscopic hysterectomy (TLH). The median total sQoL score was 28.97 for vNOTES vs. 24.99 for TLH. This also translates to a faster re-introduction to sexual life. Patients with adenomyosis specifically showed improved arousal and orgasm scores post-operatively, regardless of surgical technique.
  • Surgeon Experience and Learning Curve (3 min)
    • vNOTES retroperitoneal lymph node dissection is a relatively new technique requiring a surgeon with expertise in both vaginal and laparoscopic surgery.
    • There is a significant learning curve for this procedure, with approximately 30 cases required to reach a learning curve plateau.
    • Perioperative complications and surgical time are expected to decline as surgeons gain more experience. Experienced laparoscopic surgeons may have a rapid learning curve for vNOTES.
    • Surgeons participating in trials are often beyond their learning curves, with a minimum of 3 years of experience as an independent vaginal and laparoscopic surgeon and at least 50 vNOTES cases.
  • B. Potential Complications and Management (3 min)
    • While generally comparable safety profiles to LH and VH are reported, the initial developmental phase of vNOTES may see higher rates of specific complications.
    • For example, bladder injury (cystotomy) has been reported in 5% of cases in early series of retroperitoneal vNOTES, compared to ~1% in laparoscopic hysterectomies overall, attributed to the developmental phase of the technique.
    • Postoperative bleeding, neuropraxy (e.g., obturator nerve), and deep vein thrombosis have also been observed, though often managed conservatively or with re-intervention.
    • Blood Loss Variation: While some studies show similar or even less blood loss with vNOTES compared to LH or VH, others have observed greater total blood loss in vNOTES due to access through a highly vascularized vaginal area. However, this typically does not require blood transfusion.
  • C. Study Limitations and Future Research (2 min)
    • Many existing studies are retrospective, single-center, or observational, which introduces potential bias and limits generalizability.
    • There is a need for more high-quality randomized controlled trials (RCTs) to establish the effective role and determine superiority of vNOTES over other techniques, especially comparing vNOTES directly with VH and LH in larger, multicenter settings.
    • Further research should also include cost-effectiveness analyses and comprehensive quality-of-life measures beyond cosmetic satisfaction to verify broader societal impacts.
  • Summary (1 min)
    • vNOTES stands as a safe, reliable, and effective minimally invasive surgical technique for various benign gynecological conditions and is emerging as a feasible option for endometrial cancer staging.
    • It offers significant patient benefits including earlier recovery of intestinal function, faster return to work, shorter hospital stays, enhanced cosmetic outcomes, and improved sexual quality of life.
    • For medical specialists, understanding and mastering vNOTES expands the horizons of minimally invasive gynecologic surgery, addressing challenging anatomies and advancing oncologic care.
  • B. Q&A (1 min)
    • Open for questions and discussion.

PowerPoint slides

Slide 1: Introduction to Hysterectomy and Minimally Invasive Surgery

  • Hysterectomy is one of the most commonly performed gynecological surgical procedures worldwide, ranking as the second most common surgery for women in the United States.
  • The primary indication for hysterectomy is benign gynecological disorders, accounting for over 90% of cases globally.
  • Minimally Invasive Surgical (MIS) techniques have significantly evolved, including vaginal hysterectomy (VH), laparoscopic hysterectomy (LH), robot-assisted laparoscopic hysterectomy (RH), and vaginal natural orifice transluminal endoscopic surgery (vNOTES).
  • Rapid postoperative recovery is highly valued by both surgeons and patients, especially for younger individuals actively engaged in family and societal roles, to minimize daily life disruptions.

Slide 2: Understanding vNOTES: The Next Evolution in MIS

  • vNOTES, or vaginal natural orifice transluminal endoscopic surgery, represents the latest innovation in gynecological surgery, combining principles of minimally invasive surgery.
  • This technique utilizes the vaginal canal to insert a single-port platform, allowing laparoscopic instruments to access the abdominal cavity and perform complex procedures.
  • A key feature of vNOTES is that it eliminates the need for abdominal incisions, offering patients a minimally invasive, painless, and scarless alternative.
  • Its feasibility and safety for hysterectomy were initially demonstrated in a study involving 16 patients with benign uterine conditions in 2012.

Slide 3: Theoretical Advantages of vNOTES

  • vNOTES offers the benefits of a vaginal, scarless entrance to the abdomen combined with an endoscopic overview of the surgical field. This enhances cosmetic satisfaction, particularly valued by younger patients.
  • It is considered less invasive than traditional laparoscopic approaches, minimizing physical and psychological stress by aligning with Enhanced Recovery After Surgery (ERAS) principles.
  • vNOTES can overcome limitations of conventional vaginal hysterectomy, such as poor visualization of anatomy and difficulties with complex manipulation.
  • The technique has been successfully applied in various gynecological surgeries, including adnexal surgery, myomectomy, hysterectomy, and rectal prolapse repair.

Slide 4: vNOTES vs. Laparoscopic Hysterectomy (LH): Recovery Highlights

  • Studies show that vNOTES hysterectomy (vNOTEH) significantly decreases recovery times compared to laparoscopic hysterectomy (LH).
  • Key recovery metrics include the time to first anal exhaust (an essential marker of gastrointestinal recovery) and return-to-work (RTW) time (closely tied to social and mental well-being).
  • The vNOTES approach was identified as an independent factor influencing recovery outcomes in a prospective cohort study.
  • This rapid postoperative recovery is crucial for minimizing disruptions to patients’ daily lives and reducing socioeconomic costs associated with lost productivity.

Slide 5: vNOTES vs. LH: Faster Intestinal Function Recovery

  • The vNOTEH group demonstrated a significantly shorter median time to first anal exhaust compared to the LH group.
  • Specifically, vNOTEH patients achieved their first bowel recovery in a median of 48.0 hours, compared to 69.0 hours for LH patients. This represents a 21-hour acceleration in bowel function recovery.
  • Linear regression analysis indicated a significant association between the vNOTES approach and a shorter time to first anal exhaust.
  • This expedited gastrointestinal recovery is a well-established ERAS surrogate and reinforces the translational relevance of these findings.

Slide 6: vNOTES vs. LH: Accelerated Return to Work

  • For employed patients, the vNOTEH subgroup experienced a significantly decreased median return-to-work (RTW) time.
  • The median RTW time for vNOTEH patients was 2.0 months versus 3.0 months for LH patients (P=0.011).
  • By 4 months postoperatively, 81.8% of vNOTEH patients had returned to employment, compared to 68.4% in the LH group.
  • Multivariate Cox logistic regression revealed that surgical approach (vNOTES) and shorter postoperative hospitalization were significantly related to earlier RTW time. The hazard ratio for vNOTES indicated a higher likelihood of returning to work sooner.

Slide 7: vNOTES vs. LH: Operational Efficiency and Cosmetic Appeal

  • The vNOTEH group consistently showed significantly shorter operation times compared to LH. One study reported a median of 90.0 minutes for vNOTEH versus 110.0 minutes for LH.
  • vNOTES hysterectomy is associated with a shorter length of hospital stay compared to LH.
  • Patients undergoing vNOTEH reported remarkably increased cosmetic satisfaction scores compared to LH, with a median of 9 points versus 8 points (P < 0.001).
  • While some meta-analyses suggest reduced estimated blood loss with vNOTES compared to LH, others indicate no significant difference in blood loss between the two methods.

Slide 8: vNOTES vs. LH: Safety Profile

  • Studies generally indicate that vNOTES and LH have comparable safety profiles, with no significant differences in surgical complications requiring clinical intervention or postoperative dyspareunia.
  • Pooled analyses show no significant differences in intraoperative or postoperative complications, readmission rates, or hemoglobin drop on day 1 postoperatively when comparing vNOTES to LH.
  • One retrospective study observed no intraoperative complications in the TLH group, while the vNOTES group had one bladder perforation and the VH group had two bladder perforations and one intraoperative bleeding case. Overall, no significant difference in intraoperative complications was observed across surgical techniques in this study.

Slide 9: vNOTES vs. Vaginal Hysterectomy (VH): Overview

  • Conventional vaginal hysterectomy (VH) is often preferred for benign conditions due to benefits such as shorter operative time, faster recovery, reduced pain, and fewer complications. It is also considered the most cost-effective option.
  • However, VH can be limited by factors including large uterine size, narrow vaginal access, nulliparity, or a history of cesarean sections. It also provides inherent poor visualization of the anatomy.
  • vNOTES aims to overcome many of these limitations of conventional VH by preserving the benefits of laparoscopic visualization and easier manipulation.
  • Systematic reviews and meta-analyses comparing vNOTES directly with VH have been recent and highlight key similarities and differences.

Slide 10: vNOTES vs. VH: Surgical Outcomes & Recovery

  • A systematic review and meta-analysis found no statistically significant difference between vNOTES hysterectomy and conventional VH in terms of operation time, length of hospital stay, VAS pain score at Day 1, intraoperative complications, or postoperative complications.
  • One study reported that the vNOTES group had a longer mean operation time (108 ± 41 min) compared to VH (85 ± 29 min), a statistically significant difference. This might be attributed to the learning curve of a newer procedure.
  • Despite operative time differences, the lowest 6th-hour pain score (1.53 on NRS) was observed in the vNOTES hysterectomy group, suggesting better immediate postoperative comfort compared to VH (2.19) and TLH (4.51).
  • The cost of vNOTES hysterectomy was found to be significantly less costly than TLH, though VH remained the least costly overall.

Slide 11: vNOTES vs. VH: Access to Adnexa and Complex Cases

  • vNOTES offers superiority over VH in terms of ease of access to the adnexa, facilitating procedures like oophorectomy and salpingectomy more frequently. This is important for reducing the incidence of future ovarian malignancy.
  • It provides a clearer view for the surgeon in cases with large uterine volumes, making it a safe alternative where VH might be difficult due to retraction challenges.
  • vNOTES can be used more safely than VH in patients with a history of previous cesarean section and/or pelvic surgery due to better visualization of intraabdominal adhesions.
  • This technique also facilitates hysterectomy in patients without uterine descensus, where conventional vaginal hysterectomy can be challenging.

Slide 12: vNOTES in Gynecologic Oncology: Endometrial Cancer Staging

  • vNOTES is emerging as a promising technique for gynecologic malignancies, particularly for endometrial cancer staging.
  • The current standard treatment for endometrial cancer often involves laparoscopic hysterectomy with adnexectomies and bilateral sentinel node resection.
  • Sentinel lymph node analysis is a highly accurate and sensitive method for detecting metastasis, now standard practice for staging endometrial cancer, and helps avoid complications associated with complete lymphadenectomy.
  • A multicenter, prospective case series has demonstrated the feasibility and safety of vNOTES retroperitoneal sentinel lymph node dissection for endometrial cancer staging.

Slide 13: Retroperitoneal vNOTES Sentinel Lymph Node Dissection

  • A novel retroperitoneal vNOTES approach was developed to provide better exposure of the entire pelvic area, including the caudal part of the obturator space, iliac arteries, and sacral plexus.
  • The procedure involves entering the paravesical space through a vaginal incision after injecting the cervix with indocyanine green, then placing a vNOTES port to create a sealed retroperitoneal space with CO2 insufflation.
  • Sentinel lymph nodes are identified bilaterally using near-infrared light and subsequently removed endoscopically.
  • This technique is performed entirely transvaginally, without abdominal incisions, and explores the lymphatic system along its natural distribution from caudally to cranially.

Slide 14: Distinct Advantages in Cancer Staging (Retroperitoneal vNOTES)

  • This approach offers significant anesthetic advantages, especially in obese patients, as it eliminates the need for a Trendelenburg position, thereby facilitating easier ventilation. Obesity affects a significant portion of endometrial cancer patients.
  • By following the natural lymph node trajectory from caudally to cranially, the technique may reduce the risk of missing sentinel nodes.
  • The vaginal access shortens the distance to the sentinel nodes, making abdominal adiposity less of an obstacle compared to laparoscopic procedures.
  • It allows for sole transvaginal access with comprehensive exposure of the entire retroperitoneal space.

Slide 15: Feasibility and Success in Cancer Staging

  • A prospective multicenter case series of 64 women demonstrated that bilateral sentinel nodes were identified in 97% of cases using the retroperitoneal vNOTES technique for endometrial cancer staging.
  • This high success rate is comparable to trials assessing laparoscopic sentinel node resection.
  • The median total operative time was 126 minutes, with a median estimated blood loss of 80 mL.
  • While bladder injury occurred in 5% of cases, these were managed conservatively with complete recovery, and no complications with sequelae were observed.

Slide 16: Sexual Quality of Life (sQoL) After Hysterectomy

  • Postoperative recovery metrics extend beyond physical recovery to include aspects related to social and mental well-being, such as return-to-work time and sexual quality of life (sQoL).
  • Traditionally, literature on the impact of vNOTES on dyspareunia, overall well-being, and sQoL has been limited.
  • The Female Sexual Function Index (FSFI) is the gold standard, multidimensional self-report instrument used for over 20 years to assess female sexual function across six domains: desire, arousal, lubrication, orgasm, satisfaction, and pain.

Slide 17: Positive Impact of vNOTES on Sexual Quality of Life

  • A study comparing sQoL after vNOTES vs. conventional LH found that patients who underwent vNOTES surgery had significantly higher scores in the areas of arousal, orgasm, and overall sexual satisfaction.
  • The median total FSFI score was 28.97 for the vNOTES group, significantly better than 24.99 for the LH group (P=0.003), with the vNOTES score being above the clinical threshold for sexual dysfunction (26.55).
  • This suggests that vNOTES may lead to a faster re-introduction to sexual life and improved sQoL outcomes compared to LH.
  • For patients with adenomyosis, hysterectomy generally improved arousal and orgasm scores, regardless of the surgical technique, indicating that treatment can improve sQoL for these patients.

Slide 18: Socioeconomic Significance of Rapid Recovery with vNOTES

  • The demonstrated rapid postoperative recovery with vNOTES carries substantial socioeconomic implications.
  • For women undergoing hysterectomy, who often bear significant societal and familial responsibilities, prolonged recuperation can lead to extended workforce absence, diminished quality of life, and substantial societal costs.
  • The 21-hour acceleration in bowel function recovery and 30% reduction in workforce reintegration time offered by vNOTEH collectively suggest it may alleviate both physiological stress and socioeconomic strain.
  • This includes reducing the cascading burdens on familial care systems and overall productivity losses.

Slide 19: Limitations of Current vNOTES Research

  • Many existing studies are retrospective, monocentric, and non-randomized, which introduces potential biases such as selection bias and measurement bias. Unmeasured confounders may still persist.
  • Research often focuses on specific patient subgroups, potentially limiting the generalizability of results to broader populations or different healthcare settings.
  • Important factors like social support and specific postoperative care protocols (e.g., ERAS implementation) are frequently not assessed, which could bias recovery time comparisons.
  • The current literature lacks comprehensive cost-effectiveness analyses and broader quality-of-life measures (beyond cosmetic satisfaction), leaving a gap in understanding the full societal impacts.
  • For newer techniques like vNOTES, surgeons may still be within their learning curve, which can influence early surgical outcomes, including operative time and complication rates.

Slide 20: Future Directions and Conclusion

  • In conclusion, vNOTES hysterectomy is considered a safe, reproducible, and less invasive alternative to conventional laparoscopic and vaginal hysterectomy for benign conditions. It also shows promise for early-stage endometrial cancer staging when performed by experienced surgeons.
  • Key benefits include earlier recovery of intestinal function, accelerated return to work, shorter operation time, reduced postoperative hospitalization, and superior cosmetic outcomes.
  • Additional high-evidence randomized controlled trials are crucial, especially multicenter studies with larger sample sizes and long-term follow-up, to confirm and expand upon these promising results.
  • Such future studies should also incorporate cost-effectiveness analyses and comprehensive quality-of-life measures to fully ascertain the broader societal impacts of vNOTES.
  • In the absence of contraindications, vNOTES can be considered a first-line management option in benign gynecological surgery.