Comparative outcomes of robotic single-port vNOTES versus robotic-Xi assisted single-incision transumbilical surgery for hysterectomy

Introduction This study was to evaluate the safety and feasibility of robotic single-port transvaginal natural orifice transluminal endoscopic surgery (RSP-vNOTES) compared with robotic Xi-assisted single-incision transumbilical surgery (RXi-SITS) for hysterectomy. Method A total of 405 patients was retrospectively analyzed, comprising 278 individuals who underwent RXi-SITS hysterectomy and 127 who underwent RSP-vNOTES hysterectomy. Results A significantly higher prevalence of endometriosis-associated concomitant procedures, including ovarian cystectomy, lesion excision, adhesiolysis, appendectomy, bowel shaving, and bowel oversew, was observed among patients undergoing RSP-vNOTES (all p 0.05). The RXi-SITS group saw uterosacral ligament suspension and ovarian vein ligation more commonly performed (both p 0.05). A multivariable linear regression approach was employed to account for heterogeneity in procedural complexity. Following multivariable adjustment, estimated blood loss, hysterectomy time, and postoperative pain outcomes were comparable between the two surgical approaches. In contrast, multivariable linear regression accounting for concomitant procedures demonstrated that the RXi-SITS approach was independently associated with a significantly prolonged total operative time, with an adjusted mean increase of 21.8 min compared with RSP-vNOTES (B = 21.83; 95% CI: 6.05-37.61; p = 0.007). This is despite unadjusted analyses showing a longer median operative time in the RSP-vNOTES group (160 IQR 140-194 vs. 151 120–200 minutes; p = 0.02). Discussion Compared with RXi-SITS hysterectomy, RSP-vNOTES hysterectomy demonstrated comparable surgical outcomes, supporting its safety and feasibility across a range of gynecologic procedures. Despite greater procedural complexity in the RSP-vNOTES cohort, the RXi-SITS approach was independently associated with a longer total operative time, suggesting a potential efficiency advantage of RSP-vNOTES in appropriately selected patients.