Transvaginal endoscopic surgery-assisted versus conventional laparoscopic adnexectomy (TVEA vs . CLA): A propensity-matched study and literature review

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.

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.

Clinical relevance of vaginal natural orifice transluminal endoscopic surgery (vNOTES) in gynecology

This study reviews the progress and recent advances in vaginal natural orifice transluminal endoscopic surgery (vNOTES) as a minimally invasive gynecologic procedure. The proposed advantages of vaginal natural orifice transluminal surgery include enhanced cosmesis due to a scarless procedure, better exposure compared with the pure vaginal approach, tolerable pain scores, fewer perioperative complications, and a shorter hospital stay. Recent advances in surgical instrumentation and technology have improved the feasibility of vNOTES as an innovative treatment option for gynecological conditions. However, technical challenges and training issues must be overcome before its widespread use. As a promising surgical innovation, further randomized comparative studies are required to clarify the safety and effectiveness of vNOTES in gynecology.

Assessment of women's sexual quality of life after benign adnexal surgery using vNOTES approach in comparison to conventional laparoscopy: protocol for a randomised controlled trial

INTRODUCTION

Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) has already proven its non-inferiority to conventional abdominal laparoscopy (CAL) for hysterectomy without conversion. The results in terms of efficacy and safety are promising. However, we note a lack of medical literature and no specific randomised controlled trial assessing women's sexual function after vNOTES for benign adnexal surgery. The aim of this RCT is to confirm the non-inferiority of the vNOTES approach for benign adnexal pathology compared with CAL on women's sexual function. Secondary outcomes will evaluate vNOTES's efficiency, morbidity and postoperative complications compared with CAL for benign adnexal surgery. The relationship between adnexal mass morcellation and the quality of the histological analysis will also be evaluated as secondary outcome.

METHODS AND ANALYSIS

Women aged 18-70 years undergoing a benign adnexal surgery at the Geneva University Hospitals will be eligible and randomised with a 1:1 ratio to the CAL arm or the vNOTES arm, if inclusion criteria are met. Participants will complete the Female Sexual Function Index, the Couple Satisfaction Index-16 and a self-reported questionnaire on dyspareunia within 4 weeks prior to randomisation and at 3+6 months after surgery. General and clinical data will be collected when the patient is enrolled in the study, during hospitalisation and at 1 month postoperative to assess secondary outcomes.An absence of impairment on sexual function will be confirmed with a stability or an improvement of the evaluated scores in each group at 3 and 6 months postoperative compared with the preoperative scores. We expect to have no statistically significant difference in sexuality questionnaires scores between the two groups.

ETHICS AND DISSEMINATION

Protocol of this study was validated by the Cantonal Research Ethics Commission of Geneva, Switzerland, on 9 August 2022. We aim to publish the study's results in peer-reviewed journals within 3 years.

TRIAL REGISTRATION NUMBER

NCT05761275.

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.

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.

The Feasibility and Safety of vNOTES Hysterectomy and Uterosacral Ligament Suspension: A Case Series

The transvaginal natural orifice transluminal endoscopic surgery (vNOTES) is a recently introduced surgical approach that is even less invasive than conventional laparoscopy or robotic surgery. We conducted this study to report our experience in vNOTES hysterectomy and uterosacral ligament suspension and determine the feasibility and safety of this approach. Surgeries on 23 women were performed by a single surgeon in 1 tertiary medical center. Patient demographics, perioperative data, and follow-up details of 23 women were collected prospectively. Average age was 56.7 ± 8.9 years. Median parity was 3. Nine patients were smokers, and 4 patients had diabetes. Median stage of prolapse was 3. One patient had extensive adhesions, and after vNOTES hysterectomy was completed, decision was made to perform uterosacral suspension by conventional vaginal access. Another patient had intraoperative identification by cystoscopy of unilateral kinking of the ureter that was resolved after the most distal uterosacral stitch was released. Mean uterine weight was 271.9 ± 131.9 g. Average estimated blood loss was 85.22 ± 55.6 mL. Median length of stay in the hospital was 1 day. Only 1 patient had intermittent voiding postoperatively and required an indwelling catheter for 3 days. Hysterectomy and uterosacral ligament suspension when performed via vNOTES is a safe and feasible procedure. Large prospective trials are on the way to continue shedding light on this new surgical modality.

Comparison of Surgical Outcomes of Adnexectomy by Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) Versus Single-Port Access (SPA) Surgery

The objective of the present pilot study is to compare operative outcomes between vaginal natural orifice transluminal endoscopic surgery (vNOTES) and single-port access (SPA) adnexectomy. Subjects were patients who underwent adnexectomy for benign adnexal disease, from November 2019 to May 2021. A total of 12 patients underwent vNOTES adnexectomy, and 55 patients received SPA laparoscopic adnexectomy. All surgeries were performed by one surgeon. In order to balance the baseline characteristics of the patients, 1:2 matching was performed. The vNOTES group demonstrated a low postoperative pain score within 12 h after surgery. They also required less use of analgesic medications postoperatively. Other surgical outcomes were comparable between the two groups. This study showed that vNOTES adnexectomy has comparable surgical outcomes to SPA.

Comparison of vNOTES technique with conventional laparoscopy in gynecological emergency cases

BACKGROUND

Vaginal natural orifice transluminal endoscopic surgery (vNOTES) has emerged as a minimally invasive approach. This study aimed to evaluate the feasibility and surgical outcomes of the vNOTES method and compare it with conventional laparoscopy (CL) in gynecological emergency cases.

MATERIAL AND METHODS

A retrospective study was conducted to compare vNOTES with CL regarding pre-/intra-/postoperative outcomes. The women who were operated on for emergency indications such as ectopic pregnancy, ovarian torsion, ovarian cyst rupture and acute abdominal pain were evaluated. Patients' age, gravidity, parity, medical/surgical history, height, weight, blood pressure, heart rate, pre-/postoperative hemoglobin and hematocrit levels, the quantity of aspirated hemoperitoneum, visual analog scale (VAS) pain scores six and 12 h postoperatively, duration of surgery and hospital stay were recorded.

RESULTS

The study was conducted with 90 women. Sixty of them underwent CL, while 30 women had vNOTES. The vNOTES group had a significantly shorter duration of surgery -28.5 min (15-48 min) vs. 77 min (29-155 min), respectively, p < .001), shorter hospital stay - 32 h (11-125 h) vs. 38 h (12-201 h), respectively, p = .007), lower VAS scores after 6 h - 5 (4-7) vs. 6 (2-8), respectively, p < .001), and after 12 h - 2 (1-3) vs. 2 (1-5), respectively, p < .001) and a lower dose of postoperative analgesic administration - 2 (2-3) vs. 3 (1-5), respectively, p < .001) than the CL group.

CONCLUSION

vNOTES surgeries can be considered an alternative technique to CL by providing shorter surgery duration, lower postoperative pain scores, shorter hospital stays and better cosmetic outcomes.

Pregnancy Outcome after Vaginal Natural Orifice Transluminal Endoscopic Surgery, a First Retrospective Observational Cohort Study

STUDY OBJECTIVE

Vaginal natural orifice transluminal endoscopic surgery (vNOTES) is a novel minimal invasive surgical technique allowing a variety of gynecological procedures. The current literature describes improved patient comfort, improved better cosmetic results, and reduced operation time. This is a first study to assess pregnancy outcome after fertility-preserving vNOTES procedures. Design/Participants/Materials/Setting/Methods: We performed a retrospective observational cohort study including 125 patients under 43 years that underwent fertility-preserving vNOTES over a 5-year period (2014-2019). The gynecological surgical procedures included were vNOTES myomectomy, vNOTES salpingectomy for ectopic pregnancy, vNOTES unilateral adnexectomy, and vNOTES cystectomy. A total of 26 pregnancies in 21 cases were observed, with deliveries between 2015 and 2020.

RESULTS

Retrospective analysis in this patient group showed that 18 pregnancies were diagnosed within 1 year after vNOTES (85.7%). Mean interval between surgery and pregnancy was 6 months. Fertility treatment was performed in 28.6%. In the 26 observed pregnancies, no vNOTES-related complications were observed and delivery was at term in all cases. Mode of delivery was a vaginal delivery in twenty cases (76.9% of total) of which 2 cases vacuum assisted (7.7%) and a Caesarean section in 6 cases (23.1% of total). Two cases of trial of labor after Caesarean are described after vNOTES surgery, both ended in an uncomplicated vaginal delivery. In case of vaginal delivery, the perineum was intact in 15%, a mediolateral episiotomy was performed in 50 and 35% a grade 1-2 perineal rupture was described. No grade 3-4 perineal ruptures are described.

LIMITATIONS

A limitation of this study is the retrospective design which does not correct for confounding factors. Further larger multicenter studies are needed to validate these data.

CONCLUSIONS

This is the first study describing pregnancy outcome after fertility-preserving vNOTES procedures. vNOTES did not affect the mode of delivery or cause pregnancy-related complications. vNOTES did not increase the risk of extensive perineal tears during vaginal delivery. These preliminary data show no adverse events when vNOTES is performed in women of reproductive age. Posterior colpotomy as performed in all vNOTES procedures is by itself not an indication for an elective Caesarean section.

The Comparison of Surgical Outcomes following Laparoscopic Hysterectomy and vNOTES Hysterectomy in Obese Patients

AIM

This study aimed to compare the surgical outcomes of total laparoscopic hysterectomy (TLH) and vaginally assisted natural orifice transluminal endoscopic surgery (vNOTES) hysterectomy procedures in obese patients.

MATERIALS AND METHODS

This cross-sectional study was conducted with 83 obese women (BMI > 30 kg/m²) who underwent TLH (35 patients) or vNOTES hysterectomy (48 patients) for benign gynecological indications. The duration of surgery, intra/postoperative complications, intra- and postoperative hemoglobin (Hb) and hematocrit (Hct) levels, hospital stay, Visual analogue scale (VAS) scores at the postoperative 6th and 24th hours of the patients were compared.

RESULTS

There was no significant difference between TLH and vNOTES groups regarding age (49 vs. 52 years, p = 0.35), parity (2 vs. 3, p = 0.17), and uterine weight (290 vs. 230 g., p = 0.13) The median BMI was 31.6 kg/m² (30-42.2 kg/m²) in the TLH group and 31.9 kg/m² (30-54.6 kg/m²) in the vNOTES group (p = 0.31). The vNOTES hysterectomy group had significantly shorter durations of surgery (67.5 vs. 136 min) and postoperative hospitalization than the TLH group (p < 0.05 for all comparisons). Besides, the 6th-hour (6 vs. 7, p = 0.02) and 24th-hour (4 vs. 3, p < 0.001) VAS scores were significantly lower in the vNOTES hysterectomy group. The propensity-matched group analysis showed significantly lower 6th-hour and 24th-hour VAS scores and shorter duration of surgery (80 vs. 135 min, p < 0.001) in the vNOTES hysterectomy group than the TLH group.

CONCLUSION

vNOTES is a feasible technique in obese women who require a hysterectomy and provides favorable outcomes considering the shorter duration of surgery and postoperative hospitalization and lower pain scores.

Use of human fibrin glue (Tisseel) versus suture during transvaginal natural orifice ovarian cystectomy of benign and non-endometriotic ovarian tumor: a retrospective comparative study

Background

To evaluate the use of a human fibrin glue (Tisseel) for minor bleeding control and approximation of ovarian defect during transvaginal natural orifice ovarian cystectomy (TNOOC) of benign and non-endometriotic ovarian tumors.

Methods

A total of 125 women with benign and non-endometriotic ovarian tumors who underwent TNOOC between May 2011 and January 2020: 54 with the aid of Tisseel and 71 with traditional suture for hemostasis and approximation of ovarian defect. Surgical outcomes such as length of surgery, operative blood loss, postoperative pain score, and postoperative hospital stay were recorded. Before and immediately (10 days) and at 6 months after the procedure, serum anti-Müllerian hormone (AMH) levels were also determined.

Results

Complete hemostasis and approximation of ovarian defect were achieved in all cases. No significant difference was noted in the operating time, operative blood loss, postoperative pain scores after 12, 24 and 48 h, length of postoperative stay, and baseline AMH levels between the two groups. The operation did not have a negative effect on the immediate and 6-month postoperative AMH levels in the suture group. However, the decline in the AMH levels was significant immediately after surgery in the Tisseel group, nevertheless, no significant difference was noted in the AMH levels at 6 months (3.3 vs. 1.7 mg/mL; p = 0.042, adjusted p = 0.210).

Conclusion

The use of Tisseel in TNOOC of benign and non-endometriotic ovarian tumors without suturing the ovarian tissue is clinically safe and feasible.

Comparative analysis of vaginal natural orifice transluminal endoscopic surgery versus transumbilical laparoendoscopic single-site surgery in ovarian cystectomy

AIM

To objectively assess the safety, feasibility, advantages and disadvantages and health economics benefits of vaginal natural orifice transluminal endoscopic surgery (vNOTES) versus transumbilical laparoendoscopic single-site surgery (TU-LESS) in ovarian cystectomy.

METHODS

We retrospectively analyzed the data of all patients in our hospital who had undergone vNOTES and TU-LESS ovarian cystectomy due to 'unilateral ovarian cyst' from March 2019 to May 2020. Patients were classified into vNOTES group (86) and TU-LESS group (210) based on surgical paths. The patients' general characteristics and perioperative outcomes were compared.

RESULTS

All 296 patients completed surgery with no need to switch to conventional laparoscopy or laparotomy procedures. There were no complications of Grade III, IV, V in Clavien-Dindo classification. There were two patients in the vNOTES group and four patients in the TU-LESS group with complications of Grade I, all of whom were treated with antipyretic drugs for postoperative fever. One patient in the TU-LESS group presented the complication of Grade II and was treated with blood transfusion due to postoperative anemia. The two groups had similar general characteristics. Perioperative outcomes: The visual analogue scale (VAS) scores 24 h postoperation were significantly lower in the vNOTES group than in the TU-LESS group. The cosmetic scores were significantly higher in the vNOTES group than in the TU-LESS group. Postoperative stay and time of flatus after surgery were significantly shorter in the vNOTES group than in the TU-LESS group. There was not significant statistical differences between the two groups in operation time, estimated blood loss, Hb decrease at 48 h postoperation, maximum body temperature in 48 h after surgery and hospital costs.

CONCLUSION

It was proved to be safe and feasible in ovarian cystectomy by vNOTES. It worked better than TU-LESS in relieving postoperative pain, shortening postoperative stay and improving cosmetic effects and so on. As an emerging surgical path, large sample multicenter randomized controlled trials are required to further verify its safety and advantages.

Learning Curve Analysis of Transvaginal Natural Orifice Adnexal Surgery

STUDY OBJECTIVE

This study was designed to evaluate the learning curve of transvaginal natural orifice surgery (NOS) for adnexal tumors based on the type of procedure (adnexectomy or cystectomy).

DESIGN

Retrospective cohort study.

SETTING

Tertiary-care university hospital.

PATIENTS

One hundred thirty-six women with adnexal tumors.

INTERVENTIONS

A series of 136 consecutive transvaginal NOS for adnexal tumor were performed between April 2011 and June 2016. Eighty-five patients (62.5%) had undergone cystectomy, and 51 patients (37.5%) had undergone adnexectomy.

MEASUREMENTS AND MAIN RESULTS

The transvaginal NOS procedures included vaginal, endoscopic, single-port access techniques and were divided into 2 categories: adnexectomy and cystectomy. Operating time was electronically recorded and was defined as the time from the creation of a posterior colpotomy incision until the complete closure of the posterior colpotomy opening. The average operating time for the cystectomy and adnexectomy groups was 42.7 and 37.7 minutes, respectively (p = .015). The learning curve was analyzed using the cumulative summation method and showed that 36 cases were needed to achieve proficiency in transvaginal NOS for ovarian cystectomy. However, there was no significant cut-off point to determine the number of patients who had undergone adnexectomy.

CONCLUSION

A well-trained gynecologic endoscopist can achieve surgical proficiency in transvaginal NOS cystectomy after 36 cases. It is suggested that the surgical transvaginal NOS procedure should begin with adnexectomy rather than with cystectomy to avoid initial technical challenges.