A Comparison of vNOTES to Traditional Vaginal Hysterectomy on Surgical Outcomes and Future Interest in Vaginal Surgery

INTRODUCTION: ACOG reports that the vaginal hysterectomy is the most preferred route of hysterectomy whenever feasible. However, even with this recommendation there has been a steady decline in vaginal hysterectomies. In 2010 an additional method to perform vaginal hysterectomies, vaginal natural orifice transluminal endoscopic surgery (vNOTES), was first reported. The theoretic advantage of this technique is the ability to perform more complex cases vaginally that were previously approached using the laparoscopic route. To date, there have not been published comparisons of vNOTES to vaginal hysterectomy to help validate the theoretic advantages. OBJECTIVE: To gain an understanding of the patient populations undergoing hysterectomy via vNOTES versus traditional total vaginal hysterectomies (TVH); comparing patient characteristics and surgical outcomes to see if vNOTES technique is a reasonable alternative to TVH. The secondary purpose was to assess the impact of vNOTES training and future vaginal hysterectomies among general OBGYNs. METHODS: We performed a retrospective cohort analysis of patients who underwent vaginal hysterectomy for benign indications at a single-center, multi-site health system between 1/2018 and 12/2024. Patients who had a hysterectomy performed for treatment of prolapse were excluded. Patient demographics and surgical characteristics were extracted from the electronic medical record. Primary outcome was any surgical complication. Secondary outcomes were operative time, successful adenectomy, blood loss, and conversion to different approach. Log-binomial regression models were used to estimate relative risks (RR) of composite outcomes (intraoperative complications, postoperative complications, any complications) in patients undergoing TVH versus vNOTES. In addition, general OBGYNs who trained at the center in the past 10 years were surveyed on their interest in performing vaginal hysterectomies beyond training. RESULTS: Among a total of 342 vaginal hysterectomies, 150 cases were performed for non-prolapse indications. Of these, 99 were completed using traditional vaginal technique, and 51 were performed utilizing the vNOTES technique. Those undergoing vNOTES had a higher median BMI (31.7 vs 29 kg/m2, p=0.027). Any surgical complication, including any intraoperative and postoperative Clavien–Dindo grade 1–3, was less common among those undergoing vNOTES (16.7% vs 33.3%, RR 1.24, 95% 0.64, 2.39; Table 2), however not statistically significant. Median uterine weight was larger for those undergoing vNOTES (Table 1). Median operative time was slightly longer in vNOTES; however, adnexal surgery was more likely to be completed with vNOTES. Conversion to laparoscopy/laparotomy and median blood loss did not differ between surgical approach. The graduate survery was sent to a total of 40 individuals with 18 responses. Of the 13 who perform GYN surgery, 5 perform vaginal hysterectomies. Of those 5, 3 were exposed to vNOTES in residency; however, only 1 reports this is their preferred technique. When asked, participants believed a formal training program and skilled assistance would increase their interest in vaginal hysterectomies. CONCLUSIONS: The vNOTES technique has allowed us to offer more obese women with larger uteri an outpatient, vaginal hysterectomy experience with overall fewer complications. vNOTES has also increased the success of concomitant salpingectomies. There remains a need for dedicated surgical mentorship and skilled assistants post-residency to preserve vaginal hysterectomy skills.Table 1