vNOTES for Hysterectomy Cuts Surgery Time, Blood Loss, and Complications vs Vaginal Approach

A new study has found that vaginal natural orifice transluminal endoscopic surgery (vNOTES) for hysterectomy with high uterosacral ligament suspension (USLS) offers shorter surgical times and fewer complications compared with conventional vaginal hysterectomy with USLS. The multicenter randomized controlled trial, conducted between 2019 and 2021 at Rambam Health Care Campus in Israel and Imelda Hospital in Belgium, compared surgical outcomes in 60 women with pelvic organ prolapse.

The study randomized 30 women to undergo vNOTES hysterectomy with USLS and 30 to undergo conventional vaginal hysterectomy with USLS. The primary outcome measured was total surgical time. Secondary outcomes included intraoperative blood loss, complications, postoperative pain, length of hospital stay, and patient-reported outcomes. The trial was designed to be single-blinded, with patients unaware of their assigned procedure until the day of surgery.

Results showed that total surgical time was shorter in the vNOTES group, with an average of 77 minutes compared with 93 minutes in the conventional vaginal group (P = 0.004). Hysterectomy time was also shorter at 26 minutes versus 33 minutes (P < 0.001), and USLS time was reduced to 20 minutes compared with 26 minutes (P = 0.02). Estimated blood loss was significantly lower in the vNOTES group, with an average of 60 ml versus 143 ml in the conventional vaginal group (P < 0.001). The decline in hemoglobin levels postoperatively was also less pronounced in the vNOTES group (1.2 ml/dL vs. 1.8 ml/dL; P = 0.01).

No intraoperative complications were reported in the vNOTES group, whereas three patients in the conventional vaginal group experienced intraoperative adverse events (P < 0.001). Short-term postoperative complications within the three-month follow-up period were also more frequent in the conventional vaginal group, affecting six patients compared to one in the vNOTES group (P = 0.05). Postoperative pain scores were similar between groups, and there were no significant differences in the use of analgesics or patient-reported outcomes.

The study’s limitations include the fact that only two surgeons performed all procedures, potentially limiting generalizability. The follow-up period was limited to 3 months, and the sample size may not have been sufficient to detect smaller differences in surgical morbidity.

“Given these results, together with the surgical challenges performing conventional vaginal hysterectomy and USLS, an adoption of vNOTES USLS may contribute to a further increase in apical suspension that is performed vaginally,” the researchers concluded.

Reference
Lowenstein L, Mor O, Matanes E, Justman N, Stuart A, Baekelandt J. Conventional vaginal approach vs. transvaginal natural orifice transluminal endoscopic surgery for treating apical prolapse, a randomized controlled study. Eur J Obstet Gynecol Reprod Biol. 2024;303:180-185. doi:10.1016/j.ejogrb.2024.10.032