Comparing vNOTES Hysterectomy with Laparoscopic Hysterectomy for Large Uteri

Comparison of Perioperative Outcomes Between V-NOTES and Total Laparoscopic Hysterectomy: A Retrospective Analysis

BACKGROUND

This retrospective study compared the perioperative outcomes of vaginal natural orifice transluminal endoscopic surgery (V-NOTES) and total laparoscopic hysterectomy (TLH).

MATERIALS AND METHODS

This analysis included 62 patients: 32 underwent V-NOTES and 30 underwent TLH. Patients with a body mass index (BMI) >30, a history of endometriosis, multiple cesarean sections, or a uterine size >12 week were excluded. Perioperative data-including visual analog scale (VAS) scores, analgesia use, mobilization time, hospitalization duration, and hemoglobin deficit-were compared using independent sample t tests and Mann-Whitney U tests.

RESULTS

There were no significant differences in BMI, number of pregnancies, or operative time (p > 0.05). VAS scores at 6 and 24 h were significantly lower in the V-NOTES group (p < 0.001). Patients in the V-NOTES group required less analgesia, had shorter mobilization and hospitalization periods, and returned to daily activities sooner (p < 0.001). However, the hemoglobin deficit was higher in the V-NOTES group (1.85 g/dl vs. 0.7 g/dl, p < 0.001). The neutrophil-to-lymphocyte ratio (NLR) was lower in the V-NOTES group (p = 0.013), whereas the platelet-to-lymphocyte ratio (PLR) and mean platelet volume (MPV) did not differ significantly between the two groups.

CONCLUSION

V-NOTES offers advantages such as reduced postoperative pain and faster recovery compared to TLH. The higher hemoglobin deficit observed with V-NOTES may be related to the surgeon's experience. Further randomized studies are warranted to validate these findings and define appropriate patient selection criteria.

Comparison of rapid recovery outcomes between vNOTES hysterectomy and laparoscopic hysterectomy: a prospective study

BACKGROUND

This study was aimed at evaluating the postoperative outcomes of vaginal natural orifice transluminal endoscopic hysterectomy (vNOTEH).

METHODS

This prospective cohort study was conducted for comparing recovery outcomes, the time to first anal exhaust and return-to-work (RTW) time in vNOTEH versus laparoscopic hysterectomy (LH) groups. Linear regression analysis and cox proportional hazards regression were employed for analyzing the association between the recovery outcomes and surgical procedures.

RESULTS

Altogether 330 patients were enrolled, with 92 in vNOTEH group whereas 238 in LH group according to the surgical procedure. Among them, 22 patients undergoing vNOTEH and 76 patients receiving LH returned to work. The operation time, the first anal exhaust time, RTW time, postoperative hospitalization of vNOTEH group remarkably decreased relative to LH group (P<0.05). Linear regression analysis indicated that the vNOTES approach was related to the time to first anal exhaust. Besides, Kaplan-Meier curve demonstrated the shorter median time to first anal exhaust in vNOTEH group than that in LH group (48.0 h vs. 69.0 h, P < 0.001). For patients who returned to work, multivariate Cox logistic regression revealed that surgical approach and postoperative hospitalization were significantly related to the RTW time. Furthermore, Kaplan-Meier curve showed that the median RTW time significantly decreased in vNOTEH subgroup relative to that in LH subgroup (2.0 months vs.3.0 months, P = 0.011).

CONCLUSIONS AND RELEVANCE

vNOTES in women might be advantageous in the earlier recovery of intestinal function and the earlier return to work after hysterectomy compared with laparoscopy.

TRIAL REGISTRATION

This study has been registered at https://www.chictr.org.cn with registration NO. ChiCTR2200063125 on Sep 27, 2022. The minimal postoperative follow up period was 1 month.

Comparative outcomes of hysterectomy using single-port umbilical laparoscopy versus vaginal natural orifice transluminal endoscopic surgery

BACKGROUND

This study compared two minimally invasive hysterectomy techniques-single-port umbilical laparoscopy (SPLS) and vaginal natural orifice transluminal endoscopic surgery (vNOTES)-in terms of operating time, blood loss, postoperative pain, and hospitalization duration.

METHODS

We retrospectively analyzed patients who underwent hysterectomy via SPLS or vNOTES. Inclusion criteria were patients who had a hysterectomy with bilateral salpingectomy, with additional procedures such as salpingo-oophorectomy or sentinel lymph node dissection as indicated.

RESULTS

Among the 121 patients studied, 63 underwent SPLS and 58 underwent vNOTES. The mean operative time was 67.3 ± 15.9 min for vNOTES and 75.7 ± 12.1 min for SPLS. Six patients (9.5%) in the SPLS group and four (6.9%) in the vNOTES group underwent sentinel lymph node biopsies for endometrial cancer. Pain assessment at six, 12, and 24 h after surgery indicated lower visual analog scale (VAS) scores in the vNOTES group. Notably, patients in that group reported reduced shoulder and umbilical pain at 24 h postoperatively. Those patients also showed improved sexual function index scores and reduced dyspareunia, although the differences were not statistically significant.

CONCLUSIONS

The vNOTES approach to hysterectomy is a viable alternative, characterized by shorter operative times and decreased postoperative pain without increasing complication rates.

Comparison of robotic and conventional laparoendoscopic single-site hysterectomy for large uterus using da Vinci Xi system: A propensity score matching analysis

INTRODUCTION

The robotic surgical system equipped with enhanced visualization, flexible instruments, tremor filtration, and improved ergonomics can greatly address difficulties encountered in conventional laparoendoscopic single-site surgery. This study aimed to evaluate whether robotic laparoendoscopic single-site surgery performed by da Vinci Xi system was an optimal approach in performing benign hysterectomy for large uterus.

METHODS

This was a single-center retrospective cohort study. Between May 2021 and September 2023, patients who underwent transumbilical single-site hysterectomy with or without da Vinci Xi system indicated for uterine myoma or adenomyosis with uterine weight exceeding 280 g were enrolled. After conducting propensity score matching to balance the baseline characteristics, perioperative outcomes were compared between the two groups.

RESULTS

After 1:1 propensity score matching, 74 patients were included in each group. No patient required additional ports, conversion to laparotomy or multi-port laparoscopy. The robotic group showed significantly longer exhaust time (2.4 ± 0.7 vs 2.0 ± 0.7 days, p < 0.001) and lower postoperative complication rate (4.1 % vs 13.5 %, p = 0.042) compared to the conventional group. No significant differences were found in operative time (183.6 ± 53.6 vs 178.2 ± 55.4 min, p = 0.546), blood loss (100.0 vs 50.0 mL, p = 0.296) and intraoperative complication (1.4 % vs 0, p = 1.000) even though the robotic group had heavier uterine weights (412.5 vs 394.0 g) and a higher rate of severe adhesion (33.8 % vs 17.6 %).

CONCLUSION

Robotic and conventional laparoendoscopic single-site hysterectomy for large uterus were both feasible and safe with satisfying surgical outcomes. However, the laparoendoscopic single-site surgery was easier to be mastered and more likely to handle challenging conditions with assistance of da Vinci Xi system.

Success of outpatient hysterectomy: V-Notes versus Vaginal hysterectomy

STUDY OBJECTIVE

Vaginal hysterectomy (VH) is the approach of choice for benign uterine conditions and is suitable for outpatient care. Many studies suggest that the vaginal natural orifice transluminal endoscopic surgery (V-Notes) technique is reliable and safe for outpatient surgery, but the literature includes only pilot studies with small cohorts. The aim is to assess the V-Notes technique compared to VH in outpatient settings with a larger cohort.

METHOD

This is a retrospective cohort study including patients who underwent V-Notes or VH, scheduled as outpatient procedures, at Lille University Hospital between 2016 and 2022. Baseline characteristics and surgical outcomes were compared. The primary outcome was the success of outpatient surgery. Secondary outcomes were intraoperative and postoperative complication rates and factors limiting outpatient feasibility.

MEASUREMENTS AND MAIN RESULTS

373 patients were included, 204 underwent V-Notes and 169 VH. In the V-Notes group there were more nulliparous women (27.9% vs 14.8 %, p < 0.002), more larger uteri (>280 g) (30.8% vs 12.9 %, p < 0.001) and more salpingectomy performed (98% vs 79.9 %, p < 0.001), compared with the VH group. The outpatient success rate did not differ significantly between the two groups (83.3% vs 79.9 %, p = 0.39, adjusted p = 0.50), even after adjusting for nulliparity, salpingectomy, and uterine weight greater than 280 g (adjusted OR 1.24), with no differences in complications or factors limiting outpatient feasibility.

CONCLUSION

V-Notes hysterectomy is a safe outpatient procedure, showing no differences for outpatient care success compared to VH, even for patients with larger uteri or nulliparity, while allowing for more salpingectomies. Additionally, the V-Notes approach appears promising for hysterectomies in nulliparous women or those with large uteri.

Adoption of vaginally assisted natural orifice transluminal endoscopic surgery for hysterectomy: A single tertiary experience

BACKGROUND

Vaginal hysterectomy (VH) rate is declining despite being considered as the optimal minimally invasive option for hysterectomy with reduced operative time and length of stay compared with laparoscopic hysterectomy (LH). Vaginal assisted natural orifice transluminal endoscopic surgery hysterectomy (VANH) combines the advantages of both vaginal and endoscopic approach to surgery.

AIMS

To report feasibility and early experience of a single surgeon adopting VANH at a tertiary Australian hospital.

MATERIALS AND METHODS

Prospective review of the first 20 VANH cases with complete data set collected retrospectively including patient demographics, indication for surgery and perioperative outcomes.

RESULTS

The median age of the first 20 participants was 51.5 years (47-57 years of age) and the median body mass index was 33.5 kg/m2 (27.8-38.3 kg/m2). The predominant indication was complex hyperplasia with atypia (12/20, 60%). The median parity was two (1-3) where four patients were nulliparous. The median blood loss was 125 mL (100-200 mL) with an operative time of 149 min (138-198 min) and median weight of the specimen of 181.5 g (66.5-219 g). The mean length of stay was 1.4 days (1-2 days). Five cases had conversion to laparoscopy and the majority (80%) occurred within the first ten cases.

CONCLUSIONS

VANH is feasible but there is a learning curve to achieve competence in this technique, which requires adequate training in the early stages of adoption with careful case selection. Until further robust data is available to determine the clinical benefit and safety profile of VANH, patients should be carefully counselled and the decision on mode of hysterectomy be individualised.

Vaginal natural orifice transvaginal endoscopic surgery (vNOTES) for benign ovarian cysts is safe and feasible in same-day discharge: a retrospective cohort study

BACKGROUND

Advances in minimally invasive surgery and the development of Enhanced Recovery After Surgery (ERAS) have favored the spread of day-surgery programs. Even though Vaginal natural orifice transvaginal endoscopic surgery (vNOTES) is accepted as an innovative treatment for benign ovarian cysts that is rapidly gaining recognition worldwide, the safety and feasibility of same-day surgery (SDS) have yet to be established.

OBJECTIVE

This study aimed to evaluate the safety and feasibility of day surgery compared to inpatient surgery of patients undergoing vNOTES for benign ovarian cysts by determining perioperative outcomes.

MATERIALS AND METHODS

The study consisted of 213 patients who underwent vNOTES for ovarian cystectomy at a single institution from January 2020 to November 2022. Based on the hospital stay, patients were classified into the same-day surgery group (SDSG) and the inpatient surgery group (ISG); after data processing and screening considering the balance of the two groups, SDSG has 83 samples(n = 83), and ISG has 113 samples(n = 113). The patient's demographic characteristics and follow-up data were collected during the perioperative period by doctors and nurses for medical tracking and analysis purposes and 1-month postoperatively by doctors in charge of their operation. Independent sample t-tests were performed to verify if there was any major difference between these two groups for continuous data like age, BMI, and cyst diameter, and Pearson's chi-squared tests were used to test whether there was a major difference between these two groups for categorical data like cyst count, abdominal surgery history and whether their cyst is bilateral ovarian cysts or not. The association between exhaust time and postoperative characteristics and the association between levels of pain and postoperative characteristics were further analyzed to unveil the confounding factors contributing to the same-day discharge method's quick recovery nature.

RESULTS

Upon performing propensity score matching, 196 patients were finally enrolled in this study for the matched comparison, including 83(42.3%) patients in the SDSG and 113(57.7%) patients in the ISG. There was no statistical difference between the two groups in terms of duration of operation (85.0 ± 41.5 min vs. 80.5 ± 33.5 min), estimated blood loss (27.7 ± 28.0 ml vs. 36.3 ± 33.2 ml), preoperative hemoglobin levels (128.8 ± 13.2 g/L vs. 128.6 ± 14.0 g/L), postoperative hemoglobin difference at 24 h (16.5 ± 15.4 g/L vs. 19.3 ± 9.1 g/L), pelvic adhesions (42 (50.6%) vs. 47 (41.6%)), and postoperative complications (7(8.4%) vs. 4(3.5%)). The SDSG group showed less time of feeding/off-bed/exhaust/urination after surgery, shorter hospitalization duration, a lower postoperative 6-hour pain score, and a lower incidence of analgesic drug use. Multiple linear regression analysis showed that advancing the time of postoperative off-bed activity and feeding reduced the postoperative exhaust time by 0.34 (95% CI: 0.185-0.496, 0.34 h, p < 0.001) and 0.299(95% CI: 0.158-0.443, 0.229 h, p = 0.036) hours. In addition, Ordinal logistic regression revealed a correlation between pain scores and bilaterality of cyst, increasing about 25.98 times the risk of pain levels when ovarian cysts are bilateral (OR: 26.98, 95% CI: 1.071-679.859, P = 0.045).

CONCLUSION

In this pilot study, same-day discharge after vaginal natural orifice transvaginal endoscopic ovarian cystectomy is safe and feasible. The vNOTES for ovarian cystectomy combined with the same-day discharge shorten the exhaust time and duration of hospitalization, reduce postoperative pain, and lower the use incidence of analgesic drugs.

Vaginal assisted NOTES hysterectomy in The Netherlands; A prospective cohort study

Objectives

Vaginal assisted Natural Orifice Transluminal Endoscopic Surgery (NOTES) combines the benefits of vaginal and endoscopic surgery. This study presents the results of the first vaginal assisted NOTES hysterectomies (VANH) in The Netherlands.

Study design

A prospective cohort study was performed in two non-academic teaching hospitals in The Netherlands. Data was collected from patients who underwent a VANH for benign indications between August 2019 and April 2023. Baseline characteristics and data of intra- and postoperative surgical outcomes were recorded and analysed. The VANHs were performed by four experienced vaginal and endoscopic gynaecological surgeons.

Results

A total of 200 patients underwent a VANH. Indications were dysfunctional menstrual bleeding (61 %; n = 122), abnormal cervical cytology (15.5 %; n = 31), abdominal pain (11.5 %; n = 23), post ablation/sterilization pain syndrome (3.5 %; n = 7), uterine fibroids (5.0 %; n = 10), atypical endometrial hyperplasia (2.5 %; n = 5) and Lynch or BRCA gene mutation carriers (1.0 %, n = 2). The mean surgical time was 61.4 min ( ± 22.8 min) with a mean blood loss of 88 mL ( ± 89 mL) and a mean uterine weight of 150 g ( ± 112 g). In 2.0 % (n = 4) of the cases a conversion was necessary. Same day discharge (SDD) was feasible in 80.2 % (n = 105) of the patients planned in day-care. In 2.0 % (n = 4) an intra-operative complication and in 9.0 % (n = 18) a post-operative complication occurred.

Conclusion

This study shows vNOTES to be a safe and feasible surgical technique and can be safely implemented with appropriate patient selection and skilled surgeons. It highlights the importance of surgeon awareness of the challenges inherent in the initial stages of the implementation of a new surgical technique when performing their first vNOTES procedures. Additional randomized clinical trials are needed to show superiority of vNOTES compared to traditional surgery.

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.

Total vNOTES hysterectomy versus conventional total laparoscopic hysterectomy in virgin transgender men

BACKGROUND AND AIM

Comparison of the applicability, safety, and surgical outcomes of total vaginal NOTES hysterectomy (TVNH) using natural orifice transluminal endoscopic surgery, which is considered a natural orifice surgery for hysterectomy with bilateral salpingo-oophorectomy (HBSO) in virgin transgender men, with conventional total laparoscopic hysterectomy (TLH).

MATERIAL AND METHODS

A retrospective cohort study was conducted between 2019 and 2021. The results of transgender male individuals who underwent HBSO operations using TVNH (n = 21) were compared with those who underwent operations using TLH (n = 62).

RESULTS

TVNH was performed in 21 individuals, while TLH was performed in 62 individuals. Patients in the TVNH approach group had a longer operation duration than those in the TLH group (p = .001). Patients in the TVNH group experienced less pain at two hours (5 ± 1.56), six hours (4 ± 1.57), 12 h (2 ± 0.91), and 24 h (1 ± 0.62) postoperatively (p = .001). The postoperative hospitalization duration was shorter in the TVNH group (1.6 ± 1.01) than in the TLH group (2.9 ± 0.5) (p = .001).

CONCLUSIONS

For the HBSO operation of female-to-male transgender individuals, TVNH, which is completely endoscopically performed, can be preferred and safely conducted as an alternative surgical method to conventional laparoscopy.

Comparison of hysterectomy cases performed by transvaginal natural orifice transluminal endoscopic surgery: A paired sample cross-sectional study

This study aimed to investigate the feasibility, indications, and benefits of transvaginal natural orifice transluminal endoscopic surgery (v-NOTES) hysterectomy for nonmalignant gynecological diseases. The clinical data, including the baseline information and surgical conditions of 81 patients who underwent v-NOTES hysterectomy for nonmalignant gynecological diseases in a tertiary university hospital from October 2018 to August 2022, were retrospectively analyzed and compared with the total laparoscopic hysterectomy group (200 cases) and the transumbilical laparoendoscopic Single Site Surgery group (150 cases). In comparison with the other 2 groups, the highest proportion of patients in the v-NOTES group had cervical intraepithelial neoplasia. Accordingly, mean preoperative uterine volume measured by sonography was significantly smaller in the v-notes group. In the v-NOTES group, the mean number of vaginal deliveries and age were significantly higher, while the mean number of previous abdominal surgeries was lower compared to the other 2 groups. The V-NOTES group had a shorter operation time, shorter postoperative urinary catheter insertion time, earlier intestinal recovery days, shorter hospital stay, and lower visual analogue scale scores after surgery, and the differences were statistically significant. When indicated appropriately, v-NOTES hysterectomy can be a feasible and advantageous surgical modality. In particular, in comparison to the laparoendoscopic Single Site Surgery and total laparoscopic hysterectomy groups, the v-NOTES group had advantages in postoperative recovery and had more aesthetic surgical results.

Impact of Uterine Weight and Shape on vNOTES Hysterectomy: Analysis of 238 Consecutive Cases

STUDY OBJECTIVE

To compare the perioperative outcomes of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) hysterectomies for different uterine weights and shapes.

DESIGN

Observational study.

SETTING

Swiss teaching hospital.

PATIENTS

Women who underwent vNOTES hysterectomy for benign conditions between May 2020 and July 2023 (N = 238). Patients were divided into 4 subgroups depending on uterus weight and shape. Uteri weighting <280 g were classified as type 0. Uteri weighting ≥280 g were categorized as type 1 (no vascular pedicle displacement), type 2 (cranial displacement of adnexal vascular pedicles), and type 3 (displacement of uterine arteries).

INTERVENTIONS

All women underwent vNOTES hysterectomies. We compared perioperative outcomes for the 4 subgroups.

MEASUREMENT AND MAIN RESULTS

We classified 168 patients (70.6%) as uterus type 0, 33 patients (13.9%) as type 1, 24 patients (10.1%) as type 2, and 13 patients (5.4%) as type 3. Mean uterine weight was 135.8 ± 59.5 g in type 0, 398.0 ± 167.3 g in type 1, 603.5 ± 217.9 g in type 2, and 661.7 ± 281.6 g in type 3. Operative time in type 0 (65.1 ± 30.9 minutes) and type 1 (65.1 ± 24.0 minutes) was shorter than in type 2 (102.3 ± 60.0 minutes) and type 3 (115.2 ± 40.3 minutes). Blood losses were more significant in type 2 (158.5 ± 212.0 mL) and type 3 (158.5 ± 110.7 mL) than in type 0 (85.6 ± 113.5 mL). No difference in the rate of total complications among groups was observed (8.3%, 3.0%, 12.5%, and 15.4% in types 0, 1, 2, and 3, respectively).

CONCLUSION

The displacement of the vascular pedicles seems associated with longer operative time and more blood loss and could represent a marker for technical difficulty in vNOTES hysterectomy. However, it does not influence the perioperative complication rate.