Surgical outcomes of hysterectomy by transvaginal natural orifice transluminal endoscopic surgery (vNOTES) compared with laparoscopic total hysterectomy (LTH) in women with non-prolapsed and benign uterine diseases

Systematic review and meta-analysis of vaginal natural orifice transluminal endoscopic surgery hysterectomy versus vaginal hysterectomy for benign indications

Objective

As the second most common surgery performed on women in the United States, hysterectomy techniques are constantly examined for validity and superiority. The vaginal natural orifice transluminal endoscopic surgery (vNOTES) has increased in popularity since the first vNOTES hysterectomy was performed in 2012. We sought out to evaluate the safety and effectiveness of hysterectomy by vNOTES compared to conventional vaginal hysterectomy for various benign indications.

Data sources

We searched Scopus, Medline, PubMed, ClinicalTrials.Gov, and the Cochrane Library. Our search included all studies from each respective database's inception until September 1, 2023.

Study eligibility criteria

We included eligible studies that compare vNOTES hysterectomy versus conventional vaginal hysterectomy for various benign indications, and included at least one of our preselected outcomes. The main outcomes were estimated blood loss (mL), operation time (min), length of hospital stay (d), Visual Analogue Scale pain score at Day 1, intraoperative complications, and postoperative complications.

Study appraisal and synthesis methods

We analyzed data of our continuous outcomes using RevMan 5.4.1. Continuous outcomes were analyzed using mean difference (MD) and 95% confidence intervals (CIs) under the inverse variance analysis method. We assessed the quality of the studies using the ROBINS-I assessment tool.

Results

We found 4 eligible studies to include in our analysis. Surgeon declared estimated blood loss was found to be similar in both groups (MD=-44.70 [-99.97, 10.57]; P=.11). Also, the total length of hospital stay (in days) was found to be comparable in both groups (MD=-0.16 [-1.62, 1.30]; P=.83). We also found no other statistically significant difference between hysterectomy by vNOTES and vaginal hysterectomy in other studied outcomes, including the duration of the operation, the Visual Analogue Scale Pain score after 1 day, intraoperative complications, and postoperative complications.

Conclusion

vNOTES seems to be associated with a nonsignificant lower surgeon declared estimated blood loss. We found no other significant differences in hospital stay, intraoperative, or postoperative outcomes. Further studies may clarify if other differences in safety or efficacy exist.

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.

Risk factors for perioperative blood transfusion in patients undergoing total laparoscopic hysterectomy

PURPOSE

The goal is to identify risk factors associated with receiving a blood transfusion during the perioperative period in patients who undergo total laparoscopic hysterectomy (TLH) using a large-scale national database.

METHODS

In this retrospective analysis, data from the Nationwide Inpatient Sample (NIS) was utilized to review the medical records of all patients who underwent TLH from 2010 to 2019. The researchers identified patients who had received a blood transfusion during the perioperative period and compared with those who had not. The subsequent factors associated with blood transfusion were examined: hospital characteristics (type of admission and payer, patient demographics (age and race), bed size, teaching status, location, and region of hospital), length of stay (LOS), total charges during hospitalization, in-hospital mortality, comorbidities, and perioperative complications. The data was analyzed using descriptive statistics. The independent risk factors of perioperative blood transfusion after TLH was identified by performing multivariate logistic regression.

RESULTS

A total of 79,933 TLH were captured from the NIS database, among which 3433 (4.40%) patients received a perioperative blood transfusion. TLH patients affected by blood transfusion were 2 days longer hospital stays (P < 0.001), higher overall costs (P < 0.001), the patients who received a transfusion after a long-term hospitalization had a significantly higher rate of mortality (0.5% vs. 0.1%; P < 0.001). Perioperative blood transfusion after TLH was associated with chronic blood loss anemia, deficiency anemia, coagulopathy, congestive heart failure, fluid and electrolyte disorders, renal failure, metastatic cancer, sepsis, weight loss, deep vein thrombosis, gastrointestinal hemorrhage, shock, acute myocardial infarction, and pneumonia, stroke, hemorrhage, pulmonary embolism, and disease of the genitourinary system.

CONCLUSION

Studying the risk factors of perioperative blood transfusion after TLH is advantageous in order to ensure proper management and optimize outcomes.

Comparing vNOTES Hysterectomy with Laparoscopic Hysterectomy for Large Uteri

STUDY OBJECTIVE

Our study aimed to compare conventional laparoscopic hysterectomies (LHs) with vaginal natural orifice transluminal endoscopic surgery (vNOTES) hysterectomies performed for patients with large uteri (weight >280 g) at our institution, which underwent a change in practice from conventional LH to vNOTES for large uteri.

DESIGN

Retrospective cohort.

SETTING

French tertiary university hospital.

PATIENTS

Two cohorts: the last 54 patients who underwent vNOTES hysterectomy and the last 52 patients who underwent conventional LH for large uteri.

INTERVENTION

Baseline characteristics and surgical outcomes were assessed, including uterine weight, mode of delivery for previous pregnancies, history of abdominal surgery, indication for hysterectomy, associated procedures, operative time (OT), complications, volume of intraoperative bleeding, and length of postoperative hospital stay.

MEASUREMENTS AND MAIN RESULTS

Both groups were comparable, with a mean uterine weight of 586.4 ± 289.2 g in the laparoscopy group compared with 686.7 ± 374.6 g in the vNOTES group. There was a significant decrease in the OT in the vNOTES group with a median of 99 minutes (66.5-138.5 minutes) compared with 171 minutes (131-208 minutes) in the laparoscopy group, p <.001. The length of hospital stay was also decreased in the vNOTES group with a median of 0.5 nights compared with 2 nights in the laparoscopy group, p <.001. More patients were managed in an ambulatory setting in the vNOTES group (50% vs 3.7%, p <.001). Our study did not find any significant difference in terms of bleeding or the number of conversions to another surgical approach. The frequency of intraoperative and postoperative complications was very low.

CONCLUSION

Compared with the laparoscopic approach, vNOTES hysterectomy for large uteri (>280 g) is associated with decreased OT, a shorter hospital stay, and increased performance in the ambulatory setting.

Comparison of quality of life after robotic-transvaginal natural orifice transluminal endoscopic surgery and robot-assisted laparoscopic hysterectomy

OBJECTIVES

We investigated quality of life (QOL) of patients who underwent total hysterectomy for benign uterine diseases using two surgical approaches: robotic-transvaginal natural orifice transluminal endoscopic surgery (R-vNOTES) and robot-assisted laparoscopic hysterectomy (RALH).

STUDY DESIGN

This single-center retrospective study was conducted in a tertiary academic setting and included 65 patients who underwent robotic-assisted hysterectomy for benign uterine diseases. Total hysterectomy was performed using R-vNOTES or RALH by the same gynecologist between December 2021 and June 2022. The primary outcome was a comparison of QOL over time and complete QOL recovery (postoperative QOL score/preoperative QOL score ≥ 1) by postoperative day 28 (POD28) in the R-vNOTES and RALH groups. QOL was examined using EQ-5D-5L in this study. The secondary outcome was a comparison of the surgical outcomes in the R-vNOTES and RALH groups.

RESULTS

Complete QOL recovery was achieved by 62.7% in the R-vNOTES group and 7.3% in the RALH group at POD7 (p <.001) and by 100% in the R-vNOTES group and 56.1％ in the RALH group at POD28 (p <.001). In a multivariable model, patients who underwent R-vNOTES achieved higher complete QOL recovery at POD 28 [adjusted hazard ratio: 4.03, 95% confidence interval: 2.03-8.04]. There was no significant difference between the R-vNOTES and RALH groups in terms of operating time (p =.07), intraoperative blood loss (p =.35), uterus weight (p =.76), or postoperative complications (p =.71).

CONCLUSION

The R-vNOTES approach for total hysterectomy for benign uterine diseases provided better complete QOL recovery by POD28 compared to the RALH approach. The surgical outcomes for R-vNOTES were equivalent to those for RALH, suggesting that R-vNOTES may provide a safe approach for robot-assisted hysterectomy.

Obvious advantage of vaginal natural orifice transluminal endoscopic surgery hysterectomy against total laparoscopic hysterectomy in small uterus patients and the future prospects at a regional core institution: A retrospective study

Objective

Owing to the combination of benefits, including permanent visual guidance and no abdominal skin incision, vaginal natural orifice transluminal endoscopic surgery hysterectomy (vNOTES-H) is currently widely used. However, the introduction of vNOTES-H has been delayed in many Japanese regional core hospitals because of its specific device and skill requirements. Therefore, the characteristics and advantages should be explained for the widespread use of this technique.

Study design

We reviewed the medical records of 17 patients with vNOTES-H and 94 patients with total laparoscopic hysterectomy (TLH) from January 1, 2015 to December 31, 2022. In this analysis, to compare the results of vNOTES-H to TLH, we excluded certain patients with a relatively heavy uterus (>255 g) and the presence of abdominal adhesions. In this report, first, the characteristics of the vNOTES-H procedures using a transvaginal access platform are explained by referring to one representative patient. Second, the patient characteristics of the vNOTES-H and TLH groups, including operation time and blood loss amount, were compared. Then, to detect the influence of vNOTES-H on the difficulty of operation among all 111 patients, we performed a multivariate logistic regression analysis to assess the influence of each of 9 factors, including "vNOTES-H", "Advanced age", "High BMI", "3 parity", "Gynaecological operation history", "Adenomyoma", "Large leiomyoma", "Heavy uterus" and "Large uterus", on the two indexes, including "Short time operation" and "Massive blood loss".

Results

In the simple comparison between the groups with vNOTES-H and TLH, the operation time in the former group was significantly shorter than in the latter group, although other factors did not show significant differences, including blood loss amount. Moreover, in the multivariate logistic regression analysis of all 111 patients, the "vNOTES-H" factor showed a significantly high possibility of "short time operation", although no factor, including "vNOTES-H", showed a significant influence on "massive blood loss".

Conclusions

vNOTES-H showed advantages in terms of operation time without increasing blood loss for patients with a relatively small uterus. However, to expand the selection for vNOTES-H, we should accumulate further patients and perform more analyses.

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.

vNOTES Hysterectomy: What about Obese Patients?

STUDY OBJECTIVE

To compare the surgical outcomes of hysterectomy by vaginal natural orifice transluminal endoscopic surgery (vNOTES) for patients with body mass index (BMI) <30 and BMI ≥30.

DESIGN

A retrospective cohort study.

SETTING

A French teaching hospital.

PATIENTS

All patients who underwent a vNOTES hysterectomy from February 2020 to January 2022 were included (N = 200). The vNOTES approach was chosen for all patients requiring a hysterectomy, unless the procedure was for endometriosis or cancer (except grade 1 endometrioid adenocarcinoma).

INTERVENTIONS

Patients were categorized into 2 groups based on their BMI (<30 or ≥30 kg/m²). The population characteristics, surgical outcomes, and hospitalization outcomes were compared. The main outcome was the intraoperative conversion rate. Secondary end points were blood loss, operative time, perioperative and postoperative complications, and same-day surgery management.

MEASUREMENTS AND MAIN RESULTS

A total of 146 patients were included in the BMI <30 group, and 54 patients in the BMI ≥30 group. There was no statistical difference between obese and nonobese patients concerning intraoperative conversion (p = .150), with 4 cases occurring in the BMI <30 group (2.74%) and 4 occurring in the BMI ≥30 group (7.41%). Operative times were longer in obese patients (115.93 min [±55.28] vs 79.78 min [±40.38], p <.001). There was no significant difference in blood loss (p = .337) or perioperative and postoperative complications (p = .346 and p = .612, respectively). The ability to complete the surgery as a same-day procedure was no different between obese and nonobese patients (p = .150).

CONCLUSION

The results concerning intraoperative conversion and perioperative and postoperative complications show that vNOTES hysterectomies seem to be feasible for obese patients. When same-day surgery was decided before surgery, no more obese than nonobese patients were converted to conventional hospitalization. Further studies are needed to confirm these observations.

Laparoendoscopic Single-Site Surgery (LESS): A Shift in Gynecological Minimally Invasive Surgery

Laparotomy was once the preferred modality of treatment for various gynecological conditions. However, over the years, with the advancements worldwide, a new technique for surgery, laparoscopy, came into play. Since then, laparoscopy is preferred over laparotomy for diagnostic and therapeutic purposes since it was less invasive than laparotomy. Further advancements include laparoendoscopic single-site surgery (LESS), which is a procedure that, as the name implies, only uses one port. It includes using a single incision near the umbilicus in contrast to laparoscopy, which traditionally includes one main port incision and various other side ports. Through the port, multiple devices can be inserted into the cavity. The use of a single port can reduce post-operative complications and help reduce the duration of hospital stays. A single incision near the umbilicus would not leave a very significant scar, and the wound healing time would be comparatively less, reducing the hospital stay time. This novel technique is, therefore, an amalgamation of traditional surgery and recently surfacing minimally invasive surgery. Other modalities which are being used widely include vaginal natural orifice transluminal endoscopic surgery (vNOTES). Since the ports formed are frequently inconspicuous, these procedures leave patients with "scarless" results.

vNOTES Hysterectomy, Adnexectomy and Uterosacral Ligament Suspension: A Walk-through Guide

OBJECTIVE

To provide a stepwise guide to performing vNOTES hysterectomy, adnexectomy and vault suspension, using two access platform methods.

DESIGN

Narrated surgical video based on two cases of vNOTES for abnormal uterine bleeding and endometrial intra-epithelial neoplasia.

SETTING

A single tertiary-care academic centre.

INTERVENTIONS

Step-by-step walk-through is shown to demonstrate the successful completion of a hysterectomy, adnexectomy, and vault suspension. Use of a traditional glove platform and that of an advanced access system, the GelPOINT Access System® (Applied Medical, Rancho Santa Margarita, CA, USA), are illustrated. The surgical steps are summarized as: (1) colpotomy and abdominal entry; (2) transection of the uterosacral ligaments; (3) placement of an access platform; (4) upper abdominal survey; (5) transection of the uterine and cornual pedicles; (6) identification of the ureters; (7) bilateral salpingo-oophorectomy; (8) uterosacral ligament suspension; (9) cystoscopy; (10) vaginal vault closure and tying of the suspension sutures.

CONCLUSION

This video demonstrates the steps to safely reproduce a vNOTES hysterectomy, adnexectomy and uterosacral ligament suspension with two access techniques. vNOTES offers scar-free surgery, improved access to high pedicles and surgical fields, and a favourable recovery profile, making it an attractive surgical route in appropriate candidates.

Comparison of Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) and Laparoendoscopic Single-Site (LESS) Hysterectomy on Postoperative Pain Reduction: A Randomized Pilot Study

INTRODUCTION

Vaginal natural orifice transluminal endoscopic surgery (vNOTES) hysterectomy has shown benefit in postoperative pain and operation time compared to laparoscopic hysterectomy in recent studies. However, no prospective studies comparing laparoendoscopic single-site (LESS) and vNOTES hysterectomy have been performed. This study aims to evaluate postoperative pain and safety of vNOTES hysterectomy compared to LESS hysterectomy for benign uterine disease.

METHODS

This study is a prospective, investigator-initiated randomized controlled pilot trial. A total of 26 patients were randomized and allocated to vNOTES group (n = 13) and LESS group (n = 13). The primary outcome was postoperative abdominal and vaginal pain evaluated 24 h after surgery. Secondary outcomes included the number of additional analgesics administered and the maintenance rate of patient-controlled analgesia (PCA).

RESULTS

No differences were shown in baseline characteristics between the two groups. Operation time was longer in the LESS group (median, 55 vs. 75 min; P = 0.027), and there were no differences in estimated blood loss, postoperative hemoglobin level, surgical indications, and hospitalization days. Postoperative abdominal pain intensity did not differ between the two groups, while the vNOTES group showed higher postoperative vaginal pain than the LESS group at 16 and 24 h after surgery (median, 3 vs. 1 and 2 vs. 0, P = 0.007 and P = 0.010, at 16 and 24 h respectively). No differences were shown in the number of additional analgesics and PCA use between the two groups.

CONCLUSIONS

vNOTES hysterectomy can be safely performed for benign uterine disease requiring hysterectomy. However, vNOTES hysterectomy might be associated with higher postoperative vaginal pain intensity compared to LESS hysterectomy.

TRIAL REGISTRATION

CRIS identifier KCT0004605.

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.

Ectopic pregnancy management by V-NOTES technique

Ectopic pregnancy is a frequent and life-threatening risk of childbearing. Its management represents a mainstay of emergency gynecological surgery, and laparoscopy is the surgical gold standard technique. The technique of transvaginal natural orifice transluminal endoscopic surgery (V-NOTES) for the management of ectopic pregnancy is presented herein. The procedure is illustrated by an instructive video article that standardizes the essential steps to make the technique ergonomic and easy to perform (step-by-step explanations). This surgical technique allows to consider vaginal salpingectomy using a combined cœlio-vaginal approach. After a posterior colpotomy, an Alexis retractor was inserted in the pouch of Douglas followed by the placement of a dedicated platform on which three trocars were fixed. Pneumoperitoneum was then achieved. Once the diagnosis of ruptured tubal ectopic pregnancy was established, a salpingectomy was performed. As a minimally invasive approach, this procedure has high patient acceptance and seems to improve favorable clinical outcomes.

Systematic Review and Meta-Analysis on Hysterectomy by Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) Compared to Laparoscopic Hysterectomy for Benign Indications

(1) Objective: We aimed to report an update of the systematic review and meta-analysis by Baekelandt et al. (2016). (2) Method: We followed PRISMA guidelines to perform this systematic review. We searched MEDLINE, EMBASE, CENTRAL and additional sources and aimed to retrieve randomised controlled trials (RCTs), controlled clinical trials (CCTs) and prospective/retrospective cohort studies in human subjects that allowed direct comparison of vNOTES to laparoscopy. (3) Results: Our search yielded one RCT and five retrospective cohort trials. Pooled analysis of two subgroups showed that, compared to conventional laparoscopy, vNOTES is equally effective to successfully remove the uterus in individuals meeting the inclusion criteria. vNOTES had significantly lower values for operation time, length of stay and estimated blood loss. There was no significant difference in intra- and postoperative complications, readmission, pain scores at 24 h postoperative and change in hemoglobin (Hb) on day 1 postoperative.