Implementing the transvaginal natural orifice transluminal endoscopic surgery (vNOTES) "first" strategy in benign gynecological surgeries

Transvaginal natural orifice transluminal endoscopic surgery for tubal ectopic pregnancy(vNOTESTEP): a protocol for a randomized controlled trial

BACKGROUND

Tubal ectopic pregnancy is a life-threatening condition in early pregnancy. Minimally invasive laparoscopic surgery is increasingly used for the treatment of this disease. Retrospective studies suggest that Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) offers lower perioperative complications, faster recovery, and better cosmetic outcomes compared to other approaches. However, the lack of comprehensive perioperative and long-term postoperative data limits its widespread adoption in gynecology.

METHODS

The vNOTESTEP study is a randomized controlled trial (RCT) enrolling 72 patients requiring laparoendoscopic surgery for tubal ectopic pregnancy. After obtaining informed consent, preoperative assessments will be conducted. Following randomization, salpingectomy will be performed using either vNOTES or TU-LESS approach. The postoperative assessment and a structured 5-year follow-up, including eight visits, will be conducted. Baseline sociodemographic and clinical data will be collected from the Hospital Information System and patient interviews. Outcomes will be assessed perioperatively and postoperatively at designated time points (1st, 2nd, and 3rd postoperative day; 1st, 3rd, and 6th month; 1st-5th year). Key long-term outcomes include sexual function, pregnancy, vaginal delivery, and incisional hernia.

DISCUSSION

This RCT aims to provide robust clinical evidence on the perioperative and long-term outcomes of vNOTES versus TU-LESS for tubal ectopic pregnancy, focusing on key reproductive and surgical outcomes. The study seeks to refine patient selection criteria and contribute to guideline development for gynecologic vNOTES.

TRIAL REGISTRATION NUMBER

ChiCTR2400082909 (registered on April 10th, 2024).

A comparative study of prone split-leg position and lithotomy position in posterior uterine myomectomy by transvaginal natural orifice transluminal endoscopic surgery

BACKGROUND

To assess and compare the efficiency and outcomes between prone split-leg position and lithotomy position in posterior uterine myomectomy by transvaginal natural orifice transluminal endoscopic surgery (vNOTES).

METHODS

33 patients with posterior uterine myomectomy by vNOTES in the prone split-leg position and 15 patients in the lithotomy position were retrospectively recruited. Important baseline characteristics and outcome parameters such as age, body mass index, volume of myoma, delivery mode, hospital length, intraoperative blood loss, hemoglobin values before and 72 h after operation, VAS score, operation time and operation preparation time were compared between two patient groups.

RESULTS

The operation time of the prone split-leg position group was significantly shorter than that of the lithotomy position group (P < 0.05), but the operation preparation time of the prone split-leg position group was longer than that of the lithotomy position group (P < 0.05). No significant difference was found in other indicators between the two patient groups.

CONCLUSIONS

Our study suggests the potential application of the prone split-leg position in posterior uterine myomectomy by vNOTES.

Gasless vNOTES vs. traditional vNOTES for benign gynecological disease: a randomized controlled clinical trial

BACKGROUND

Gasless transvaginal natural orifice transluminal endoscopic surgery (G-vNOTES) can avoid complications related to pneumoperitoneum, but there is limited research on G-vNOTES. Here, we aimed to compare the hemodynamic profiles and outcomes of G-vNOTES with traditional vNOTES (T-vNOTES) in the treatment of patients with benign gynecologic disease.

METHODS

A total of 120 patients with benign gynecologic disease were randomly assigned to G-vNOTES (n = 60) or traditional vNOTES (n = 60). The primary outcome was vital sign at different time points. Secondary outcomes included conversion rate, surgical time, anesthesia time, the usage of anesthetics, estimated intraoperative blood loss, visual analogue scale (VAS) score for abdominal and shoulder pain and postoperative nausea and vomiting (PONV) at 2 and 24 h, intraoperative and postoperative complications, time to first anal exhaust, eating, and getting out of bed after surgery, and length of postoperative hospital stay. Multi-level model analysis was used for intraoperative hemodynamic indicators.

RESULTS

There was no significant difference between the two groups at the baseline level. The results of the multilevel model indicate that there is no difference in intraoperative hemodynamic performance between the G-vNOTE group and the T-vNOTES group. The conversion rate in the G-vNOTES group was higher than that in the T-vNOTES group (16.95% vs. 5.26%, p = 0.046). No significant differences were observed in other areas.

CONCLUSIONS

This study did not find advantages of gasless vNOTES in intraoperative hemodynamic fluctuations. The surgical conversion rate of the G-vNOTES group is higher than that of the T-vNOTES group, which may be related to poor surgical field exposure in the G-vNOTES group, making it more suitable for experienced and confident surgeons.

Proctored single surgeon learning curve for vaginal natural orifice transluminal endoscopic surgery (NOTES) hysterectomy

OBJECTIVE

We studied the learning curve of vaginally assisted NOTES hysterectomy (VANH) for individual surgical steps and competence scores.

DESIGN

Single centre, prospective cohort study in a Belgian teaching hospital.

MEASUREMENTS AND MAIN RESULTS

In a cohort of 57 women undergoing VANH we analysed 29 procedures performed completely or partly by the novice and 35 procedures performed completely or partly by the expert. Primary outcome was operation time dedicated to the endoscopic steps, unique to vNOTES. Operation time was determined by post hoc analysis of surgical videos. Standardised values of the operation time were expressed as a moving average. Adequate operation time, i.e. an operation time within 2 standard deviations of the average operation time of the expert, was after 16 cases. Secondary outcomes were operation time per step and competence scores based on Objective Structured Assessment of Technical Skills (OSATS). These measurements were used to determine critical steps in the learning process, which are not captured by reporting total operation time alone. Adequate operating times for critical steps (anterior colpotomy and right uterine artery), were obtained after 16 cases. Conversely, some vaginal and endoscopic steps on the right-hand side took longer. Competence was obtained after 18 cases.

CONCLUSION

We present the results of a proctored learning curve of a novice in vaginally assisted NOTES hysterectomy, expressed as operation time for different steps compared to an expert and with competence scores. For the primary outcome, the endoscopic operation time, adequate operation time was achieved after 16 cases. Regarding secondary outcomes, analysis per step showed that several vaginal steps and the endoscopic steps on the patient's right-hand side required a longer learning period. Competence score expressed as a CUSUM chart suggest a learning curve of 18 cases. Identifying critical steps can be used to adapt training novices. Adding competence scores rather than focusing on operation time alone provides valuable insights in the learning process of a new technique by trained surgeons.

Operative complications of open and minimally invasive adnexal surgery compared with cases with hysterectomy: A narrative review

The decision to add hysterectomy to planned adnexectomy is often nuanced and likely increases the complexity of the planned procedure; however, these risks are not well characterized in practice. We conducted a comprehensive search in the PubMed database for English-language articles from 1997 to 2022, identifying studies reporting complication rates for open and minimally invasive surgery (MIS) hysterectomy and adnexal surgeries. We calculated medians and first and third quartiles for each complication and used a Mann-Whitney U test to calculate differences between complications for minimally invasive hysterectomy and adnexal case data. We identified 135 appropriate studies for inclusion. There were higher prevalences of blood loss requiring transfusion (1.70% versus 0.13%, P = 0.01) and urinary tract injury (0.80% versus 0.20%, P = 0.001) in MIS hysterectomy cases compared with MIS adnexal surgery, respectively. MIS hysterectomy cases were similar to MIS adnexal surgery cases in the risk of surgical site infection (1.20% versus 1.49%, P = 0.74), bowel injury (0.50% versus 0.35%, P = 0.45), vascular injury (0.20% versus 0.9%, P = 0.82), and conversion to laparotomy (1.95% versus 3.84%, P = 0.49). There were not enough data on open adnexal surgery complications to make a meaningful comparison between complications of open hysterectomy and adnexal-only cases. Patients should be counseled that the addition of hysterectomy to planned MIS adnexal surgery likely increases the risk of blood loss requiring transfusion and urinary tract injury. The increased comorbidity associated with adding hysterectomy to planned open adnexal removal is less clear.

Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) in Benign Gynaecology: A Systematic Review of Adnexal, Myomectomy and Prolapse Procedures

OBJECTIVE

Vaginal natural orifice transluminal endoscopic surgery (vNOTES) is utilised for gynecological procedures globally, however evidence to support its application aside from hysterectomy is lacking. A systematic review to determine feasibility and safety profile of vNOTES for benign gynaecology was conducted.

DATA SOURCES

A literature search of MEDLINE, EMBASE, CINAHL, SCOPUS, and CENTRAL was conducted, including all types of studies reporting vNOTES for gynecological indications. After excluding cases with concurrent hysterectomy, the review focuses on procedures for benign indications and oncological procedures are reported separately. Patient characteristics and perioperative outcomes were reported, with pooled analysis for sufficiently powered categories.

METHODS OF STUDY SELECTION

Fifty-four articles were analyzed, including 7 comparative studies (n = 439) and 1 RCT (n = 34), reporting 2469 cases of vNOTES, including adnexal (tubal and/or ovarian) (43 articles, n = 2261), myomectomy (10 articles, n = 136) and prolapse repair (6 articles, n = 72) in predominantly premenopausal women with BMI <30 kg/m2 on pooled analysis.

TABULATION, INTEGRATION AND RESULTS

The overall conversion rate was low (1.38%, n = 34) with procedure specific conversion rates of 0.45 to 6.8% for adnexal procedures, 1.47% for myomectomy and none reported for prolapse repair. Overall complication rates were low (3.44%, n = 85) with no associated mortality. Five (0.20%) adhesion-related rectal injuries at colpotomy were noted, all repaired intraoperatively without long-term sequelae.

CONCLUSION

vNOTES appears feasible based on limited evidence, for uterine-sparing gynecological indications, despite a notable rate of rectal injury at colpotomy. There is a negligible risk of rectal injury observed at conventional laparoscopy and robotically assisted surgery, but similar rate of entry-related gastrointestinal injury. This may be due to the learning-curve or suboptimal case selection, necessitating careful training, assessment, and appropriate patient selection. Surgeons should continue registering prospective vNOTES cases via iNOTESs, to evaluate emerging perioperative trends with global uptake of this novel technique.

Analysis of feasibility, effectiveness and safety of transvaginal natural orifice transluminal endoscopic surgery(vNOTES) of ectopic pregnancy: a retrospective study

BACKGROUND

vNOTES has been documented as a viable approach for conducting benign gynecologic surgery; however, its application in ectopic pregnancy cases remains relatively scarce. The principal objective of this investigation was to assess the practicability, effectiveness, and safety of vNOTES in surgical procedures related to ectopic pregnancy.

METHODS

Clinical data pertaining to patients diagnosed with ectopic pregnancy at Beijing Hospital between January 2018 and August 2023 were retrospectively collected (This study retrospectively registered with the China Clinical Trial Registry with the registration number ChiCTR2100052223 in September 22, 2021.). Based on the surgical technique employed, participants were categorized into two groups: the vNOTES group (29 cases) and the conventional laparoscopy (CL) group (34 cases). The baseline data, including age, body mass index (BMI), parity, and maximum diameter of pregnancy objects, were collected and analyzed, along with intraoperative indicators such as operation time and intraoperative blood loss, and postoperative indicators including postoperative exhaust time, hospital stays after surgery, and postoperative pain score at 24 h.

RESULTS

A total of 73 patients were included in this study, and all surgeries in both groups were performed according to the assigned procedures. There were no statistically significant differences observed in operation time, intraoperative blood loss, and hospital stays between the vNOTES group and the CL group (P > 0.05). However, the vNOTES group exhibited significantly lower postoperative exhaust time and 24-hour VAS scores compared to the CL group (P < 0.05).

CONCLUSIONS

vNOTES proves to be a safe and effective approach for performing conservative tubal festration or salpingectomy in cases of tubal pregnancy. Furthermore, vNOTES offers a more minimally invasive surgical technique, resulting in reduced postoperative pain in patients.

Early surgical outcomes of 550 consecutive patients treated for benign gynecological conditions by transvaginal natural orifice transluminal endoscopic surgery

INTRODUCTION

Evidence about intra- and postoperative complication rates related to transvaginal natural orifice transluminal endoscopic surgery (vNOTES) for benign gynecological conditions is still limited. We report and analyze data from a large cohort of patients operated in a single institution during 3.5 years.

MATERIAL AND METHODS

To evaluate the safety and feasibility of vNOTES for benign gynecological indications, we performed a single-center observational study reporting and analyzing perioperative outcomes of 550 consecutive patients operated between 2020 and 2024.

RESULTS

Of the 550 included patients, 365 (66.4%) underwent a vNOTES hysterectomy, 167 (30.4%) a procedure limited to the adnexa, and 18 (3.3%) other interventions, including myomectomy, pelvic adhesiolysis, post-hysterectomy pelvic hematoma drainage, pelvic organ prolapse repair, and appendectomy. The mean age was 49.4 ± 12.2 years, and the mean BMI was 26.2 ± 5.8 kg/m2. The total complication rate was 6.5% (36 cases), of which 2.7% (15 cases) were intraoperative complications and 4.0% (22 cases) were postoperative complications. Patients presented postoperative complications classified as Clavien-Dindo (CD) grade I in 4 cases (0.7%), grade II in 10 cases (1.8%), and grade III in 8 cases (1.5%). We observed no CD grade IV and V complications. Three patients (0.5%) were rehospitalized for postoperative complications management. The conversion rate was 1.6%, with nine cases of conversion to conventional laparoscopy and none to laparotomy.

CONCLUSIONS

The application of vNOTES appears safe and feasible for most benign gynecological surgeries. Our study focused on surgical complications and demonstrated a profile similar to those reported in previous studies.

vNOTES versus Laparoscopic Uterosacral Ligament Suspension for Apical Pelvic Organ Prolapse: Perioperative and Short-Term Outcomes

INTRODUCTION AND HYPOTHESIS

Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) is a novel approach in gynecological surgery. This study was aimed at comparing perioperative and short-term postoperative outcomes of vNOTES versus laparoscopic approaches to uterosacral ligament suspension (USLS) for apical pelvic organ prolapse.

METHODS

A retrospective cohort study included all women who underwent vNOTES versus laparoscopic USLS at two university-affiliated centers between 2017 and 2023. The relationships between variables were tested using Fisher's exact test or t test, including a sub-analysis comparing hysterectomy and hysteropexy outcomes within the groups. Logistic regression assessed the influence of baseline factors and operative factors on the primary and main secondary outcomes of interest.

RESULTS

This study comprised 47 vNOTES and 54 laparoscopic USLS cases (including 11 and 15 hysteropexies respectively). Baseline demographics in the two groups were similar. There were no differences in operative outcomes and no instances of ureteral injury. The vNOTES technique allowed for the use of significantly more sutures per side (2.0 [2.0-4.0] vs 1.0 [1.0-1.0], p = 0.001). Postoperative complications within 6 weeks demonstrated no significant differences. Both groups exhibited comparable rates of baseline subjective POP symptoms (100% vs 96.2%, p = 1.00) which improved significantly at 6 weeks (4.3% vs 11.1%, p = 0.282). At 6 weeks, anatomical success was achieved by significantly more patients with vNOTES (93.5% vs 78.6%, p = 0.042). Baseline and 6-week POP symptoms in the hysterectomy and hysteropexy subgroups were similar.

CONCLUSION

Both vNOTES and laparoscopic USLS demonstrated comparable subjective success rates at 6 weeks postoperatively. The vNOTES approach demonstrated improved anatomical success at 6 weeks, but the difference was not significant after adjusting for operative factors.

Sexual quality of life and postoperative deep dyspareunia after vNOTES benign adnexal procedures

OBJECTIVE

This study aimed to investigate the impact of vNOTES on postoperative sexual dysfunction in patients undergoing adnexal procedures.

METHODS

We analyzed data from patients who underwent vNOTES adnexal surgeries for benign conditions between May 2020 and May 2023. The primary outcome was the presence of new postoperative deep dyspareunia (DD) or other sexual dysfunctions, which were assessed through a phone survey conducted 6 to 24 months after surgery. Secondary outcomes included surgical feasibility, operative times, complications rate, and postoperative pain evaluation.

RESULTS

We included 103 patients for primary and secondary outcomes and 111 patients for secondary outcomes analysis only. Newly postoperative DD was reported by three patients (2.9%), remained present at 12 postoperative months in one case (1.0%), and spontaneously disappeared in two cases (1.9%) after four and 10 postoperative months, respectively. In the remaining 100 patients (97.1%), no new DD or other sexual function disorders were reported after surgery. vNOTES procedures were successfully performed in all cases, with a mean operative time of 38.2 ± 19.6 min and a conversion rate to conventional laparoscopy of 0.9%. No significant complication was observed.

CONCLUSION

This study suggests a very limited risk of developing postoperative sexual dysfunction after vNOTES benign adnexal procedures.

Retrospective analysis between total laparoscopic and vNOTES hysterectomy in obese patients: single-center study

INTRODUCTION

Hysterectomy is one of the most common major gynecological surgeries, and it is performed for benign and malignant reasons. Currently, five types of hysterectomies are described: vaginal (VH), abdominal (AH), laparoscopic (LH), robotic, and vNOTES (vaginal natural orifice transluminal endoscopic surgery). This paper compares these two types of surgery in obese patients by analyzing the surgeries performed by our team.

MATERIALS AND METHODS

The research was conducted from January 2022 to December 2023 at the Department of Gynecology and Obstetrics of the General Hospital in Zadar. The study included female patients aged 18-75 years with a BMI > 30 kg/m2, regardless of parity, who were operated on for benign pathology.

RESULTS

There were 24 patients included in total. One conversion was observed in the TLH group because of excessive bleeding. Median operative time (IQR) was significantly lower in the vNOTES group (p < 0.05) than in the TLH group 35 (10.9) vs 125 (74.0) min.

CONCLUSION

The results concerning the duration of surgery, conversion rate, and postoperative bleeding and complications show that vNOTES hysterectomies seem to be feasible for obese patients. Further studies are needed to confirm these observations.

Surgical outcomes of transvaginal natural orifice transluminal endoscopy in treating ovarian cysts and risk factors for surgical conversions

Objective

This study aimed to assess the surgical outcomes and identify the conversion risk factors of Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) in treating ovarian cyst.

Methods

This was a retrospective study of 505 patients who underwent vNO TES for treating ovarian cyst from March 2019 to February 2022 wherein the patients were classified into "converted" or "nonconverted" groups. T-tests, χ2 tests, and logistic regression were used for statistical analyses.

Results

There were 16 (3.17 %) surgical conversions and 12 (2.38 %) other surgical complications in our study cohort. Teratomas accounted for 56.8 % of complications in nonconverted cases and 18.8 % in converted cases. Adenocystomas were found in 12.3 % of nonconverted cases and 18.8 % of converted cases. Other types included paraovarian cysts (3.3 % and 0 %), fibroma, granulosa cell tumor, Brenner tumor (1.2 % and 0 %), corpus luteum cysts, follicular cysts (7.6 % and 6.3 %), old abscess (0.2 % and 0 %), and simple cysts (17.6 % and 12.5 %) in the nonconverted and converted groups, respectively. The converted group included more cases of endometriotic cysts (43.8 % vs 12.3 %, p = 0.023), bilateral cysts (37.5 % vs 8.2 %, p < 0.001), severe pelvic adhesion (68.8 % vs 3.3 %, p < 0.001), deep endometriosis (12.5 % vs 0.4 %, p < 0.001), and at least two cysts (37.5 % vs 8.81 %; p < 0.001). Severe pelvic adhesion (adjusted odds ratio [OR], 86.96; range, 18.33-431.77; p < 0.001), bilateral cysts (adjusted OR, 4.75; range, 1.05-21.57, p = 0.043) and endometriotic cysts (adjusted OR, 7.69; range, 3.11-17.08; p < 0.001) were also predictors of surgical conversion.

Conclusion

vNOTES demonstrates low complication and conversion rates in treating ovarian cyst compared with TU-LESS. Surgical conversion is associated with severe pelvic adhesions, bilateral cysts, and endometriotic cysts.

Transvaginal natural orifice endoscopic surgery for tubal ectopic pregnancy: A more suitable surgical approach for enhanced recovery after surgery

Objective

We aimed to determine the safety of Vaginal natural orifice transluminal endoscopic surgery (vNOTES) in terms of the Enhanced Recovery after Surgery (ERAS) concept for tubal pregnancy surgery and provide a detailed process of vNOTES for tubal pregnancy surgery, including experience and key points for surgeons performing this procedure.

Methods

The Longitudinal Vaginal Natural Orifice Transluminal Endoscopic Surgery Study (LovNOTESS), which was conducted in Chengdu, China. A total of 219 patients who underwent tubal ectopic pregnancy surgery between September 2021 and March 2022. The patients underwent salpingectomy or salpingostomy using transumbilical laparoendoscopic single-site surgery (LESS) or vNOTES, according to their preferences. This study prospectively collected perioperative and one-year follow-up data on tubal pregnancy outcomes after vNOTES and compared them with those after LESS.

Results

The vNOTES group showed a shorter surgical duration, hospitalization duration, and postoperative exhaust time and a lower analgesic medication usage rate, but it showed a higher surgical conversion rate. The vNOTES approach reduced the postoperative exhaust time by approximately 9 h (95% confidence interval [CI]: -11.93, -5.57 h, p < .001) and the risk of postoperative analgesic drug use by 77% (odds ratio, 0.23; 95% CI: 0.10, 0.61, p = .023).

Conclusion

vNOTES can shorten the exhaust time and duration of hospitalization, reduce postoperative pain, and avoid surface surgical scars in tubal pregnancy surgeries, consistent with the ERAS concept. However, more comprehensive preoperative evaluation of patients who choose vNOTES is required to reduce the occurrence of intraoperative conversion.Trial registration: ChiCTR2100053483.

Transvaginal natural Orifical transluminal Endoscopy for sacrocolpopexy: A case series report

Background

To describe the surgical technique and operative outcomes of transvaginal natural orifice transluminal endoscopic surgery (V-NOTES) for sacrocolpopexy with or without robotic surgical system in patients with pelvic organ prolapse (POP).

Methods

Patients with POP undergoing traditional transvaginal natural orifice transluminal endoscopic surgery (TV-NOTES) or robotic transvaginal natural orifice transluminal endoscopic surgery (RV-NOTES) for sacrocolpopexy performed by one surgeon from Sep 2020 to Jan 2023 in our hospital were included in this study. The baseline demographics and operative outcomes were collected and analyzed. In addition, some surgical skills were presented. The operative outcomes of V-NOTES for sacrocolpopexy performed by three beginners were also presented.

Results

Eight patients who underwent TV-NOTES, and two patients who underwent RV-NOTES were included in this study. The mean operative time was 180 ± 49 min, and the estimated blood loss was 107 ± 82 ml for these ten cases. Particularly, the operative time of the two patients who underwent RV-NOTES was 275 and 132 min, while the estimated blood loss (EBL) was 100 and 50 ml respectively. During the follow-up period, no mesh exposure and recurrence were observed. In addition, five cases of TV-NOTES for sacrocolpopexy by beginners were all successfully completed.

Conclusion

Both TV-NOTES and RV-NOTES appeared to be feasible and safe for sacrocolpopexy.

Pain in High-Dose-Rate Brachytherapy for Cervical Cancer: A Retrospective Cohort Study

High-dose-rate brachytherapy (HDR) is part of the main treatment for locally advanced uterine cervical cancer. Our aim was to evaluate the incidence and intensity of pain and patients' satisfaction during HDR. Risk factors for suffering pain were also analyzed. A retrospective study was carried out by extracting data from patients who had received HDR treatment for five years. Postoperative analgesia had been administered using pre-established analgesic protocols for 48 h. Pain assessment was collected according to a protocol by the acute pain unit. Analgesic assessment was compared according to analgesic protocol administered, number of needles implanted, and type of anesthesia performed during the procedure. From 172 patients treated, data from 247 treatments were analyzed. Pain was considered moderate in 18.2% of the patients, and 43.3% of the patients required at least one analgesic rescue. Patients receiving major opioids reported worse pain control. No differences were found regarding the analgesic management according to the intraprocedural anesthesia used or the patients' characteristics. The number of inserted needles did not influence the postoperative analgesic assessment. Continuous intravenous infusion of tramadol and metamizole made peri-procedural pain during HDR mild in most cases. Many patients still suffered from moderate pain.