Postoperative Recovery Following Vaginal Natural Orifice Transluminal Endoscopic Surgery Versus Total Laparoscopic Hysterectomy in Older Women: A Retrospective Cohort Study

Background:Minimally invasive hysterectomy techniques are increasingly preferred in older women because they may reduce surgical trauma and facilitate postoperative recovery. This study aimed to compare postoperative recovery outcomes between vaginal natural orifice transluminal endoscopic surgery (V-NOTES) and total laparoscopic hysterectomy (TLH) in women aged ≥60 years.Methods:This retrospective cohort study used a per-protocol analysis comparing 43 completed V-NOTES cases with 44 TLH cases. 5 planned V-NOTES procedures requiring conversion to laparotomy were classified as Clavien–Dindo grade IIIb complications. Primary outcomes included time to ambulation, return to daily activities, and visual analog scale (VAS) pain scores on postoperative days 1, 3, and 7. Multivariable linear regression was employed to adjust for age, body mass index (BMI), parity, presence of ≥1 comorbidity, and prior pelvic surgery.Results:In unadjusted analyses, the V-NOTES group showed significantly lower estimated blood loss, shorter hospital stay, earlier ambulation, faster return to daily activities, and lower postoperative pain scores compared with the TLH group. After multivariable adjustment for age, BMI, parity, presence of ≥1 comorbidity, and prior pelvic surgery, only postoperative day 1 pain remained independently associated with surgical approach (β = −1.16, 95% confidence interval [CI]: −2.13 to −0.19; p = 0.028). Differences in time to ambulation and return to daily activities did not retain statistical significance after adjustment.Conclusion:For women aged ≥60, V-NOTES was associated with significantly lower early postoperative pain compared with TLH. Although unadjusted functional recovery metrics initially appeared superior, these differences lost significance after adjustment for age and BMI. These findings suggest that although V-NOTES may provide advantages in early postoperative recovery, patient-related factors and procedural feasibility remain important determinants of postoperative outcomes in older women.