Functional Outcomes After Vaginal Natural Orifice Transluminal Endoscopic Surgery Hysterectomy: A Systematic Review of Sexual Function and Pelvic Floor Integrity

INTRODUCTION: Vaginal hysterectomy is guideline-preferred for benign disease, yet uptake is declining. Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) offers enhanced visualisation while optimising recovery; however, impact on functional outcomes remains unclear. AIMS: To evaluate sexual function and pelvic floor outcomes following vNOTES hysterectomy compared with minimally invasive alternatives. METHODS: A systematic review was conducted per PRISMA 2020 and Cochrane guidelines (PROSPERO CRD420251247524). MEDLINE, Embase, Cochrane and Scopus were searched to February 2026. Comparative studies (≥ 25 vNOTES patients) reporting functional outcomes (Female Sexual Function Index [FSFI], Pelvic Floor Distress Inventory [PFDI], International Consultation on Incontinence Questionnaire [ICIQ], Pelvic Organ Prolapse Quantification [POP-Q]) were included. Non-comparative studies and those without validated measures were excluded. Risk of bias was assessed using RoB2 and Newcastle-Ottawa Scale. Results were synthesised narratively (SWiM). RESULTS: Five studies (n = 526; one randomised trial, four cohort studies) were included. Sexual function was equivalent between vNOTES and laparoscopic approaches at 3-6 months. One study with variable follow-up extending beyond 6 months reported higher FSFI scores (p = 0.003), whereas others showed no difference (p > 0.05). Dyspareunia rates were comparable (2 studies). Pelvic floor outcomes (1 study) were limited, suggesting improved anterior compartment support (POP-Q Aa; p < 0.003), with similar apical and posterior support. Overall certainty of evidence was low. DISCUSSION: vNOTES hysterectomy demonstrates comparable medium-term sexual and pelvic floor outcomes to laparoscopic approaches, with no signal of harm. Small samples, observational design and heterogeneity limited evidence, restricting definitive conclusions. Standardised long-term studies are required to define functional safety and guide counselling.