The revival of vaginal surgery in the era of endoscopy: V-NOTES initial experience with a series of 32 patients

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.

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.

Comparison of laparoscopy and vNOTES in early-stage endometrial cancer

AIM

To compare the demographic, clinical, surgical, histopathological, and oncological outcomes of vNOTES and conventional laparoscopy (CL)for early-stage endometrial cancer.

METHODS

A retrospective study was carried out in the Gynecologic Clinic of a tertiary hospital from January 2019 to November 2020. Patient demographic characteristics, surgical outcomes, histopathological characteristics, visual analog scale (VAS) pain scores at postoperative 6th, 12th, and 24th, intra- and postoperative complications, and follow-up results were noted.

RESULTS

A total of 45 patients enrolled, of which 16 underwent CL and 29 were vNOTES. The operative time and decrease in hemoglobin levels were similar for both groups (p = 0.202, p = 0.699). Postoperative hospital stay did not differ between the vNOTES group and the CL group (p = 0.549). VAS pain scores at postoperative 6th, 12th, and 24th h were significantly lower in vNOTES group than in the CL group (p < 0.001). The requirement for additional opioid/narcotic analgesic was lower in the vNOTES group than in the CL group (p = 0.037).

CONCLUSION

vNOTES may be a safe and feasible option in early-stage endometrial cancer, having less postoperative pain and less requirement of opioid/narcotic analgesic compared with laparoscopy.

Defining a Uterine Extraction Score based on a Volume/Access Ratio in Total Hysterectomy: a retrospective cohort study

Background

Regardless of the technique used, extraction of the uterus is a crucial step in hysterectomy. There is currently no scoring system to predict its feasibility.

Objectives

Our main objective was to determine a predictive score of uterine extraction feasibility to optimise surgical planning of total hysterectomy. As secondary objectives, we examined the correlation between uterine volume predicted by preoperative ultrasound and the final weight of the surgical specimen and analysed the impact of the uterine extraction modality on operative and hospitalisation times.

Materials and Methods

We defined a Uterine Extraction Score (UES) based on the ratio between uterine sizes and vaginal access. This score was retrospectively applied to a cohort of 178 patients who were hysterectomised for benign conditions between January 2019 and December 2022.

Main outcome measures

The UES allows identification of three groups of decreasing feasibility of vaginal extraction, symbolised by traffic light colours: green - vaginal extraction without morcellation, orange -vaginal extraction with morcellation, red - abdominal morcellation by mini-laparotomy or primary laparotomy.

Results

The results show that the UES--predicted, and the observed routes of extraction concord in 92% of cases. There is a strong correlation between estimated volume and final uterine weight. Uterine morcellation lengthens the operative time and the hospital stay.

Conclusions

The UES seems to be a reliable tool to predict the route of uterine extraction in total hysterectomy.

What is new?

The development of a new scoring system empowers surgeons with decisive information to enhance perioperative outcomes.

Systematic review and meta-analysis of vaginal natural orifice transluminal endoscopic surgery vs laparoscopic hysterectomy

OBJECTIVE

Because vaginal natural orifice transluminal endoscopic surgery and laparoscopic hysterectomy techniques both aim to decrease tissue injury and postoperative morbidity and mortality and to improve a patient's quality of life, we sought to evaluate the safety and effectiveness of a hysterectomy by vaginal natural orifice transluminal endoscopic surgery and compared that with conventional laparoscopic hysterectomy among women with benign gynecologic diseases.

DATA SOURCES

We used Scopus, Medline, ClinicalTrials.Gov, PubMed, and the Cochrane Library and searched from database inception to September 1, 2023.

STUDY ELIGIBILITY CRITERIA

We included all eligible articles that compared vaginal natural orifice transluminal endoscopic surgery hysterectomy with any conventional laparoscopic hysterectomy technique without robotic assistance for women with benign gynecologic pathology and that included at least 1 of our main outcomes. These outcomes included estimated blood loss (in mL), operation time (in minutes), length of hospital stay (in days), decrease in hemoglobin level (g/dL), visual analog scale pain score on postoperative day 1, opioid analgesic dose required, rate of conversion to another surgical technique, intraoperative complications, postoperative complications, and requirements for blood transfusion. We included randomized controlled trials and observational studies. Ultimately, 14 studies met our criteria.

METHODS

The study quality of the randomized controlled trials was assessed using the Cochrane assessment tool, and the quality of the observational studies was assessed using the ROBINS-I tool. We analyzed data using RevMan 5.4.1. Continuous outcomes were analyzed using the mean difference and 95% confidence intervals under the inverse variance analysis method. Dichotomous outcomes were analyzed using OpenMeta[Analyst] and odds ratios and 95% confidence intervals were reported.

RESULTS

The operative time and length of hospitalization were shorter in the vaginal natural orifice transluminal endoscopic surgery cohort. We also found lower visual analog scale pain scores, fewer postoperative complications, and fewer blood transfusions in the vaginal natural orifice transluminal endoscopic surgery group. We found no difference in the estimated blood loss, decrease in hemoglobin levels, analgesic usage, conversion rates, or intraoperative complications.

CONCLUSION

When evaluating the latest data, it seems that vaginal natural orifice transluminal endoscopic surgery techniques may have some advantages over conventional laparoscopic hysterectomy techniques.