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Baekelandt J, De Mulder PA, Le Roy I, Mathieu C, Laenen A, Enzlin P, Morlion B, Weyers S, Mol B, Bosteels J. Adnexectomy by vaginal Natural Orifice Transluminal Endoscopic Surgery versus laparoscopy: results of a first randomised controlled trial (NOTABLE trial). BJOG 2021; 128:1782-1791. [PMID: 34246198 DOI: 10.1111/1471-0528.16838] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2021] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To compare adnexectomy by vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) versus laparoscopy. DESIGN Parallel group, 1:1 single-centre single-blinded randomised trial, designed as non-inferiority study with a margin of 15%. SETTING Belgian teaching hospital. POPULATION Non-pregnant non-virgin women with an intact uterus and without obliteration of the pouch of Douglas scheduled to undergo removal of an adnexal mass assessed to be benign on ultrasound by IOTA criteria. METHODS Randomisation to laparoscopy (control group) or vNOTES (experimental group). Stratification according to adnexal size. Blinding of participants and outcome assessors by sham incisions. MAIN OUTCOME MEASURES The primary outcome measure was adnexectomy by the allocated technique. Secondary outcomes included duration of surgery, pain scores and analgesics used, quality of life and adverse events. RESULTS We randomly assigned 67 participants (34 to the vNOTES group and 33 to the laparoscopy group). The primary end point was always reached in both groups: there were no conversions. We performed a sensitivity analysis for the primary outcome, assuming one conversion in the vNOTES group and no conversions in the laparoscopy group: the one-sided 95% upper limit for the differences in proportions of conversion was estimated as 13%, which is below the predefined non-inferiority margin of 15%. The secondary outcomes demonstrated a shorter duration of surgery, lower pain scores, lower total dose of analgesics and a trend for more adverse events in the vNOTES group. CONCLUSIONS vNOTES is non-inferior to laparoscopy for a successful adnexectomy without conversion. vNOTES allowed shorter operating times and less postoperative pain but there was a trend for more adverse events.
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Affiliation(s)
- J Baekelandt
- Department of Gynaecology, Imelda Hospital, Bonheiden, Belgium.,Department of Development and Regeneration, Faculty of Medicine, Group Biomedical Sciences, KU Leuven-University of Leuven, Leuven, Belgium
| | - P A De Mulder
- Department of Anaesthesiology, Imelda Hospital, Bonheiden, Belgium
| | - I Le Roy
- Department of Anaesthesiology, Imelda Hospital, Bonheiden, Belgium
| | - C Mathieu
- Department of Clinical and Experimental Medicine, Clinical and Experimental Endocrinology, KU Leuven-University of Leuven, Leuven, Belgium
| | - A Laenen
- Leuven Biostatistics and Statistical Bioinformatics Centre (L-BioStat), KU Leuven-University of Leuven, Leuven, Belgium
| | - P Enzlin
- Department of Neurosciences, Interfaculty Institute for Family and Sexuality Studies, KU Leuven-University of Leuven, Leuven, Belgium
| | - B Morlion
- Department of Cardiovascular Sciences, Section Anaesthesiology & Algology, KU Leuven-University of Leuven, Leuven, Belgium
| | - S Weyers
- Universitaire Vrouwenkliniek, University Hospital Gent, Gent, Belgium
| | - Bwj Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Vic., Australia.,Aberdeen Centre for Women's Health Research, School of Medicine Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Jja Bosteels
- Department of Gynaecology, Imelda Hospital, Bonheiden, Belgium.,Department of Development and Regeneration, Faculty of Medicine, Group Biomedical Sciences, KU Leuven-University of Leuven, Leuven, Belgium.,Universitaire Vrouwenkliniek, University Hospital Gent, Gent, Belgium.,The Centre for Evidence-based Medicine, Cochrane Belgium, Academic Centre for General Practice, CEBAM, KU Leuven-University of Leuven, Leuven, Belgium
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Baekelandt JF, De Mulder PA, Le Roy I, Mathieu C, Laenen A, Enzlin P, Weyers S, Mol BWJ, Bosteels JJA. Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) adnexectomy for benign pathology compared with laparoscopic excision (NOTABLE): a protocol for a randomised controlled trial. BMJ Open 2018; 8:e018059. [PMID: 29326183 PMCID: PMC5780723 DOI: 10.1136/bmjopen-2017-018059] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Natural orifice transluminal endoscopic surgery (NOTES) uses natural orifices to access the cavities of the human body to perform surgical interventions. NOTES limits the magnitude of surgical trauma and potentially reduces postoperative pain. Our group published a protocol on a randomised study comparing transvaginal NOTES (vNOTES) versus laparoscopy for hysterectomy (HALON). We simultaneously designed a similar randomised controlled trial (RCT) comparing vNOTES with laparoscopy for adnexectomy. To the best of our knowledge, this is the first RCT comparing vNOTES with laparoscopy for adnexal surgery. METHODS AND ANALYSIS The methodology of the Notes Adnexectomy for Benign Indication versus Laparoscopic Excision (NOTABLE) study is similar to that of the HALON trial. Women aged 18-70 years with an indication for benign adnexal surgery will be eligible. We will use stratification according to adnexal size. Entrants will be randomised to the laparoscopic treatment (control) or vNOTES (intervention). Participants will be evaluated on days 0-7 and at 3 and 6 months. The primary outcome will be the proportion of women successfully treated by removing an adnexa by the allocated technique without conversion. We will collect the following data (secondary outcomes): proportion of women hospitalised on the day of surgery, postoperative pain scores measured two times per day from day 1 to 7, total dosage of pain killers used from day 1 to 7, hospital readmission during the first 6 weeks, dyspareunia and sexual well-being at baseline, 3 and 6 months using a validated questionnaire (Short Sexual Functioning Scale), health-related quality of life at baseline, 3 and 6 months after surgery using a validated questionnaire (EQ-5D-3L), duration of surgical intervention, infection or other surgical complications and direct costs up to 6 weeks following surgery. For the primary outcome measure, a one-sided 95% CI of the difference in the proportions of women with a successful removal of the uterus by the randomised technique will be estimated. Non-inferiority will be concluded when 15% lies above the upper limit of this 95% CI. ETHICS AND DISSEMINATION The study was approved on 1 December 2015 by the EthicsCommitteeof the Imelda Hospital (registration no: 689), Bonheiden, Belgium. We aim to present the final results of the NOTABLE trial in peer-reviewed journals and at scientific meetings within 4 years after the start of the recruitment. TRIAL REGISTRATION NUMBER NCT02630329.
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Affiliation(s)
| | | | - Ilse Le Roy
- Department of Anaesthesiology, Imelda Hospital, Bonheiden, Belgium
| | - Chantal Mathieu
- Department of Clinical and Experimental Medicine, KU Leuven-University of Leuven, Leuven, Belgium
- Division of Clinical and Experimental Endocrinology, Department of Chronic Diseases, Metabolism and Ageing, KU Leuven-University of Leuven, Leuven, Belgium
| | - Annouschka Laenen
- Leuven Biostatistics and Statistical Bioinformatics Centre (L-BioStat), KU Leuven-University of Leuven, Leuven, Belgium
| | - Paul Enzlin
- Department of Neurosciences, Interfaculty Institute for Family and Sexuality Studies, KU Leuven-University of Leuven, Leuven, Belgium
| | - Steven Weyers
- Universitaire Vrouwenkliniek, Ghent University Hospital, Ghent, Belgium
| | - Ben W J Mol
- The Robinson Institute, The University of Adelaide, Adelaide, South Australia, Australia
- School of Paediatrics & Reproductive Health, The University of Adelaide, Adelaide, South Australia, Australia
| | - Jan J A Bosteels
- Department of Gynaecology, Imelda Hospital, Bonheiden, Belgium
- Academic Centre for General Practice, KU Leuven-University of Leuven, Leuven, Belgium
- Universitaire Vrouwenkliniek, Ghent University Hospital, Ghent, Belgium
- CEBAM, The Centre for Evidence-based Medicine, Cochrane Belgium, KU Leuven-University of Leuven, Leuven, Belgium
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Wang CJ, Wu PY, Kuo HH, Yu HT, Huang CY, Tseng HT. Natural orifice transluminal endoscopic surgery-assisted versus laparoscopic ovarian cystectomy (NAOC vs. LOC): a case-matched study. Surg Endosc 2016; 30:1227-34. [PMID: 26139483 DOI: 10.1007/s00464-015-4315-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 06/05/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Natural orifice transluminal endoscopic surgery (NOTES) has shown its prospection as a minimally invasive endoscopic surgery. This study aimed to examine the safety and efficacy of combined NOTES and vaginal approach, natural orifice transluminal endoscopic surgery-assisted ovarian cystectomy (NAOC), in the conservative management of benign ovarian tumors. METHODS Records were reviewed for the 34 consecutive NAOC procedures between May 2011 and March 2014. Age, body mass index, parity, size of the mass, and bilaterality of the mass were used to select comparable patient who had undergone laparoscopic ovarian cystectomy (LOC). RESULTS A total of 277 patients were recruited in this study (243 LOCs and 34 NAOCs, respectively). There was no incidence of switching to abdominal laparotomy. Length of operation and length of postoperative stay were significantly greater in the LOC group than in the NAOC group, but total hospital charges were similar in both groups. There was no difference in febrile morbidity between the two groups but more estimated blood loss (EBL) in NAOC group, although EBL was <50 mL in the two groups. Linear correlations of mass size with operating time and EBL existed in LOC group, but not in NAOC group. CONCLUSION NAOC can be safely performed for benign and large ovarian tumors. Besides, NAOC offers a superior operative efficiency compared with LOC.
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Tolcher MC, Kalogera E, Hopkins MR, Weaver AL, Bingener J, Dowdy SC. Safety of culdotomy as a surgical approach: implications for natural orifice transluminal endoscopic surgery. JSLS 2013; 16:413-20. [PMID: 23318067 PMCID: PMC3535790 DOI: 10.4293/108680812x13462882735854] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To evaluate the efficacy and safety of culdotomy as a surgical approach to access the peritoneal cavity and discuss its implications for natural orifice transluminal endoscopic surgery (NOTES). METHODS A retrospective chart review of women undergoing culdotomy for tubal sterilization (N 219) between January 1995 and December 2005 was performed. The Accordion Grading System was used for the severity of complications. RESULTS No intraoperative complications were noted. Postoperative complications occurred in 7 patients (3.2%): 6 infections (grade 2) and 1 case of hemorrhage (grade 3). Conversion to laparoscopy was necessary in 10 patients (2.2%) due to anatomical constraints or pelvic adhesions; however, culdotomy with entry into the abdominal cavity was nevertheless successful in all 10 cases. The difference in the proportion with a history of pelvic surgery between the conversion and nonconversion groups was not statistically significant (P = .068). Patients with BMI ≥30 had a higher conversion rate compared to patients with BMI <30 (11.4% versus 1.5%, P = .011). Tubal sterilization via culdotomy was successfully performed in all 11 women with no prior vaginal deliveries. CONCLUSION Culdotomy appears to be a safe surgical approach to access the peritoneal cavity and is associated with a low complication rate. These data support the feasibility and safety of utilizing the cul-de-sac as an access portal for natural orifice transluminal endoscopic surgery.
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