Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES): A Survey on Attitudes and Barriers Among Practicing Gynecologic Surgeons

INTRODUCTION: The three major approaches to gynecologic surgery remain abdominal (open), transabdominal minimally invasive surgery (MIS), and vaginal approaches. The American College of Obstetricians & Gynecologists recommends vaginal hysterectomy as the preferred approach to hysterectomy whenever feasible due to the lowest rate of complications, lowest cost, and fastest recovery. Since the introduction of laparoscopy and robotic-assisted laparoscopy in the United States, the abdominal and vaginal hysterectomy rates have declined as transabdominal MIS routes increased. The introduction of vaginal natural orifice transluminal endoscopic surgery (vNOTES) has emerged as an alternative to the transabdominal MIS route. OBJECTIVE: The aim of this study was to evaluate gynecologic surgeons' attitudes towards vNOTES, as well as perceived barriers towards vNOTES for gynecologic surgeons. METHODS: We conducted a cross-sectional questionnaire of members of the Society of Gynecologic Surgeons from January 2025 to March 2025. A 24-item online survey was created to assess surgeon demographics, preferred approach to gynecologic surgery, surgical volume, exposure to vNOTES training, and potential barriers and benefits for performing vNOTES using a Likert scale. The scores for perceived benefits and barriers to vNOTES were summarized using medians and interquartile ranges, and the Wilcoxon rank-sum test was utilized to assess the differences in perceived benefits and barriers to vNOTES among users and non-users. Results yielding p<0.05 were considered statistically significant. RESULTS: Seventy gynecologic surgeons responded, with 67% practicing at academic or university institutions and 30% within 10 years of completing training. 50% percent were female and 43% had performed vNOTES. Common contraindications cited were narrow introitus (34%), prior pelvic radiation (53%), and prior rectal surgery (50%). Incentives for increased vNOTES use included higher reimbursement (29%), patient requests (24%), and institutional support (26%). Users rated vNOTES as offering better visualization (p<0.0001), easier adnexal access (p<0.0001), improved patient satisfaction (p=0.0040), and pain control (p=0.0100) as compared to non-users. Non-users ranked availability of vNOTES (p=0.0100), surgical complications (p=0.005), time to return to normal activities (p=0.0100), and patient satisfaction (p=0.002) as significant barriers to performing vNOTES as compared to users. Overall, improved visualization during vaginal surgery and easier access to the adnexa were the highest-ranked benefits of vNOTES across all participants. 64% of participants responded that they would recommend vaginal route of surgery for themselves or a family, while only 10.14% preferred vNOTES, and 14% laparoscopy. CONCLUSIONS: Our study demonstrates that all participants found vNOTES helpful in improving visualization during vaginal surgery and accessing the adnexa during vaginal surgery. However, respondents to this survey still prefer the vaginal route of surgery over vNOTES and laparoscopy. Improving reimbursement or decreasing the cost of vNOTES may contribute to increasing use by gynecologic surgeons. Potential future studies could focus on a qualitative evaluation of surgeon and external factors in decision-making for choosing the route of hysterectomy.Table 1Table 2Table 3Table 4Table 5