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

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.

Minimally Invasive Vaginal Natural Orifice Transluminal Endoscopic Surgery Technique for Successful Polypropylene Mesh Removal in Pelvic Organ Prolapse: A Case Report

In the treatment of pelvic organ prolapse, the insertion of polypropylene mesh is often necessary but can lead to subsequent complications, such as a high incidence of pain and infections, necessitating mesh removal. However, the removal of polypropylene mesh can be challenging due to the risks of postoperative complications and technical difficulties. The key to effective healing often lies in the complete removal of the mesh, but this process is associated with complications, including severe pain and potential foreign body reactions. These challenges underscore the need for less invasive and more precise removal techniques. In our clinical practice, traditional approaches, such as vaginal and open abdominal surgeries, have often been hindered by limited visibility and accessibility at the mesh fixation sites. To address these issues, our team has pioneered the development of vaginal natural orifice transluminal endoscopic surgery (vNOTES) for mesh removal. This innovative and minimally invasive technique, performed through the vaginal route, holds particular promise for repairs within the pelvic cavity. vNOTES not only enhances surgical visibility but also reduces the invasiveness of the procedure. In this case report, we present an 85-year-old female patient, who underwent transvaginal mesh (TVM) insertion at the age of 68 years. The patient developed pain in the left buttock, left lower back, and vulvar region, necessitating the removal of TVM. The vNOTES approach significantly reduced postoperative pain and complications, enabling efficient and safe removal of the polypropylene mesh. Moreover, the pathological examination of the polypropylene mesh, which was causing hip and buttock pain, revealed the presence of poor granulation tissue, indicative of a specific pathological tissue pattern. To the best of our knowledge, this is the first detailed account of the successful application of vNOTES in mesh removal.

Analysis and suggestions on the complications in 2000 cases of transvaginal natural orifice transluminal endoscopic surgery: Can it be a conventional surgery?

OBJECTIVE

To reflect on the complications of transvaginal natural orifice transluminal endoscopic surgery (vNOTES), identify the corresponding risk factors, and provide caution to surgeons when performing this novel surgery.

METHODS

A retrospective study was carried out among 2000 patients in our hospital who underwent vNOTES between May 2019 and May 2022. Perioperative complications were stratified in chronological order and divided into those developed while establishing the vNOTES approach, during surgery, postoperatively, and 1 month after discharge. The complications were classified based on the Modified Clavien-Dindo classifications. The causes of each type III/IV complication were analyzed.

RESULTS

Of the 2000 patients, 88 (4.4%) experienced complications, which is not higher than that reported in laparoendoscopic surgery in previous studies. Grade I, II, III, IV, and V complications developed in 19 (0.95%), 57 (2.85%), 11 (0.55%), 1 (0.05%), and 0 (0%) patients, respectively. Complications were developed while establishing the approach platform, during the surgery, postoperatively, and within 1 month after discharge in 5 (0.25%), 30 (1.50%), 50 (2.50%), and 3 (0.15%) patients, respectively. Eight patients (0.4%) underwent conversion, including five cases of rectal injury repair.

CONCLUSION

The summarized suggestions were divided into three levels. Considering the security and effectiveness of vNOTES, it can be routinely used in various gynecologic operations. However, surgeons should focus on preoperative evaluation, strictly conduct preoperative disinfection, conform to prompt conversion during surgery, call for the presence of experienced doctors, and have routine use of antibiotics to prevent postoperative infections.

TRIAL REGISTRATION

ChiCTR2100053483.