Transvaginal natural orifice transluminal endoscopic surgery for ectopic pregnancy

Vaginal natural orifice transluminal endoscopic surgery (vNOTES): a new chapter in vaginal surgical innovation

Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) is a novel minimal invasive technique which employs the vaginal orifice for surgical access, after which endoscopic instruments are introduced, thus obviating the need for any external skin incisions. This approach has gained traction as it is associated with reduced morbidity, improved cosmesis, lower pain scores and decreased length of hospital stay, with no increase in adverse events, when compared with conventional laparoscopic surgery. Initially limited to hysterectomy and adnexectomy, its role has now expanded to include indications such as urogynaecology, oncology and fertility. Clinicians wishing to implement vNOTES need to undergo appropriate training and appreciate judicious governance. Further randomised controlled trials will allow us to better understand if this newer technique will offer well-evidenced preferable outcomes and become the preferred surgical approach.

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).

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.

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.

A Case Control Study of vNOTES Versus Conventional Laparoscopic Salpingectomy for Ectopic Pregnancy

STUDY OBJECTIVE

While the laparoscopic approach is the surgical treatment of choice for ectopic pregnancy, vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) is emerging as an alternative route with its good optical visibility and avoidance of abdominal incisions. The authors compare demographics and outcome data of vNOTES vs conventional laparoscopic (CL) salpingectomy for the surgical management of ectopic pregnancy.

DESIGN

Case-control study.

SETTING

A London University hospital.

PATIENTS

Women with ectopic pregnancy unsuitable for medical management who underwent surgical management.

INTERVENTION

Twenty-five cases of vNOTES vs 25 CL salpingectomy.

MEASUREMENTS AND MAIN RESULTS

The mean patient age (29.7 ± 53 vs 31.4 ± 6.7 days), parity (1.2 ± 1.1 vs 1.6 ± 2.1), body mass index (26.7 ± 5.3 vs 27.2 ± 5.4 kg/m3), gestation age (8.44 ± 2.1 vs 7.3 ± 1.7 weeks) and β human chorionic gonadotrophin (βhCG) levels (3725.4 ± 3674.8 vs 4376.5 ± 6493.4 IU/liter) were comparable (p >.05, t test) between patients having vNOTES vs CL salpingectomy. While estimated blood loss was similar (218.2 ± 491.7 vs 173.5 ± 138.7 mL) (p >.001), vNOTES patients had a statistically shorter duration of surgery (35.8 ± 14.4 vs 75.8 ± 19.7 mins) (p <.001, t test) and length of stay (median: 11.5 vs 19.7 hours) (U = 72, p <.05, Mann-Whitney U test). Less patients in the vNOTES group required postoperative opioids (9% vs 25%), and the median visual analog score (/10) for pain at 24 hours was significantly lower (2.0 vs 4.0) (U = 75, p <.05, Mann-Whitney U test). Patients from the vNOTES group were able to return to normal daily activity 11.3 days quicker (5.8 ± 4.3 vs 17.1 ± 8.2 days) (p <.05, t test). vNOTES cases cost approximately USD150 more due to the price of the commercial kits but this is offset by reduced intraoperative time, length of stay and need for postprocedure analgesia.

CONCLUSION

Patients undergoing vNOTES have shorter intraoperative times and length of stays, less postoperative pain, and more rapid recovery, which help mitigate higher costs incurred by commercial kits. While the vNOTES approach for ectopic pregnancy appears safe and efficacious, more robust data from larger randomized studies are needed.

Feasibility and safety of transvaginal natural orifice transluminal endoscopic surgery (V-NOTES) panhysterectomy: a polycentric retrospective study

OBJECTIVES

To investigate the feasibility and safety of Transvaginal Natural Orifice Transluminal Endoscopic Surgery (V-NOTES) panhysterectomy.

METHODS

A retrospective analysis was conducted on the data of 75 patients who underwent panhysterectomy for hysteromyoma in the Department of Obstetrics and Gynecology of Tongxiang Maternal and Child Health Hospital; Department of Gynecology, The Affiliated Changzhou Second People's Hospital of Nanjing Medical University and Department of Gynecology, The First Affiliated Hospital of USTC from June 2019 to June 2020. According to the operation mode, the patients were divided into two groups: the traditional multi-port laparoscopic surgery (MPLS) group (n = 45) and the Transvaginal Natural Orifice Transluminal Endoscopic Surgery (V-NOTES) group (n = 30). The operation duration, intraoperative blood loss, postoperative exsufflation time, postoperative activity time, hospital stay, treatment cost, 6 h activities of daily living (ADL) score after the operation, cosmetic score, visual analog score, and complications were observed in the two groups.

RESULTS

Perioperative period related indicators: Compared with the MPLS group, the total treatment cost and cosmetic score of the V-NOTES group were significantly better than those of the MPLS group, but the operation duration was longer, and the HB decreased more significantly (P < 0.05). However, there was no significant difference in intraoperative blood loss, postoperative exsufflation time, postoperative activity time, 6 h ADL score after the operation, and hospital stay between the two groups (P > 0.05). Postoperative pain: The VAS score 1 h, 6 h, 12 h, and 24 h after the operation was lower in the V-NOTES group than in the MPLS group (P < 0.05). Postoperative complications: The complication rate of the V-NOTES group was significantly lower than that of the MPLS group (P < 0.05).

CONCLUSIONS

In treating panhysterectomy patients, both V-NOTES and MPLS can achieve satisfactory efficacy and prognosis, and both have advantages and disadvantages. Specifically, the V-NOTES surgery has significant advantages such as a lower treatment cost, lower incidence of postoperative complications, less pain, and more beautiful wounds.

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.

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.

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.

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.

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.

Study on the Efficacy of "Information Platform + Self-Care Model" on the Health Status of Discharged Patients Following Vaginal Natural Orifice Transluminal Endoscopic Surgery

Objective

To discuss the impact of the "information platform + self-care model" on the health status of discharged patients following vaginal natural orifice transluminal endoscopic surgery (vNOTES).

Methods

Patients underwent vNOTES at a tertiary specialized women's and children's hospital in Chengdu. They were randomly assigned to one of two groups-the intervention group (29 patients) and the control group (29 patients). The control group received standard education after discharge, while the intervention group received guidance based on an "information platform + self-care model" on discharge; a questionnaire survey was conducted for both groups one month after discharge.

Results

The quality of life score in the intervention group was higher than that in the control group, and the difference was statistically significant (P < 0.05); the scores of the intervention group on dimensions such as vitality, general health perceptions, physical role functioning, social role functioning, emotional role functioning, and mental health, except for physical functioning (Z = 0.034, P = 0.973) and bodily pain (Z = 1.470, P = 0.141), were higher than those in the control group one month after discharge, and the difference was statistically significant (P < 0.05). There was no patient (0) in the intervention group who had an unscheduled visit/admission, and there was 1 patient (3.6%) in the control group who had unscheduled visit/admission; there were no statistical differences between the two groups in the number of patients who had an unscheduled visit/admission 1 month after discharge (P = 0.491).

Conclusion

The application of the "information platform + self-care model" can, to a certain extent, improve the health status of patients following vNOTES after discharge, and it can also reduce unscheduled visits/admissions, but more research with a larger sample size is required.

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

PURPOSE

The use of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) as the first choice of surgical route for patients scheduled to undergo conventional laparoscopy is still being debated. We aimed to evaluate and compare the outcomes of the "vNOTES first" strategy in benign gynecological cases.

METHODS

All benign gynecological surgeries were initiated using vNOTES during the study period, regardless of the difficulty. Surgical outcomes, short-term patient satisfaction and sexual pain were compared between hysterectomies, adnexal and diagnostic procedures. Visual Analog Score (VAS), Patients Global Impressions of Improvements scale (PGI-I) and Female Sexual Function Index (FSFI) were used to assess the postoperative pain, satisfaction and sexual pain, respectively.

RESULTS

A total of 105 vNOTES procedures were performed during the study period: 63 (60.58%) adnexal procedures, 36 (34.62%) hysterectomies, 5 (4.81%) diagnostic procedures and one (0.96%) myomectomy. The median 24th hour VAS scores for adnexal, hysterectomy, and diagnostic procedures were 1.29 ± 1.41, 2.06 ± 2.08, and 2.6 ± 2.41, respectively. The satisfaction rate was 96.19% at the 1st postoperative week and 97.14% at the first month. There was either no change or a slight improvement in the patients' total score on the FSFI/pain domain before and after surgery. There were two conversions (1.9%) from vNOTES to laparoscopy and laparotomy, and two (5.56%) bladder injuries in hysterectomy cases.

CONCLUSION

Implementing the vNOTES technique as an initial approach for all benign gynecological surgeries seems feasible, safe and satisfactory, even in those with a non-prolapsed or enlarged uterus and those that have previously undergone abdominal surgery. The pain scores were found to be low and patients stated a high satisfaction with no or better change in their sexual life.