Transvaginal natural orifice transluminal endoscopic versus conventional vaginal hysterectomy with uterosacral ligament suspension for apical compartment prolapse

Evaluation of the mid-term surgical outcomes of vNOTES sacrocolpopexy and vNOTES high uterosacral ligament suspension in pelvic organ prolapse

BACKGROUND

This multicenter retrospective study aimed to assess the surgical outcomes of vNOTES-HUSLS and sacrocolpopexy after vNOTES hysterectomy for apical pelvic organ prolapse (POP).

METHODS

A total of 101 patients were included. Pre and postoperative modified POP-Q scores, postoperative Visual Analog Scale (VAS) scores and complications were among the information gathered. POP-Q-C score of less than -1 cm was considered an apical recurrence. 'Overall success' was defined as the absence of each of the following factors: ≥ Stage 2 POP (in any compartment), retreatment for prolapse.

RESULTS

vNOTES-HUSLS (n = 78) achieved an overall success rate of 92.2%, accompanied by a low intraoperative complication rate of 2.6% (n = 2) at the 23-month median follow-up. vNOTES-sacrocolpopexy (n = 23) achieved an anatomical success rate of 78.3% and exhibited a low intraoperative complication rate of 4.3% (n = 1) at the 21-month median follow-up. The apical prolapse recurrence rate was 2.6% and 8.7% in the HUSLS and sacrocolpopexy groups, respectively (p = 0.185). Total duration of surgery and VAS scores were significantly lower in the vNOTES-HUSLS group than in the vNOTES-sacrocolpopexy group.

CONCLUSIONS

In POP surgery, HUSLS and sacrocolpopexy may be performed using the vNOTES technique depending on the patient's preference for natural tissue repair or mesh use.

Two-Year Follow-Up on Surgical Outcomes of vNOTES High Uterosacral Ligament Suspension for the Prophylaxis and Treatment of Pelvic Organ Prolapse: A Multicenter Prospective Cohort Study

STUDY OBJECTIVE

We aimed to evaluate the medium-term outcomes of high uterosacral ligament suspension (HUSLS) with vaginal-assisted natural orifice transluminal endoscopic surgery (vNOTES) in patients either having pelvic organ prolapse or undergoing routine prophylaxis to prevent posthysterectomy vaginal vault prolapse.

DESIGN

Multicenter prospective cohort study.

SETTING

Three tertiary care hospitals.

PATIENTS

Patients who received vNOTES-HUSLS between January 1, 2021, and January 1, 2023, were included in the study.

INTERVENTIONS

vNOTES-HUSLS.

MEASUREMENTS AND MAIN RESULTS

The data collected included surgery duration, intraoperative and postoperative complications, postoperative visual analog scores, and Female Sexual Function Index pain subdomain scores. The changes in prolapse levels were measured using modified Pelvic Organ Prolapse Quantifications System scores, including the C, Ba, and Bp scores recorded before surgery and during the postoperative follow-up examination. Patient satisfaction was assessed using the Patient Global Impression of Improvement questionnaire. The final analysis included 55 women. Of these, vNOTES-HUSLS was performed in 43 patients (78.2%) to treat apical prolapse, whereas the remaining 12 patients (21.8%) underwent prophylaxis after hysterectomy to prevent vaginal vault prolapse. The median follow-up period was 23.5 months, with a range of 12 to 37 months. Ba, C, and Bp points significantly improved in patients who underwent surgery for prolapse (p <.001). There was no recurrence in the apical compartment after vNOTES-HUSLS for both performed prophylactic and treatment purposes after hysterectomy. Two patients (3.6%) were diagnosed as having stage 3 anterior compartment prolapse. The overall vNOTES-HUSLS success rate was 96.4% at approximately 2-year follow-up. Bladder injury was detected as an intraoperative complication in 1 patient (1.8%). The overall satisfaction rate was 98.1% at the final follow-up.

CONCLUSION

vNOTES-HUSLS was effective in the treatment and prophylaxis of apical prolapse, demonstrating high anatomic success rates. The procedure demonstrated a low complication rate, with intraoperative and postoperative complications each observed in 1.8% of patients (n = 1).

Conventional vaginal approach vs. transvaginal natural orifice transluminal endoscopic surgery for treating apical prolapse, a randomized controlled study

OBJECTIVE

Vaginal hysterectomy combined with uterosacral suspension (USLS) is a technique for treating pelvic organ prolapse. Vaginal natural orifice transluminal endoscopic surgery (vNOTES) has been described as an alternative minimal invasive approachfor treating various gynecological and non-gynecological pathologies. The aim was to compare the surgical time between conventional vaginal hysterectomy combined with USLS and vNOTES hysterectomy combined with USLS.

STUDY DESIGN

Multi-center randomized controlled trial performed 2019-2021 at Rambam Health Care Campus (Israel) and Imelda Hospital (Belgium). Thirty women underwent vNOTES procedures and 30 women underwent conventional vaginal procedures. The primary outcome was total surgical time. Secondary outcomes included hysterectomy time, USLS time, intraoperative bleeding, length of hospitalization, pain during the first 24 h postoperative, the need of analgesia, intraoperative and postoperative adverse events, and patient-reported outcomes questionnaires. Parametric statistical methods were used to analyze the data.

RESULTS

Compared to conventional vaginal procedures, vNOTES procedures were shorter in total surgical time (77 vs. 93 min, p = 0.004), hysterectomy time (26 vs 33 min, p < 0.001), and USLS time (20 vs 26 min. p = 0.02). Blood loss was higher in conventional vaginal compared to vNOTES surgery, as reflected by the mean blood loss estimate (143 vs 60 ml. p < 0.001) and the delta-hemoglobin (pre-operation minus the post-operation hemoglobin level (1.8 vs 1.2 ml/dL, p = 0.01). There was no difference between the groups regarding analgesics used, postoperative pain, surgical objective outcomes, and scores on patient-reported outcomes questionnaires. Adverse events were significantly more frequent in the conventional vaginal group than in the vNOTES group (p < 0.001 for intraoperative events and p = 0.05 for events that occurred in the follow-up time interval).

CONCLUSION

vNOTES hysterectomy with USLS has lower surgical times than conventional vaginal hysterectomy with USLS, lower blood loss and less adverse events. Other surgical objective and subjective outcomes were similar between the approaches.

Assessing Feasibility and Outcomes of Robotic Single Port Transvaginal NOTES (RSP-vNOTES) Hysterectomy: A Case Series

OBJECTIVE

To demonstrate the feasibility and short-term outcomes of Robot-Assisted Single Port vaginal NOTES (RSP-vNOTES) for total hysterectomy, with or without endometriosis resection for all stages.

DESIGN

Retrospective case series.

SETTING

Single academic tertiary care hospital in Houston, Texas, USA.

PARTICIPANTS

Twenty-eight adult women with chronic pelvic pain who underwent RSP-vNOTES hysterectomy, with or without endometriosis resection.

INTERVENTIONS

Hysterectomy with or without excision of endometriosis via single-port robot-assisted vNOTES platform (Intuitive Da Vinci SP Platform).

MAIN RESULTS

Twenty-eight patients with a mean age of 40.1 years (range 24.0-54.0 years), mean BMI 28.5 kg/m2 (range 19.5-48.4 kg/m2), underwent RSP-vNOTES from November 11, 2023 to May 7, 2024. Five (17.9%) patients underwent solely a hysterectomy, while 23 (82.1%) patients underwent additional endometriosis resection; 28.6% with stage I, 25.0% stage II, 7.1% stage III, and 21.4% with stage IV. Mean total operative time was 188.7 minutes (range 135.0-427.0 minutes), with robot dock time of 2.9 minutes (range 1.0-10.0 minutes), robot console time of 97.3 minutes (range 51.0-221.0 minutes), and hysterectomy time of 55.3 minutes (range 24.0-170.0 minutes). Estimated blood loss averaged 32.1 mL (range 25.0-50.0 mL). One case required a mini-laparotomy as the irregularly shaped 1668 g fibroid uterus was unable to be removed vaginally. Complications included one case of vaginal cuff cellulitis and one case of urinary tract infection.

CONCLUSION

Our findings indicate that RSP-vNOTES, a novel single-port surgical approach, presents a promising alternative surgical platform in vaginal surgeries.

Vaginal hysterectomy and transvaginal natural orifice transluminal endoscopic surgery for uterosacral ligament suspension for pelvic organ prolapse: 53 cases of single-surgeon experience

OBJECTIVE

The objective of this study was to describe the single-surgeon experience on transvaginal natural orifice transluminal endoscopic surgery for uterosacral ligament suspension in patients with severe prolapse who had concomitant vaginal hysterectomy.

METHODS

A total of 53 patients with severe uterine prolapse who underwent vaginal hysterectomy and transvaginal natural orifice transluminal endoscopic surgery for uterosacral ligament suspension between January 2021 and March 2023 were included in the study. Operation time, intraoperative and postoperative complications, de novo urinary continence, and duration of hospitalization were obtained from the patient records. Initial postoperative follow-up visits were scheduled for the first week of the month. Patients were followed up yearly, and they had the opportunity to reach the surgical team at any time. Symptomatic prolapse beyond the hymen is defined as recurrence.

RESULTS

Patients had a mean age of 61.7 years ±7.7 SD. All patients received bilateral opportunistic salpingectomy and salpingo-oophorectomy. The total operation time was 162±31 min, with transvaginal natural orifice transluminal endoscopic surgery taking 32.3±5.37 min. There were no intraoperative complications. 12 patients had recurrence; 8 anterior, 3 apical, and 1 posterior prolapse. The mean recurrence time was 11.5 months (range 5-23 months). The reoperation rate was 13.2% (n:7). Three of the patients had obliterative vaginal surgery, three of the patients had anterior, and one patient had posterior repair. Overall failure of apical surgical procedure was 5.6%. Two patients had de novo incontinence postoperatively.

CONCLUSIONS

Transvaginal natural orifice transluminal endoscopic surgery uterosacral ligament suspension is a feasible technique to treat severe pelvic organ prolapse with promising results for short-term efficacy and safety in patients who had concomitant vaginal hysterectomy. Longer follow-up periods are needed to evaluate the long-term efficacy profile of transvaginal natural orifice transluminal endoscopic surgery for uterosacral ligament suspension.

Vaginal Hysterectomy: A Network Meta-Analysis Comparing Short-Term Outcomes of Surgical Techniques and Devices

OBJECTIVE

To provide available evidence comparing surgical outcomes of different vaginal hysterectomy (VH) techniques and devices.

DATA SOURCES

PubMed, Embase, and ClinicalTrials.gov databases were searched from inception to December 1, 2023, using relevant keywords.

METHODS OF STUDY SELECTION

Studies comparing at least 2 surgical techniques and devices for VH were included. An arm-based random effect frequentist network meta-analysis was performed. All available surgical outcomes were evaluated.

TABULATION, INTEGRATION, AND RESULTS

Ten randomized controlled trials and 7 observational studies were eligible reporting on 1577 women undergoing VH with different techniques and devices (50% conventional, 22.5% Ligasure, 17.3% BiClamp, and 9.2% transvaginal natural orifice transluminal endoscopic surgery [vNOTES]). All surgical techniques/devices had a comparable risk ratio (RR) in terms of intraoperative complications, but Clavien-Dindo grade III postoperative complications were significantly reduced in the vNOTES group (RR, 0.15; 95% confidence interval [CI], 0.03-0.82; I2 = 0%) compared with conventional VH. The pooled network analysis showed a lower standard mean deviation for blood loss when comparing energy-based vessel sealing technologies (Ligasure: standard mean deviation, -0.92; 95% CI, -1.47 to -0.37; BiClamp: standard mean deviation, -1.66; 95% CI, -2.77 to -0.55) with conventional VH. Total operative time, postoperative hemoglobin variation, and pain were significantly reduced only in the Ligasure group compared with conventional VH. Bilateral salpingectomy or bilateral salpingo-oophorectomy was most commonly performed in the vNOTES group (RR, 1.9; 95% CI, 1.17-3.10) compared with the conventional VH group.

CONCLUSION

Modern surgical techniques/devices have the potential to improve anatomic exposure and to reduce morbidity of VH. This may drive resurgence of vaginal approach to hysterectomy.

Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) in Urogynecological Surgery: A Systematic Review

Background: Minimally invasive surgery could improve cosmetic outcomes and reduce the risks of surgical injury with less postoperative pain and a quicker patient's discharge. Recently, transvaginal natural orifice transluminal endoscopic surgery (vNOTES) has been introduced in urogynecology with exciting results. Evidence Acquisition: After PROSPERO registration (n°CRD42023406815), we performed a comprehensive literature search on Pubmed, Embase, and Cochrane CENTRAL, including peer-reviewed studies evaluating transvaginal natural orifice transluminal endoscopic surgery. No limits on time or type of study were applied. Evidence synthesis: Overall, 12 manuscripts were included in the analysis. Seven studies evaluated uterosacral ligament suspension, four studies evaluated sacral colpopexy, three evaluated sacrospinous ligament suspension, and one study evaluated lateral suspension. Overall success rates were high (>90%); however, definitions of success were heterogeneous. In terms of complication, most of the studies reported low-grade complications (Clavien-Dindo I and II); only two patients needed mesh removal because of mesh exposure. The risk of bias of the trials was rated in the medium to high-risk category. Conclusions: The present review highlights important initial results for vNOTES. Future randomized clinical trials are needed to better define its role in the management of urogynecological procedures.

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.

Various Laparoscopic Techniques in Pelvic Organ Prolapse Surgery

In the past, transvaginal surgery, native tissue restoration, or obliterative methods have been used in the majority of pelvic organ prolapse (POP) surgeries. Since laparoscopy has gained popularity, other procedures have been created to provide additional POP repair alternatives. Laparoscopic technique offers many advantages compared to open or transvaginal surgery when it comes to anatomical and surgical outcomes, recurrence rates, and patient's acceptance. Furthermore, we encouraged incorporating different laparoscopic techniques into urogynecology training to attract young gynecologists. Based on our own clinical and surgical experience, we present various laparoscopic techniques for treating POP. We think that by giving patients a variety of surgical alternatives, we can treat them all more effectively.

Comparison of transvaginal natural orifice transluminal endoscopic surgery versus conventional surgery for uterosacral ligament suspension in patients who had concomitant vaginal hysterectomy for subtotal uterine prolapse

INTRODUCTION

The study aimed to compare the short-term outcomes of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) for uterosacral ligament suspension (USLS) versus nonendoscopic USLS in patients with subtotal uterine prolapse who had a concomitant vaginal hysterectomy.

METHODS

There were 51 patients who underwent vNOTES USLS, whereas the nonendoscopic conventional USLS group had 49 patients. The information about patient demographics, and perioperative data including the operative duration, blood loss, intraoperative and postoperative complications, and length of postoperative hospital stay were determined from the patients' files. Postoperative follow-up visits were scheduled at the first week and 1 month after surgery.

RESULTS

The demographic variables including age, body mass index, menopausal status, and parity were comparable, and no significant differences were found. A total of 90.2% of the patients in the vNOTES group and 69.4% of the patients in the shull group were at menopause (p = .09). Operation time was significantly shorter in the shull group (p < .001), and the hospitalization period (p = .029) was significantly shorter in the vNOTES group. Ba, Bp, and D points and total vaginal length (TVL) were significantly behind the hymenal ring in patients who had vNOTES USLS procedure (p < .001). None of the patients who had intraoperative significant blood loss required transfusion. One patient in the vNOTES and two patients in the shull group had a postoperative cuff hematoma.

CONCLUSION

vNOTES USLS has a good safety profile, higher percentage of adnexal surgeries with better improvement on POP-Q points Ba, Bp, D, and TVL compared with classic USLS in patients with subtotal uterine prolapse. Studies evaluating short- and long-term results of vNOTES versus conventional USLS are needed.

Vaginal Hysterectomy and Pelvic Organ Prolapse: History and Recent Developments

INTRODUCTION AND HYPOTHESIS

Vaginal hysterectomy (VH) was described as far back as 120 CE. However, it was not till the mid-1900s when reconstructive procedures were introduced to mitigate the risk of, or treat, pelvic organ prolapse in relation to VH. Furthermore, routine hysterectomy, particularly VH, has long been advocated in prolapse surgery. However, this indication is now questionable.

METHODS

Literature review to provide an overview of current evidence and experts' opinion regarding the relationship between VH and pelvic organ prolapse. The review presents a historical perspective on the role of VH in the management of pelvic organ prolapse, the current debate on the usefulness of the procedure in this context, a practical guide on operative techniques used during VH and the impact of recent surgical developments on its use.

RESULTS

Vaginal hysterectomy is a well-established technique that is still superior to laparoscopic hysterectomy for benign gynecological disease, although more surgically challenging. However, it is possible that some contemporary techniques, such as vaginal natural orifice transluminal endoscopic surgery, may overcome some of these challenges, and hence increase the number of hysterectomies performed via the vaginal route. Although patients should be counselled about uterine-sparing reconstructive surgery, vaginal hysterectomy continues to be a major surgical procedure in reconstructive pelvic floor surgery.

CONCLUSIONS

Therefore, it is prudent to continue to train residents in vaginal surgical skills to ensure that they continue to provide safe, cost-effective, and comprehensive patient care.

Robot-Assisted Vaginal Natural Orifice Transluminal Endoscopic Surgery (RvNOTES) With Total Hysterectomy for Management of Stage IV Endometriosis With/Without Complete Cul-de-Sac Obliteration: 23-Case Pilot Feasibility Study

STUDY OBJECTIVE

To show feasibility and short-term outcomes of robot-assisted vaginal NOTES (RvNOTES) for the treatment of stage IV endometriosis during total hysterectomy with/without complete cul-de-sac obliteration.

DESIGN

Retrospective case series.

SETTING

Single academic tertiary care hospital in Houston, Texas, USA.

PATIENTS

Twenty-three adult women with stage IV endometriosis.

INTERVENTIONS

RvNOTES with total hysterectomy for excision of severe endometriosis.

MEASUREMENTS AND MAIN RESULTS

Patients were assessed for various metrics including total operative time, robot dock time, robot console time, hysterectomy time, estimated blood loss, perioperative pain using the Visual Analogue Scale (VAS), and complications. The mean total operative time was 224.3 minutes. The study also found that patients with complete cul-de-sac obliteration had significantly longer operative times and higher estimated blood loss compared to those with partial or no obliteration. Postoperative VAS pain scores showed a significant reduction over a 6-week period. Complications included one case of complete ureteral transection, pelvic hematoma with infection, vaginal abscess, urinary tract infection, and pneumonia.

CONCLUSION

Our findings suggest that RvNOTES may be a feasible surgical approach in expert hands for treating stage IV endometriosis, even in cases with complete obliteration of the cul-de-sac.

Systematic review and meta-analysis of vaginal natural orifice transluminal endoscopic surgery hysterectomy versus vaginal hysterectomy for benign indications

Objective

As the second most common surgery performed on women in the United States, hysterectomy techniques are constantly examined for validity and superiority. The vaginal natural orifice transluminal endoscopic surgery (vNOTES) has increased in popularity since the first vNOTES hysterectomy was performed in 2012. We sought out to evaluate the safety and effectiveness of hysterectomy by vNOTES compared to conventional vaginal hysterectomy for various benign indications.

Data sources

We searched Scopus, Medline, PubMed, ClinicalTrials.Gov, and the Cochrane Library. Our search included all studies from each respective database's inception until September 1, 2023.

Study eligibility criteria

We included eligible studies that compare vNOTES hysterectomy versus conventional vaginal hysterectomy for various benign indications, and included at least one of our preselected outcomes. The main outcomes were estimated blood loss (mL), operation time (min), length of hospital stay (d), Visual Analogue Scale pain score at Day 1, intraoperative complications, and postoperative complications.

Study appraisal and synthesis methods

We analyzed data of our continuous outcomes using RevMan 5.4.1. Continuous outcomes were analyzed using mean difference (MD) and 95% confidence intervals (CIs) under the inverse variance analysis method. We assessed the quality of the studies using the ROBINS-I assessment tool.

Results

We found 4 eligible studies to include in our analysis. Surgeon declared estimated blood loss was found to be similar in both groups (MD=-44.70 [-99.97, 10.57]; P=.11). Also, the total length of hospital stay (in days) was found to be comparable in both groups (MD=-0.16 [-1.62, 1.30]; P=.83). We also found no other statistically significant difference between hysterectomy by vNOTES and vaginal hysterectomy in other studied outcomes, including the duration of the operation, the Visual Analogue Scale Pain score after 1 day, intraoperative complications, and postoperative complications.

Conclusion

vNOTES seems to be associated with a nonsignificant lower surgeon declared estimated blood loss. We found no other significant differences in hospital stay, intraoperative, or postoperative outcomes. Further studies may clarify if other differences in safety or efficacy exist.

Enabling Technologies for Gynecologic Vaginal Surgery: A Systematic Review

OBJECTIVE

To systematically review the literature to evaluate clinical and surgical outcomes for technologies that facilitate vaginal surgical procedures.

DATA SOURCES

We systematically searched MEDLINE, EMBASE, and ClinicalTrials.gov from January 1990 to May 2022.

METHODS OF STUDY SELECTION

Comparative and single-arm studies with data on contemporary tools or technologies facilitating intraoperative performance of vaginal gynecologic surgical procedures for benign indications were included. Citations were independently double screened, and eligible full-text articles were extracted by two reviewers. Data collected included study characteristics, technology, patient demographics, and intraoperative and postoperative outcomes. Risk of bias for comparative studies was assessed using established methods, and restricted maximum likelihood model meta-analyses were conducted as indicated.

TABULATION, INTEGRATION, AND RESULTS

The search yielded 8,658 abstracts, with 116 eligible studies that evaluated pedicle sealing devices (n=32), nonrobotic and robotic vaginal natural orifice transluminal endoscopic surgery (n=64), suture capture devices (n=17), loop ligatures (n=2), and table-mounted telescopic cameras (n=1). Based on 19 comparative studies, pedicle sealing devices lowered vaginal hysterectomy operative time by 15.9 minutes (95% CI, -23.3 to -85), blood loss by 36.9 mL (95% CI, -56.9 to -17.0), hospital stay by 0.2 days (95% CI, -0.4 to -0.1), and visual analog scale pain scores by 1.4 points on a subjective 10-point scale (95% CI, -1.7 to -1.1). Three nonrandomized comparative studies and 53 single-arm studies supported the feasibility of nonrobotic vaginal natural orifice transluminal endoscopic surgery for hysterectomy, adnexal surgery, pelvic reconstruction, and myomectomy. Data were limited for robotic vaginal natural orifice transluminal endoscopic surgery, suture capture devices, loop ligatures, and table-mounted cameras due to few studies or study heterogeneity.

CONCLUSION

Pedicle sealing devices lower operative time and blood loss for vaginal hysterectomy, with modest reductions in hospital stay and pain scores. Although other technologies identified in the literature may have potential to facilitate vaginal surgical procedures and improve outcomes, additional comparative effectiveness research is needed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42022327490.

Does transvaginal natural orifice transluminal endoscopic surgery affect female sexual function?: a prospective cohort study

BACKGROUND

To evaluate the effect of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) on female sexual function.

METHODS

The trial was registered at the Chinese Clinical Trial Registry (ChiCTR2100050887, 07/09/2021). In this prospective cohort study, we prospectively analyzed the data of the female sexual function index (FSFI) questionnaire of 130 patients who underwent laparoscopy in Chengdu Women's and Children's Central Hospital due to gynecological benign diseases. The patients were assigned to the vNOTES group and the control group (underwent traditional laparoscopic surgery or transumbilical laparoendoscopic single-site surgery).

RESULTS

There were 4 cases dropout in the vNOTES group and 2 cases dropout in the control group. There was no difference in the ages (31.70 ± 5.02 vs. 30.37 ± 5.74, P>0.05), BMI (body mass index, 21.76 ± 3.16 vs. 23.30 ± 2.69, P>0.05), Education level, surgical types, and FSFI scores (22.31 ± 2.25 vs. 21.55 ± 3.38) between the vNOTES group and the control group before surgery. There was no difference in FSFI scores six months postoperation between the vNOTES group and the control group (21.61 ± 3.22 vs. 20.99 ± 3.26, P>0.05), and there was no difference in FSFI scores pre- and six months postoperation in vNOTES group (21.61 ± 3.22 vs. 22.31 ± 2.25, P>0.05). The time to start sexual life after surgery in the vNOTES group was later than that in the control group (39.34 ± 0.71 d versus 37.86 ± 0.69 d, P < 0.05).

CONCLUSIONS

vNOTES has no significant adverse effect on female sexual function, however, the time to start sexual life after vNOTES is later than that after trans-abdominal laparoscopy.

Transvaginal natural orifice transluminal endoscopic surgery versus conventional vaginal surgery for sacrospinous ligament fixation of apical compartment prolapse: a retrospective analysis

BACKGROUND

To objectively assess the safety, feasibility, advantages, and disadvantages of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) versus conventional vaginal (CV) surgery for sacrospinous ligament fixation (SSLF).

METHODS

We retrospectively analyzed the data of patients who underwent hysterectomy for SSLF via vNOTES or CV surgery due to apical compartment prolapse between April 2019 and April 2020 at our hospital. The patients were classified into the vNOTES group (n = 31) and CV surgery group (n = 51) based on surgical approach and their general characteristics and perioperative outcomes compared.

RESULTS

The two groups had similar general characteristics. The anatomical success and bilateral salpingo-oophorectomy rates were higher in the vNOTES than CV surgery group, while the postoperative stay was shorter in the vNOTES than CV surgery group. All differences were statistically significant. However, there were no statistically significant intergroup differences in operation time, bilateral salpingectomy rate, colporrhaphy rate, postoperative visual analog scale score, estimated blood loss, hemoglobin decrease at 72 h postoperative, maximum body temperature at 72 h postoperative, complication rate, buttock pain, or Pelvic Floor Impact Questionnaire-7 and Pelvic Floor Distress Inventory Questionnaire-20 scores at 1 year postoperative.

CONCLUSIONS

VNOTES for SSLF was safe and feasible and resulted in superior objective and subjective outcomes versus CV surgery for SSLF. These findings suggest that vNOTES could be an alternative to CV surgery for SSLF.

Transvaginal natural orifice transluminal endoscopic surgery for presacral-uterosacral ligament compound suspension in apical compartment prolapse

INTRODUCTION AND HYPOTHESIS

We aimed to describe a novel mesh-free pelvic repair surgery for apical prolapse and to evaluate the effect of this technique and early outcomes.

METHODS

We demonstrate the key techniques in a video: exposing the anterior longitudinal ligament (ALL) of the presacral space; securing a non-absorbable suture to the ALL by horoscope stitch; shortening the right uterosacral ligament (USL); placing a non-absorbable suture around the intermediate portion of the left USL for three stitches; placing the non-absorbable suture in the transverse portion of the pubocervical and rectovaginal fascia; locking sutures in place to approximate anterior to posterior connective tissue. Fifteen patients were enrolled to undergo this procedure between December 2020 and April 2021.

RESULTS

The mean age of the patients was 60.67 (range 46-69) years, the mean body mass index was 24.25 kg/m² (range 19.61-30.08). The mean operation time was 103.6 min (range 65-166), and the mean blood loss was 82 ml (range 50-200). No intraoperative complications occurred. All patients gained a significant improvement in anatomical and objective outcomes during a mean 9.93-month follow-up, and there was no recurrence.

CONCLUSIONS

Our experience showed that this mesh-free repair surgery was a feasible and safe technique for apical prolapse.

Review of Vaginal Approaches to Apical Prolapse Repair

PURPOSE OF REVIEW

To review recent literature and provide up-to-date knowledge on new and important findings in vaginal approaches to apical prolapse surgery.

RECENT FINDINGS

Overall prolapse recurrence rates following transvaginal apical prolapse repair range from 13.7 to 70.3% in medium- to long-term follow-up, while reoperation rates for prolapse recurrence are lower, ranging from 1 to 35%. Subjective prolapse symptoms remain improved despite increasing anatomic failure rates over time. The majority of studies demonstrated improvement in prolapse-related symptoms and quality of life in over 80% of patients 2-3 years after transvaginal repair, with similar outcomes with and without uterine preservation. Contemporary studies continue to demonstrate the safety of transvaginal native tissue repair with most adverse events occurring within the first 2 years. Transvaginal apical prolapse repair is safe and effective. It is associated with long-term improvement in prolapse-related symptoms and quality of life despite increasing rates of prolapse recurrence over time. Subjective outcomes do not correlate with anatomic outcomes.

Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) meshless anterior repair for the treatment of pelvic organ prolapse

OBJECTIVE

To demonstrate the feasibility of Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) meshless anterior repair for the treatment of pelvic organ prolapse (POP).

DESIGN

Stepwise demonstration of the technique with narrated video footage.

SETTING

The vNOTES approach is a recent and rapidly developing technique which allows safe endoscopic transvaginal treatment of benign uterine pathologies (1). Its use in the treatment of POP is still in its early stages however the first results are encouraging in terms of anatomy, functionality and safety (2).

INTERVENTIONS

We describe the vNOTES technique of meshless anterior POP repair using a vaginal plastron (3). The "vaginal plastron" technique uses an autologous vaginal strip which is left attached to the bladder and suspended from the arcus tendineus. After the delimitation of a 6 cm square vaginal strip, a lateral dissection is performed on each side between the bladder and the vaginal fascia, to enter the paravesical space. The vaginal strip is left attached to the bladder wall and will later be fixed laterally to the arcus tendineus with 6 non-absorbable monofilament sutures, caliber 0 (3 on each side of the plastron). The fixation points on the arcus tendineus concern the internal obturator fascia ventrally and the iliococcygeus fascia dorsally. The sutures are placed under endoscopic view using a transvaginal access platform (GelPOINT® V-Path, Applied Medical, Rancho Santa Margarita, CA). After deflation and removal of the platform, the sutures are attached to the vaginal strip. Once the vaginal plastron is secured, the anterior vaginal wall is closed.

CONCLUSION

The vNOTES approach offers an endoscopic anatomical view of the paravesical space, thus reducing any blind surgical procedure. It provides an alternative route in the performance of meshless anterior POP repair.