Comparison of Surgical Outcomes of Total Laparoscopic Hysterectomy and vNOTES Hysterectomy for Undescended-Enlarged Uteri

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.

Same-Day Discharge is Safe, Feasible Following Vaginal Hysterectomy with Apical Suspension

Purpose

Studies involving minimally invasive hysterectomy and robotic sacrocolpopexy have demonstrated safety and feasibility of same-day discharge. There are limited data, however, on same-day discharge outcomes for vaginal hysterectomy and pelvic reconstruction. This study aimed to compare 30 and 90-day surgical outcomes between same-day discharge versus overnight stay following vaginal hysterectomy and apical suspension.

Patients and Methods

This retrospective study evaluated surgeries performed over two time periods. Overnight stay was standard between December 2018 and February 2020. Same-day discharge was standard from December 2020 to February 2022. All patients who underwent vaginal hysterectomy with apical suspension were included. The primary outcome was to determine if there was an increase in 30-day readmission rates. Secondary outcomes included emergency department visits and reoperations within 30 days, the previous variables at 90 days, and the rate for successful same-day discharge.

Results

A total of 324 patients were analyzed over the 30 months: 149 (46%) in the overnight stay group and 175 (54%) in the same-day discharge group. At 30 days, no difference was found between groups for readmissions (2.7% vs 4.0%, p = 0.56), emergency department visits (14.8% vs 14.9%, p = 1.0), or reoperations (2.0% vs.1.7%, p = 1.0). At 90 days, outcomes were also similar. Same-day discharge as standard practice was successful in 80% of patients.

Conclusion

In this retrospective two cohort study, the safety of same-day discharge following vaginal hysterectomy with apical suspension was demonstrated with no increased risk of 30 or 90-day readmissions, emergency visits, or reoperation rates. The majority (80%) of patients were discharged on the day of surgery, suggesting feasibility of this model.

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.

Impact of Uterine Weight and Shape on vNOTES Hysterectomy: Analysis of 238 Consecutive Cases

STUDY OBJECTIVE

To compare the perioperative outcomes of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) hysterectomies for different uterine weights and shapes.

DESIGN

Observational study.

SETTING

Swiss teaching hospital.

PATIENTS

Women who underwent vNOTES hysterectomy for benign conditions between May 2020 and July 2023 (N = 238). Patients were divided into 4 subgroups depending on uterus weight and shape. Uteri weighting <280 g were classified as type 0. Uteri weighting ≥280 g were categorized as type 1 (no vascular pedicle displacement), type 2 (cranial displacement of adnexal vascular pedicles), and type 3 (displacement of uterine arteries).

INTERVENTIONS

All women underwent vNOTES hysterectomies. We compared perioperative outcomes for the 4 subgroups.

MEASUREMENT AND MAIN RESULTS

We classified 168 patients (70.6%) as uterus type 0, 33 patients (13.9%) as type 1, 24 patients (10.1%) as type 2, and 13 patients (5.4%) as type 3. Mean uterine weight was 135.8 ± 59.5 g in type 0, 398.0 ± 167.3 g in type 1, 603.5 ± 217.9 g in type 2, and 661.7 ± 281.6 g in type 3. Operative time in type 0 (65.1 ± 30.9 minutes) and type 1 (65.1 ± 24.0 minutes) was shorter than in type 2 (102.3 ± 60.0 minutes) and type 3 (115.2 ± 40.3 minutes). Blood losses were more significant in type 2 (158.5 ± 212.0 mL) and type 3 (158.5 ± 110.7 mL) than in type 0 (85.6 ± 113.5 mL). No difference in the rate of total complications among groups was observed (8.3%, 3.0%, 12.5%, and 15.4% in types 0, 1, 2, and 3, respectively).

CONCLUSION

The displacement of the vascular pedicles seems associated with longer operative time and more blood loss and could represent a marker for technical difficulty in vNOTES hysterectomy. However, it does not influence the perioperative complication rate.

Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) in gynecological emergencies

Objective

Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) is an emerging minimally invasive approach increasingly applied to perform many gynecological procedures. Despite a still limited level of evidence, compared to conventional laparoscopy, vNOTES seems to be associated with reduced blood loss, shorter operative time, less postoperative pain, shorter hospitalization time, better cosmetic results and decreased postoperative morbidity. Although growing evidence supports the effectiveness of vNOTES for elective adnexal surgeries, there is still limited knowledge regarding its feasibility and safety in emergency settings. In the present study, we report our experience performing vNOTES in gynecological emergency cases.

Study design

We prospectively collected and analyzed data from patients who underwent vNOTES for gynecological emergencies between November 2021 and June 2023. Demographic and perioperative characteristics were collected and analyzed.

Results

Seventeen patients were included. Interventions were realized for suspicion of ectopic pregnancy in 7 cases (41.2%), for suspicion of adnexal torsion in 7 cases (41.2%), for post-hysterectomy hemoperitoneum in 2 cases (11.8%), and for uncontrollable uterine bleeding in 1 case (5.9%). Emergency procedures included unilateral salpingectomy (35.3%), ovarian cystectomy (23.5%), ovarian cystotomy (17.6%), adnexal detorsion (11.8%), hemoperitoneum drainage (11.8%), hysterectomy (5.9%), and appendectomy (5.9%). The overall median operative time was 38 [18-72] minutes. The median estimated intraoperative blood loss was 30 [5-150] mL, and no intraoperative complications occurred. Conversion to conventional laparoscopy or laparotomy was never needed. Patients stayed hospitalized for a median time of 30 [4-144] hours after the intervention. The median visual analog scale value for postoperative pain evaluation was 2 [0-5] at 12, 24, and 48 postoperative hours. No complications associated with the procedure occurred.

Conclusions

This study demonstrated the feasibility of performing vNOTES procedures for managing gynecological emergencies such as tubal ectopic pregnancy, adnexal torsion, painful ovarian lesions, post-hysterectomy hemoperitoneum, and uncontrollable uterine bleeding. Associated with data reported in the available literature, our results suggest potential benefits in treating gynecological emergencies by vNOTES over conventional laparoscopy. However, stronger evidence from larger studies is needed to confirm it.

Impact of gasless vNOTES vs. traditional vNOTES on hemodynamic profiles and outcomes in patients with benign gynecological disease: study protocol of a randomized controlled trial

BACKGROUND

Literature regarding the advantages of gasless vNOTES is insufficient. The aim of our study is to compare gasless vNOTES vs. traditional vNOTES on hemodynamic profiles and outcomes in patients with benign gynecological disease. We hypothesize that compared with those in the traditional vNOTES group, hemodynamic profiles will be changed less during gasless vNOTES, while safety can be promised.

METHODS

This is a single-center, prospective, single-blind, randomized controlled clinical trial, which has been approved by the Institutional Review Board of Chengdu Women's and Children's Hospital on September 27, 2022. One hundred and twenty patients will be recruited and randomly assigned to either the traditional vNOTES group or the gasless vNOTES group in a 1:1 ratio. For patients allocated to the traditional vNOTES group, after insertion of one port through the vagina, CO2 gas is infused with a pressure of 12-14 mmHg; while for those allocated to the gasless vNOTES group, a special device is used as an abdominal wall-lifting device to facilitate gasless surgery. CO2 pneumoperitoneum will not be used during the whole gasless vNOTES procedure. The primary outcome is vital signs at different time points. The secondary outcomes include surgical conversion rate, duration of surgery and anesthesia, anesthetic consumption, intraoperative estimated blood loss, VAS and PONV scores at postoperative 2 h and 24 h, administration of vasopressor drugs from the beginning of general anesthesia induction to 15 min after endotracheal intubation, including times, dosage, and type, intraoperative and postoperative complications, time of first getting out of bed after surgery, and time of first eating after surgery, including light drink.

DISCUSSION

This is the first randomized controlled trial to compare the impacts of gasless vNOTES vs. traditional vNOTES on hemodynamic profiles and outcomes in patients with benign gynecological disease. If a favorable effect and safety of gasless vNOTES for hemodynamic profiles and outcomes in patients are shown, gasless vNOTES would be an optimal treatment option for patients with benign gynecological disease.

TRIAL REGISTRATION

The trial was registered at https://www.chictr.org.cn/showproj.html?proj=182441 with registration No. ChiCTR2200064779 on Oct 17, 2022.

Development and validation of nomograms to predict preoperative anxiety and postoperative pain in patients undergoing gynecological surgery: An observational analysis

BACKGROUND

Perioperative anxiety and pain are associated with patient dissatisfaction, postoperative complications, and prolonged hospital stay. Early identification of high-risk patients with preoperative anxiety and postoperative pain will be useful for the implementation of preventive management.

METHODS

Patients, who underwent gynecological surgery in our hospital between March 2022 and September 2022, were consecutively enrolled. Perioperative anxiety and pain were evaluated with the Visual Analogue Scale of Anxiety (VAA) and Visual Analogue Scale of Pain (VAS), respectively. Step Akaike Information Criterion analysis was performed to identify risk factors and logistic regression was used to establish nomograms, followed by discrimination, calibration, and clinical utility evaluation.

RESULTS

A total of 197 patients were included for analysis, including 116 and 81 patients who were randomized to training and test groups, respectively. The prediction model of preoperative moderate to severe anxiety identified four preoperative relevant factors: age, sleep duration, preoperative pain, and regular exercise before gynecological surgery. The model had an area under the receiver operating characteristics curve of 0.808 (0.729, 0.887) and 0.754 (0.634, 0.875) in the training and test groups, respectively. The prediction model of postoperative moderate to severe pain identified four relevant factors: preoperative pain, surgery type, VAA before anesthesia, and patient-controlled analgesia. The model had an area under the receiver operating characteristics curve of 0.867 (0.798, 0.935) and 0.852 (0.761, 0.943) in the training and test groups, respectively.

CONCLUSIONS

The established nomograms accurately identified high-risk patients with preoperative anxiety and postoperative pain before gynecological surgery. Clinical registration at: www.chictr.org.cn (ChiCTR2200057757).

Robotic-assisted vaginal natural orifice transluminal endoscopic surgery versus robotic-assisted single-site port for benign hysterectomy: a comparison of surgical outcomes

The objective of this study is to evaluate the surgical outcomes for robotic-assisted vaginal natural orifice transluminal endoscopic surgery (R-VNOTES) hysterectomy versus robotic-assisted single-site port (RSSP) hysterectomy when performed for benign indications. This is a retrospective chart review in an academic tertiary setting. 404 patients underwent hysterectomy for benign indications. R-VNOTES hysterectomy and RSSP hysterectomy were performed by a single minimally invasive gynecologic surgeon from January 2015 to August 2022. The primary outcome of our study was total operative time (minutes). Secondary outcomes included estimated blood loss (mL), length of hospital stay (days), and postoperative pain score. Other intraoperative and postoperative surgical complications were also compared. 159 patients underwent R-VNOTES hysterectomy, and 269 patients underwent RSSP hysterectomy. Median length of surgery (minutes) demonstrated a statistically significant shorter operative time in the R-VNOTES hysterectomy group when compared to the RSSP hysterectomy group, (132 min versus 146 min, respectively, p = 0.0001). Additionally, patients in the R-VNOTES hysterectomy group experienced decreased postoperative pain levels at week 1 (6 versus 7, respectively, p = 0.01) and week 3 (1.5 versus 2.5, respectively, p = 0.01) after surgery. There were no statistically significant differences between the two groups when comparing length of hospital stay, estimated blood loss, and weight of the uterus. There was no difference in rates of urinary tract infection, blood transfusion, bowel injury, readmission, reoperation, conversion, deep surgical site infection, and venous thromboembolism between both groups. However, there was a higher rate of superficial SSI in the RSSP hysterectomy group (0.6% versus 4.5%, respectively, p = 0.03). When compared to RSSP hysterectomy, R-VNOTES hysterectomy is safe and feasible, as both approaches have comparable surgical outcomes. Patients undergoing R-VNOTES hysterectomy had shorter length of surgery, decreased postoperative pain, and lower rates of superficial surgical site infections.

Study on the Efficacy of "Information Platform + Self-Care Model" on the Health Status of Discharged Patients Following Vaginal Natural Orifice Transluminal Endoscopic Surgery

Objective

To discuss the impact of the "information platform + self-care model" on the health status of discharged patients following vaginal natural orifice transluminal endoscopic surgery (vNOTES).

Methods

Patients underwent vNOTES at a tertiary specialized women's and children's hospital in Chengdu. They were randomly assigned to one of two groups-the intervention group (29 patients) and the control group (29 patients). The control group received standard education after discharge, while the intervention group received guidance based on an "information platform + self-care model" on discharge; a questionnaire survey was conducted for both groups one month after discharge.

Results

The quality of life score in the intervention group was higher than that in the control group, and the difference was statistically significant (P < 0.05); the scores of the intervention group on dimensions such as vitality, general health perceptions, physical role functioning, social role functioning, emotional role functioning, and mental health, except for physical functioning (Z = 0.034, P = 0.973) and bodily pain (Z = 1.470, P = 0.141), were higher than those in the control group one month after discharge, and the difference was statistically significant (P < 0.05). There was no patient (0) in the intervention group who had an unscheduled visit/admission, and there was 1 patient (3.6%) in the control group who had unscheduled visit/admission; there were no statistical differences between the two groups in the number of patients who had an unscheduled visit/admission 1 month after discharge (P = 0.491).

Conclusion

The application of the "information platform + self-care model" can, to a certain extent, improve the health status of patients following vNOTES after discharge, and it can also reduce unscheduled visits/admissions, but more research with a larger sample size is required.

Implementing the transvaginal natural orifice transluminal endoscopic surgery (vNOTES) "first" strategy in benign gynecological surgeries

PURPOSE

The use of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) as the first choice of surgical route for patients scheduled to undergo conventional laparoscopy is still being debated. We aimed to evaluate and compare the outcomes of the "vNOTES first" strategy in benign gynecological cases.

METHODS

All benign gynecological surgeries were initiated using vNOTES during the study period, regardless of the difficulty. Surgical outcomes, short-term patient satisfaction and sexual pain were compared between hysterectomies, adnexal and diagnostic procedures. Visual Analog Score (VAS), Patients Global Impressions of Improvements scale (PGI-I) and Female Sexual Function Index (FSFI) were used to assess the postoperative pain, satisfaction and sexual pain, respectively.

RESULTS

A total of 105 vNOTES procedures were performed during the study period: 63 (60.58%) adnexal procedures, 36 (34.62%) hysterectomies, 5 (4.81%) diagnostic procedures and one (0.96%) myomectomy. The median 24th hour VAS scores for adnexal, hysterectomy, and diagnostic procedures were 1.29 ± 1.41, 2.06 ± 2.08, and 2.6 ± 2.41, respectively. The satisfaction rate was 96.19% at the 1st postoperative week and 97.14% at the first month. There was either no change or a slight improvement in the patients' total score on the FSFI/pain domain before and after surgery. There were two conversions (1.9%) from vNOTES to laparoscopy and laparotomy, and two (5.56%) bladder injuries in hysterectomy cases.

CONCLUSION

Implementing the vNOTES technique as an initial approach for all benign gynecological surgeries seems feasible, safe and satisfactory, even in those with a non-prolapsed or enlarged uterus and those that have previously undergone abdominal surgery. The pain scores were found to be low and patients stated a high satisfaction with no or better change in their sexual life.

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.

Analysis of Different Routes of Hysterectomy Based on a Prospective Algorithm and Their Complications in a Tertiary Care Institute

Introduction

Hysterectomy is the most common gynaecological operation worldwide. The objective of the study is to analyze the various routes of hysterectomy and its complications when the decision of route is based on using a prospective algorithm tree. Methodology. It is an observational study to analyze the route of hysterectomy based on using a prospective algorithm. The decision tree is based on pelvic pathology, uterine size, vaginal access, pelvic adhesion, competency of the surgeon, choice of the patient, and complication of different routes of hysterectomy. Data were collected from preoperative, intraoperative, and postoperative records. Demographic factors, indications, routes of hysterectomy, and complications were recorded and analyzed by using SPSS software version 22. Observation. Among the malignant or suspected malignant pathology groups, TAH was performed in 89 cases and TLH was performed in 3 cases. Among the benign disease groups, VH was performed in 137(38.2%) cases, TAH was performed in 118(32.9%) cases, and TLH was performed in 104 (28.9%) cases. Operative time and a number of blood transfusions were significantly less with VH (p value < 0.0001 and 0.004) compared to abdominal and total laparoscopic hysterectomy. Postoperative complication such as fever was more with abdominal hysterectomy (<i>p-</i>value<0.00001) compared to VH and TLH. Vaginal discharge was more with VH and TLH compared to TAH (p value −0.004) and wound infection was more in the abdominal route (p value 0.001).

Conclusion

The abdominal route was the route of choice for surgery in malignancy or suspected malignant pathology. In benign pathology, VH was the most common and preferable route of surgery. Complications were found to be minimal with vaginal hysterectomy.