Prioritizing vaginal hysterectomy: a stepped algorithm with vNOTES support for benign indications

Objective This prospective study aimed to evaluate the clinical outcomes of a standardized surgical algorithm adopting a “vaginal-first” approach in patients with non-descensus uteri. It sought to redefine vNOTES as an “educational bridge” and a “safety valve” within this framework. Materials and methods This single-center, prospective cohort study included 165 consecutive patients scheduled for hysterectomy for benign indications. A standardized stepwise algorithm was implemented: pure vaginal hysterectomy (VH) as the primary target; transition to vNOTES (second tier) in case of failure to progress; and laparoscopy or laparotomy as a final resort. All procedures were performed by a single surgeon. Results Vaginal completion without abdominal incision was achieved in 157 patients (95.2%). Pure VH was successful in 87.9% ( n = 145), while 7.3% ( n = 12) required vNOTES support, and 4.8% ( n = 8) were converted to laparoscopy/laparotomy. High success rates were maintained in high-risk subgroups, including obesity (93.1%) and previous cesarean sections (96.0%). Learning curve analysis showed a significant increase in pure VH rates (81.7–93.9%; p = 0.018) and a decrease in vNOTES utilization (11.0–3.6%; p = 0.045). Multivariable regression identified uterine weight as the sole independent predictor of pure VH failure. Conclusion A “vaginal-first” approach should be the standard of care for non-descensus uteri. vNOTES functions not just as a routine method, but as an educational catalyst that enhances surgical proficiency and a critical safety valve that prevents abdominal conversion. This stepped approach optimizes resource utilization while maximizing minimally invasive benefits.