Sentinel Lymph Node Mapping by Retroperitoneal vNOTES for Uterus-Confined Malignancies: A Standardized 10-Step Approach.

(1) Background: Sentinel lymph node (SLN) mapping represents an accurate and feasible technique for the surgical staging of endometrial and cervical cancer. This is commonly performed by conventional laparoscopy or robotic-assisted laparoscopy, but in recent years, a new retroperitoneal transvaginal natural orifice transluminal endoscopic surgery (vNOTES) approach has been described and developed by Jan Baekelandt. This technique provides easy visualization of lymphatic afferent vessels and pelvic lymph nodes, early SLN assessment, and a coherent mapping methodology following the lymphatic flow from caudal to cranial. However, only a few publications have reported it. Following the IDEAL (Idea Development Exploration Assessment Long-term follow-up) framework, research concerning this technique is in Stage 2a, with only small case series as evidence of its feasibility. Its standardized description appears necessary to provide the surgical homogeneity required to move further. (2) Methods: Description of a standardized approach for retroperitoneal pelvic SLN mapping by vNOTES. (3) Results: We describe a 10-step approach to successfully perform retroperitoneal vNOTES SLN mapping, including pre-, intra-, and postoperative management. (4) Conclusions: This IDEAL Stage 2a study could help other surgeons approach this new technique, and it proposes a common methodology necessary for evolving through future IDEAL Stage 2b (multi-center studies) and Stage 3 (randomized controlled trials) studies.

Surgical outcomes of transvaginal natural orifice transluminal endoscopy in treating ovarian cysts and risk factors for surgical conversions.

Objective: This study aimed to assess the surgical outcomes and identify the conversion risk factors of Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) in treating ovarian cyst. Methods: This was a retrospective study of 505 patients who underwent vNO TES for treating ovarian cyst from March 2019 to February 2022 wherein the patients were classified into "converted" or "nonconverted" groups. T-tests, χ2 tests, and logistic regression were used for statistical analyses. Results: There were 16 (3.17 %) surgical conversions and 12 (2.38 %) other surgical complications in our study cohort. Teratomas accounted for 56.8 % of complications in nonconverted cases and 18.8 % in converted cases. Adenocystomas were found in 12.3 % of nonconverted cases and 18.8 % of converted cases. Other types included paraovarian cysts (3.3 % and 0 %), fibroma, granulosa cell tumor, Brenner tumor (1.2 % and 0 %), corpus luteum cysts, follicular cysts (7.6 % and 6.3 %), old abscess (0.2 % and 0 %), and simple cysts (17.6 % and 12.5 %) in the nonconverted and converted groups, respectively. The converted group included more cases of endometriotic cysts (43.8 % vs 12.3 %, p = 0.023), bilateral cysts (37.5 % vs 8.2 %, p < 0.001), severe pelvic adhesion (68.8 % vs 3.3 %, p < 0.001), deep endometriosis (12.5 % vs 0.4 %, p < 0.001), and at least two cysts (37.5 % vs 8.81 %; p < 0.001). Severe pelvic adhesion (adjusted odds ratio [OR], 86.96; range, 18.33-431.77; p < 0.001), bilateral cysts (adjusted OR, 4.75; range, 1.05-21.57, p = 0.043) and endometriotic cysts (adjusted OR, 7.69; range, 3.11-17.08; p < 0.001) were also predictors of surgical conversion. Conclusion: vNOTES demonstrates low complication and conversion rates in treating ovarian cyst compared with TU-LESS. Surgical conversion is associated with severe pelvic adhesions, bilateral cysts, and endometriotic cysts.

A Retrospective Cohort Study of vNOTES Extraperitoneal Versus Laparoscopic Sacral Hysteropexy With Uterine Preserving Regarding Surgical Outcomes and Two-Year Follow-Up Results.

STUDY OBJECTIVE: To explore the effectiveness of transvaginal natural orifice transluminal endoscopic surgery extraperitoneal sacral hysteropexy (vNOTES-ESH) in women with symptomatic uterine prolapse over a 2 year follow-up. DESIGN: Retrospective cohort study. SETTING: Gynecological minimally invasive center. PATIENTS: Women undergoing sacral hysteropexy either by vNOTES (n = 25) or laparoscopic (n = 74) between November 2016 and December 2020. INTERVENTIONS: Both vNOTES-ESH and laparoscopic sacral hysteropexy (LAP-SH) were used for uterine prolapse. Demographic data, operative characteristics, perioperative outcomes, and follow-up information 2 years postsurgery in the 2 groups were retrospectively evaluated. RESULTS: Both procedures showed similar operation time, estimated blood loss, hospital stays, and pain scores (p >0.05). During a median follow-up of 59 (24-72) months, the surgical success rate was 96% for vNOTES-ESH and 97.3% for LAP-SH (p >0.05), with no differences in anatomical position or pelvic organ function after the operation. Women in the LAP-SH group experienced more bothersome symptoms of constipation compared to those in the vNOTES-ESH group (5.41% vs 0, p <0.05). Lastly, 1 case in the vNOTES-ESH group had a mesh exposed area of less than 1 cm2, and 1 patient in the LAP-SH group experienced stress incontinence. CONCLUSIONS: In this retrospective study, vNOTES-ESH met our patients' preference for uterine preservation and was a successful and effective treatment for uterine prolapse, providing good functional improvement in our follow-up. This procedure should be considered as an option for patients with pelvic organ prolapse.

Anatomical Distribution of Sentinel Lymph Nodes Harvested by Retroperitoneal vNOTES in 34 Consecutive Patients With Early-Stage Endometrial Cancer: Analysis of 124 Lymph Nodes.

STUDY OBJECTIVE: To determine the anatomical distribution of sentinel lymph nodes (SLNs), the overall, unilateral, and bilateral detection rates, and the bilateral SLN concordance in patients with endometrial cancer (EC) mapped through a retroperitoneal transvaginal natural orifice transluminal endoscopic surgery (vNOTES) approach. DESIGN: Prospective single-center observational study. SETTING: Swiss teaching hospital. PATIENTS: Patients with EC or endometrial complex atypical hyperplasia who had undergone surgical staging with SLN mapping by a retroperitoneal vNOTES approach between October 2021 and November 2023. INTERVENTIONS: Patients were placed in a horizontal dorsal lithotomy position under general anesthesia, and indocyanine green (ICG) was injected into the cervix. Access to the retroperitoneal space was achieved through vaginal incisions. A 7 cm GelPoint V-Path Transvaginal Access Platform was used as a vNOTES port, and CO2 was insufflated to expand the retroperitoneal space. The pelvic retroperitoneal space was inspected for ICG uptake by lymph nodes. After identification, SLNs were removed and sent for definitive histological examination. MEASUREMENT AND MAIN RESULTS: A total of 34 patients were included in this study; 33 (97.1%) had a successful procedure (unilateral or bilateral mapping), and 1 (2.9%) had failed mapping. A total of 124 SLNs were identified and removed. SLNs were observed in the obturator region (81.5%), the external iliac region (10.5%), the internal iliac region (4.8%), and the common iliac region (3.2%). Similar proportions were observed on both pelvic sides. No SLNs were detected in other regions. The SLN locations were symmetrical in 22/31 (71.0%) patients. SLNs were negatives in 120 cases (96.8%), while 2 lymph nodes (1.6%) presented isolated tumor cells, and 2 others (1.6%) presented macrometastases. CONCLUSION: We report anatomical distributions and detection rates for SLNs mapped by retroperitoneal vNOTES. Our results suggest substantial differences in the localization of SLNs compared to those reported for laparoscopic mapping.

Pathological Insights on Polypropylene Mesh Complications From Laparoscopic Sacrocolpopexy: A Case Series.

Background The use of polypropylene mesh in laparoscopic sacrocolpopexy (LSC) is a common treatment for pelvic organ prolapse (POP). Despite its widespread application, postoperative complications such as mesh pain and infection sometimes necessitate the removal of the mesh. However, it remains unclear in which cases mesh removal is warranted. Our research focused on the pathological changes at the sacral fixation point of the mesh. We sought to evaluate the pathological alterations of the sacral mesh removed through an innovative approach of transvaginal natural orifice transluminal endoscopic surgery (vNOTES). Methods This retrospective study included nine patients who underwent mesh removal surgery at the Yokosuka Urogynecology and Urology Clinic in 2023. Extraction surgery was performed using vNOTES with the GelPoint Access Platform (Applied Medical JAPAN HEADQUARTERS, Tokyo, Japan). Non-ablative Erbium YAG and Neodymium YAG lasers (RenovaLase, SP Dynamis; Fotona d.o.o., Ljubljana, Slovenia) were utilized for persistent stress urinary incontinence, fecal incontinence, vaginal erosion, and bleeding after surgery. Patients were categorized based on mesh fixation conditions, including unintended mesh overlap (Group I), excessive traction (Group II), and signs of mesh aging (Group III). This categorization helped to understand the distinct pathological outcomes associated with each condition. Results Pathological findings from the mesh removed via vNOTES varied significantly across the groups. In Group I, characteristic large vacuole formation and accumulation of atypical giant cells were observed, attributed to mesh overlap. Group II presented with vacuole formation, fiber degradation, and tissue destruction as a result of excessive mesh traction. In Group III, the aging of the mesh was marked by cracks in the surrounding tissues and granuloma formation. These detailed observations provide crucial insights into the underlying causes of mesh-related pain and other complications, highlighting the complexity of bodily responses to mesh implants. Conclusion This study demonstrated the effectiveness of vNOTES for polypropylene mesh removal in patients with post-LSC complications, resulting in significant pain reduction. Pathological analysis revealed that mesh-related issues stem from the surgical techniques, mesh properties, and long-term bodily reactions. These findings provide valuable insights for improving mesh design and POP treatment strategies. Despite the technical challenges, vNOTES is recommended for mesh removal in patients with pain. Additionally, the combination of UEL, VEL, targeted laser irradiation, AEL, and Nd:YAG laser treatments showed promising results in managing post-mesh removal complications such as stress urinary incontinence, vaginal erosion, bleeding, and fecal incontinence, offering hope for improved patient outcomes.

Transvaginal extraperitoneal single-port laparoscopic sacrocolpopexy for apical prolapse after total/subtotal hysterectomy: Chinese surgeons' initial experience.

BACKGROUND: To introduce a novel technique of transvaginal extraperitoneal single-port laparoscopic sacrocolpopexy (ESLS) for apical prolapse and to evaluate the feasibility and short-term outcomes of this technique. METHODS: Sixteen patients were enrolled to undergo ESLS between January 2020 and May 2021. Perioperative outcomes were included. Short-term results were assessed by Pelvic Floor Distress Inventory-20 (PFDI-20), Pelvic Organ Prolapse Quantification (POP-Q) scores, mesh exposure and prolapse recurrence. RESULTS: A total of 14/16 cases (87.5%) were successfully completed. The mean operation time was 118 min (range 85-160), and the mean blood loss was 68 ml (range 20-100). The mean postoperative visual analog scale (VAS) pain score at 24 h was 0.7. No intraoperative complications occurred except for one patient who developed subcutaneous emphysema. All patients gained a significant improvement in both physical prolapse and quality of life at 12 months after surgery, and there was no mesh exposure or prolapse recurrence. CONCLUSIONS: Our experience showed that transvaginal ESLS is a feasible and effective technique for apical prolapse with a previous hysterectomy. However, this technique should be performed by surgeons with extensive experience both in vaginal surgery and laparoscopic single-port surgery.

Transvaginal natural Orifical transluminal Endoscopy for sacrocolpopexy: A case series report.

Background: To describe the surgical technique and operative outcomes of transvaginal natural orifice transluminal endoscopic surgery (V-NOTES) for sacrocolpopexy with or without robotic surgical system in patients with pelvic organ prolapse (POP). Methods: Patients with POP undergoing traditional transvaginal natural orifice transluminal endoscopic surgery (TV-NOTES) or robotic transvaginal natural orifice transluminal endoscopic surgery (RV-NOTES) for sacrocolpopexy performed by one surgeon from Sep 2020 to Jan 2023 in our hospital were included in this study. The baseline demographics and operative outcomes were collected and analyzed. In addition, some surgical skills were presented. The operative outcomes of V-NOTES for sacrocolpopexy performed by three beginners were also presented. Results: Eight patients who underwent TV-NOTES, and two patients who underwent RV-NOTES were included in this study. The mean operative time was 180 ± 49 min, and the estimated blood loss was 107 ± 82 ml for these ten cases. Particularly, the operative time of the two patients who underwent RV-NOTES was 275 and 132 min, while the estimated blood loss (EBL) was 100 and 50 ml respectively. During the follow-up period, no mesh exposure and recurrence were observed. In addition, five cases of TV-NOTES for sacrocolpopexy by beginners were all successfully completed. Conclusion: Both TV-NOTES and RV-NOTES appeared to be feasible and safe for sacrocolpopexy.

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 transluminal endoscopic surgery-assisted versus transumbilical laparoendoscopic single-site ovarian cystectomy for ovarian mature cystic teratoma. A randomized controlled trial.

OBJECTIVES: Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) and transumbilical laparoendoscopic single-site surgery (LESS) have shown the prospection as minimally invasive procedures. Here we aimed to compare ovarian cystectomy assisted by vNOTES and by LESS for ovarian mature cystic teratoma (OMCT). MATERIAL AND METHODS: A total of 81 premenopausal women with OMCT were randomized to undergo ovarian cystectomy assisted by either vNOTES (n = 41) or LESS (n = 40). The main outcome was the operative time. Secondary outcomes included the length of hospital stay, visual analog scale (VAS) pain scores, abdominal contamination by teratoma contents, and intraoperative and postoperative complications. RESULTS: There were no intergroup differences in age, body mass index, tumor size, or bilaterality of tumor. The operative time for the vNOTES group was significantly shorter than that for the LESS group (68.41 ± 20.92 min vs 85.05 ± 32.94 min, p = 0.008). The highest VAS pain score 24 hours postoperatively was 1.21 ± 0.48 in the vNOTES group and 2.43 ± 0.57 in the LESS group (p < 0.001). Twenty-four of the 40 patients in the LESS group experienced teratoma rupture intraoperatively, leading to abdominal contamination by the teratoma content, while 5 abdominal contamination was observed in the vNOTES group （p = 0.005. No significant differences between the two groups were observed in the other outcomes. CONCLUSIONS: vNOTES assisted ovarian cystectomy has short operative time, fast recovery, no scarring, less pain, and low rate of abdominal contamination. Consequently, vNOTES might be superior to LESS for treating OMCTs.

Perioperative outcomes of transvaginal natural orifice transluminal endoscopic surgery and transumbilical laparoendoscopic single-site surgery in hysterectomy: A comparative study.

OBJECTIVE: This study aimed to compare the perioperative outcomes of patients who underwent hysterectomy for benign gynecologic diseases using transvaginal natural orifice transluminal endoscopic surgery (vNOTES) or transumbilical laparoendoscopic single-site surgery (TU-LESS). METHODS: A total of 314 patients who underwent hysterectomy for benign uterine disease at West China Second University Hospital between October 2018 and December 2021 were enrolled in this retrospective study. vNOTES (n = 157) and TU-LESS (n = 157) recipients were matched 1:1 in terms of uterine volume. The operation time, blood loss, postoperative decrease in hemoglobin, uterus weight, postoperative hospital stay, postoperative pain score at 12 h, postoperative indwelling catheter time, and other clinical indicators were compared between the two groups. RESULTS: All 314 patients successfully completed the surgery, and the two groups had similar baseline characteristics, with no statistical difference. Regarding intraoperative outcomes, the operation time was shorter in the vNOTES group than in the TU-LESS group (80 vs 100 min, P = 0.04), and there were no significant differences in intraoperative blood loss, intraoperative blood transfusion rate, postoperative decrease in hemoglobin, or uterine weight. Concerning postoperative outcomes, vNOTES hysterectomy was significantly superior to TU-LESS hysterectomy in terms of the length of hospital stay (3 vs 4 days, P < 0.001), visual analog scale score for pain at 12 h after surgery (P = 0.04), postoperative indwelling catheter time (39.5 vs 64.0 h, P < 0.001), and postoperative exhaust time (24.0 vs 42.0 h, P < 0.001). There were no significant differences in postoperative complications between the two groups. CONCLUSION: vNOTES and TU-LESS seem safe and feasible for hysterectomy, but vNOTES hysterectomy was more conducive to the postoperative rehabilitation of patients, with less trauma, less pain, and better cosmetic effects than TU-LESS hysterectomy. As an emerging surgical approach, more studies, including large-sample, multicenter, randomized controlled trials, are needed to validate our findings.

Feasibility and safety of hybrid transvaginal natural orifice transluminal endoscopic surgery for colon cancer: Protocol for a multicenter, single-arm, phase II trial (vNOTESCA).

Introduction: It has been a decade since the first patient with colon cancer underwent colectomy by hybrid transvaginal natural orifice transluminal endoscopic surgery (hvNOTES). However, the efficacy and safety of this procedure is not well established. Methods: This study is an open-label, multicenter, single-arm, phase 2 trial undertaken at six centers in China. Female patients aged over 18 years and below 80 years old with an Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1, with pathologically proven, resectable, cT1-3N0-2M0 disease who have previously untreated colon cancer are eligible for inclusion. The primary endpoint is a composite of major intraoperative and postoperative complications (greater than grade III, the Common Terminology Criteria for Adverse Events [CTCAE], version 5.0). Secondary endpoints include conversion to laparoscopic or open surgery, postoperative concentration of C-Reactive Protein and procalcitonine, complete pathological assessment of complete mesocolic excision specimens, postoperative pain, amount of narcotic pain medication administered, time to first flatus after surgery, number of harvested lymph nodes, R0 resection rate, length of hospital stay, sexual function assessment, quality of recovery, satisfaction with surgical scars, quality of life, postoperative recurrence patterns, relapse-free survival, and overall survival. Ethics and dissemination: The study was approved by the Research Ethics Committee, Renmin Hospital of Wuhan University, China, number: WDRY2022-K053. All patients will receive written information of the trial and provide informed consent before enrollment. The results of this trial will be disseminated in academic conferences and peer-reviewed medical journals.Trial registration number NCT04048421.

Comparative analysis of transvaginal natural orifice transluminal endoscopic surgery versus laparoendoscopic single-site sacrocolpopexy for pelvic organ prolapse: A propensity score matching study.

Purpose: To compare the safety, feasibility, and effectiveness of transvaginal natural orifice transluminal endoscopic sacrocolpopexy (vNOTES-SC) and laparoendoscopic single-site sacrocolpopexy (LESS-SC) for pelvic organ prolapse (POP). Method: Ninety-four patients with POP who underwent vNOTES-SC or LESS-SC from October 2016 to November 2018 were included. The propensity score matching method was used for 1:1 matching between the two surgery groups. After matching, the general perioperative indicators, surgical complications, and the subjective and objective therapeutic effects of the two groups 3 years post-surgery were analyzed. Results: After matching, 36 patients in each group were included, exhibiting balanced and comparable baseline data and an average follow-up of 48.6 ± 7.44 months. The operation time and postoperative hospitalization days were significantly reduced in the vNOTES-SC group (P < 0.05). However, perioperative complication incidence was not significantly different between the two groups (P > 0.05). Additionally, no significant differences were detected in de novo stress urinary incontinence (16.7% vs. 13.9%), de novo overactive bladder (de novo OAB, 8.3% vs. 0.0%), urination disorder (2.8% vs. 0.0%), defecation disorder (0.0% vs. 2.8%), lumbosacral pain (0.0% vs. 2.8%), or mesh complication (2.8% vs. 5.6%) incidences between the vNOTES-SC and LESS-SC groups (P > 0.05). Prolapse recurrence was not reported in either group. The quantitative description of pelvic organ position (POP-Q), Pelvic Floor Impact Questionnaire-7 (PFIQ-7), and Patient Global Impression of Improvement scale (PGI-I) scores showed improvement after the operation, but no significant differences were observed between the two groups (P > 0.05). Conclusion: The 3-year follow-up revealed that vNOTES-SC and LESS-SC had similar complications and efficacy rates. Compared with LESS-SC, vNOTES-SC resulted in shorter operation time and fewer postoperative hospitalization days (corresponding to the enhanced recovery after surgery [ERAS] concept), along with better cosmetic results without a scar. Therefore, our study findings suggest that clinicians should choose the surgery method based on the specific situation, and we recommend choosing vNOTES-SC when both surgeries are suitable.

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.

The Pure Extraperitoneal Approach for Sacrocolpopexy in Transvaginal Natural-Orifice Transluminal Endoscopic Surgery.

Objective: The goal of this research was to investigate the feasibility, safety, and short-term clinical outcome of pure extraperitoneal sacrocolpopexy with transvaginal natural orifice transluminal endoscopic surgery (V-NOTES) for treating central pelvic defects. Material and Methods: A total of 9 patients with central pelvic prolapse underwent extraperitoneal sacrocolpopexy with V-NOTES, at the Chengdu Women's and Children's Central Hospital, Chengdu, Sichuan, China, between December 2020 and June 2022. The patients' demographic characteristics, perioperative parameters, and clinical outcomes were analyzed retrospectively. Each patient had the following major surgical procedures: (1) Establishing a platform for an extraperitoneal approach with V-NOTES; (2) separating the extraperitoneal path to the sacral promontory region; (3) suturing the long arm of the mesh to the anterior longitudinal ligament S1; and (4) suturing and fixating the short arm of the mesh at the top of the vagina. Results: The median patient age was 55, the median operative time was 145 minutes, and the median intraoperative blood loss was 150 mL. The operations were successful for all 9 cases, with a median preoperative Pelvic Organ Prolapse-Quantification score of C: +4, and a 3-months postoperative score of C: -6. There were no recurrences during a follow-up of 3-11 months, and no complications occurred, such as mesh erosion, exposure, and infection. Conclusion: As a new surgical approach, extraperitoneal sacrocolpopexy with V-NOTES is safe and feasible. (J GYNECOL SURG 39:108).

Hysterectomy Using Vaginal Natural Orifice Transluminal Endoscopic Surgery Compared with Classic Laparoscopic Hysterectomy: A New Advantageous Approach? A Systematic Review on Surgical Outcomes.

INTRODUCTION: Minimally invasive surgery aims to reduce surgical trauma and post-operative morbidity. Natural orifice transluminal endoscopic surgery is a safe and valid surgical option for hysterectomy. The present systematic review aims to compare hysterectomy by transvaginal natural orifice transluminal endoscopic surgery (vNOTES) with laparoscopic hysterectomy in terms of efficacy, surgical outcomes, complications, and cost. MATERIALS AND METHODS: This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. It includes randomized controlled trials, controlled clinical trials, prospective or retrospective cohorts, case-control studies, and previous systematic reviews. Inclusion criteria are as follows: female patients undergoing hysterectomy for benign pathologies by vNOTES or laparoscopic hysterectomy. The assessed outcomes were the following: conversion rate, mean uterus weight (g), operative time (mins), hospital stay (days), peri-operative complications, post-operative complications, peri-operative blood loss (mL), blood transfusion needs, post-operative day 1 hemoglobin (Hb) change (g/dL), post-operative pain level (VAS), and cost (USD) in both techniques. RESULTS: Seven studies were included. vNOTES hysterectomy was not inferior to laparoscopic hysterectomy regarding surgical outcomes, with a shorter operative time, shorter recovery time, less post-operative pain, and fewer post-operative complications. There was no significant difference in the rate of peri-operative complications and no differences in peri-operative blood loss, post-operative day 1 Hb change, and transfusions. Nevertheless, vNOTES hysterectomy was shown to be more expensive than its laparoscopic counterpart. CONCLUSIONS: While the feasibility and safety of the vNOTES hysterectomy were already established, this review also underlines the noninferiority of this technique when compared to laparoscopic hysterectomy in terms of surgical outcomes. In addition, vNOTES hysterectomy was associated with faster operating time, shorter hospital stay, and better post-operative pain scores compared with laparoscopic hysterectomy.

The comparison of gasless and traditional robot-assisted transvaginal natural orifice transluminal endoscopic surgery in hysterectomy.

Study objective: To describe the surgical technique and compare the operative outcomes of gasless and traditional robot-assisted transvaginal natural orifice transluminal endoscopic surgery (GR-vNOTES vs. TR-vNOTES) in hysterectomy. Methods: The patients undergoing hysterectomy via GR-vNOTES or TR-vNOTES between February 2020 and January 2022 in our hospital were included. Clinical data regarding patient demographics, operative time, blood loss, complications, and postoperative hospital stays were collected and analyzed. Results: Five cases underwent hysterectomy via GR-vNOTES, and nine cases via TR-vNOTES. The baseline demographics and operative outcomes were not significantly different in GR-vNOTES and TR-vNOTES groups. There was no conversion to multiport robotic laparoscopy, conventional laparoscopy or laparotomy. No complications were seen in both groups, except two cases had fever postoperatively in the TR-vNOTES group. For those with early stage cervical/endometrial cancer, no recurrence or metastasis was observed in the follow-up of six months. Conclusion: Both GR-vNOTES and TR-vNOTES were feasible and safe for hysterectomy. GR-vNOTES was a promising alternative to TR-vNOTES in hysterectomy.

Diagnosing and Treating Infertility via Transvaginal Natural Orifice Transluminal Endoscopic Surgery versus Laparoendoscopic Single-Site Surgery: A Retrospective Study.

OBJECTIVE: To evaluate the efficacy and safety of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) in the treatment of female infertility. MATERIALS AND METHODS: This study includes 174 female patients with a history of long-standing female infertility. We retrospectively reviewed 41 patients who underwent hysterolaparoscopy (HL) via transvaginal natural orifice transluminal endoscopic surgery (vNOTES) and 133 patients who underwent laparoendoscopic single-site surgery (LESS). Demographic data, operation records, and pregnancy outcomes were collected and analyzed. The deadline for postoperative follow-up was June 2022. All the included patients were followed up for at least 18 months after surgery. RESULTS: Compared with the LESS group, the vNOTES group had a shorter postoperative bowel movement time and less pain at 4 and 12 h (p = 0.004 vs. 0.008); no differences were found in other perioperative indicators. The clinical pregnancy rates of the vNOTES and LESS groups were 87.80% and 74.43% (p = 0.073), respectively. CONCLUSIONS: vNOTES represents a new, less invasive approach for infertility diagnosis and treatment that is particularly suitable for women who have special esthetic requirements. vNOTES is safe and practical and may be an ideal choice for scarless infertility surgery.

Transvaginal natural orifice transluminal endoscopic surgery versus conventional vaginal surgery for sacrospinous ligament fixation of apical compartment prolapse: a retrospective analysis.

BACKGROUND: To objectively assess the safety, feasibility, advantages, and disadvantages of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) versus conventional vaginal (CV) surgery for sacrospinous ligament fixation (SSLF). METHODS: We retrospectively analyzed the data of patients who underwent hysterectomy for SSLF via vNOTES or CV surgery due to apical compartment prolapse between April 2019 and April 2020 at our hospital. The patients were classified into the vNOTES group (n = 31) and CV surgery group (n = 51) based on surgical approach and their general characteristics and perioperative outcomes compared. RESULTS: The two groups had similar general characteristics. The anatomical success and bilateral salpingo-oophorectomy rates were higher in the vNOTES than CV surgery group, while the postoperative stay was shorter in the vNOTES than CV surgery group. All differences were statistically significant. However, there were no statistically significant intergroup differences in operation time, bilateral salpingectomy rate, colporrhaphy rate, postoperative visual analog scale score, estimated blood loss, hemoglobin decrease at 72 h postoperative, maximum body temperature at 72 h postoperative, complication rate, buttock pain, or Pelvic Floor Impact Questionnaire-7 and Pelvic Floor Distress Inventory Questionnaire-20 scores at 1 year postoperative. CONCLUSIONS: VNOTES for SSLF was safe and feasible and resulted in superior objective and subjective outcomes versus CV surgery for SSLF. These findings suggest that vNOTES could be an alternative to CV surgery for SSLF.

Transvaginal natural orifice transluminal endoscopic surgery for presacral-uterosacral ligament compound suspension in apical compartment prolapse.

INTRODUCTION AND HYPOTHESIS: We aimed to describe a novel mesh-free pelvic repair surgery for apical prolapse and to evaluate the effect of this technique and early outcomes. METHODS: We demonstrate the key techniques in a video: exposing the anterior longitudinal ligament (ALL) of the presacral space; securing a non-absorbable suture to the ALL by horoscope stitch; shortening the right uterosacral ligament (USL); placing a non-absorbable suture around the intermediate portion of the left USL for three stitches; placing the non-absorbable suture in the transverse portion of the pubocervical and rectovaginal fascia; locking sutures in place to approximate anterior to posterior connective tissue. Fifteen patients were enrolled to undergo this procedure between December 2020 and April 2021. RESULTS: The mean age of the patients was 60.67 (range 46-69) years, the mean body mass index was 24.25 kg/m2 (range 19.61-30.08). The mean operation time was 103.6 min (range 65-166), and the mean blood loss was 82 ml (range 50-200). No intraoperative complications occurred. All patients gained a significant improvement in anatomical and objective outcomes during a mean 9.93-month follow-up, and there was no recurrence. CONCLUSIONS: Our experience showed that this mesh-free repair surgery was a feasible and safe technique for apical prolapse.

Transvaginal natural orifice endoscopic surgery for myomectomy: Can it be a conventional surgery?

Introduction: As a new minimally invasive surgery, transvaginal natural orifice transluminal endoscopic surgery (vNOTES) has been proved to be suitable for the treatment of a variety of gynecological benign diseases. However, compared with other minimally invasive surgeries that have been widely used, such as conventional multiport laparoscopy and transumbilical laparoendoscopic single-site surgery (LESS), their advantages and disadvantages and how to choose are still unknown. The purpose of our study is to compare the advantages and disadvantages of the three minimally invasive surgeries in myomectomy and to provide theoretical basis for the wider development of vNOTES surgery. Material and methods: This retrospective study included 282 patients at our hospital who underwent laparoscopic myomectomy from May 2021 to March 2022. Based on the surgical approach, patients were classified into multiport, transumbilical LESS, and vNOTES groups. The patients' demographic characteristics and follow-up data were collected during the perioperative period and at 1 month postoperatively. Results: Among the three procedures, vNOTES had the shortest anal exhaust time but also the highest postoperative infection rate. Multiple linear regression analysis showed that the operative time increased by 3.5 min for each 1 cm increase in myoma, and intraoperative bleeding increased by approximately 12 ml. The average duration of single pores increased by 25 min compared to that of multiports, and the operative duration increased by 10.48 min for each degree of adhesion. Conclusions: For gynecologists who have mastered vNOTES, this procedure has the same efficacy and safety as the two existing minimally invasive surgeries in myomectomy, but it shows obvious advantages in postoperative recovery.