OBJECTIVE: While the laparoscopic approach is the surgical treatment of choice for ectopic pregnancy, vNOTES is emerging as an alternative route with its good optical visibility and avoidance of abdominal incisions. The authors compare demographics and outcome data of vNOTES vs conventional laparoscopic salpingectomy for the surgical management of ectopic pregnancy.
METHODS: Case control study SETTING: A London University hospital PATIENTS: Women with ectopic pregnancy unsuitable for medical management who underwent surgical management INTERVENTION: 25 cases of vNOTES vs 25 conventional laparoscopic salpingectomy MEASUREMENTS AND MAIN RESULTS: The mean patient age (29.7±53 vs 31.4±6.7 days), parity (1.2±1.1 vs 1.6±2.1), BMI (26.7±5.3 vs 27.2±5.4 kg/m3), gestation age (8.44±2.1 vs 7.3±1.7 weeks) and βhCG levels (3725.4±3674.8 vs 4376.5±6493.4 IU/litre) were comparable (p>0.05, t test) between patients having vNOTES vs conventional laparoscopic salpingectomy. While estimated blood loss was similar (218.2±491.7 vs 173.5±138.7 mls)(p>0.001), vNOTES patients had statistically shorter duration of surgery (35.8±14.4 vs 75.8±19.7 mins)(p<0.001, t test) and length of stay (median: 11.5 vs 19.7 hours)(U=72, p<0.05, Mann-Whitney U test). Less patients in the vNOTES group required postoperative opioids (9% vs 25%) and median Visual Analogue Score (/10) for pain at 24 hours was significantly lower (2.0 vs 4.0)(U=75, p<0.05, Mann-Whitney U test). Patients from the vNOTES group were able to return to normal daily activity 11.3 days quicker (5.8±4.3 vs 17.1±8.2 days)(p<0.05, t test). vNOTES cases cost approximately USD150 more due to the price of the commercial kits but this is offset by reduced intraoperative time, length of stay and need for postprocedure analgesia.
CONCLUSIONS: Patients undergoing vNOTES have shorter intraoperative times and length of stays, less postoperative pain and more rapid recovery, which help mitigate higher cost incurred by commercial kits. While the vNOTES approach for ectopic pregnancy appears safe and efficacious, more robust data from larger randomised studies are needed.

OBJECTIVE: Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) is a novel approach in gynecological surgery. This study was aimed at comparing perioperative and short-term postoperative outcomes of vNOTES versus laparoscopic approaches to uterosacral ligament suspension (USLS) for apical pelvic organ prolapse.
METHODS: A retrospective cohort study included all women who underwent vNOTES versus laparoscopic USLS at two university-affiliated centers between 2017 and 2023. The relationships between variables were tested using Fisher\'s exact test or t test, including a sub-analysis comparing hysterectomy and hysteropexy outcomes within the groups. Logistic regression assessed the influence of baseline factors and operative factors on the primary and main secondary outcomes of interest.
RESULTS: This study comprised 47 vNOTES and 54 laparoscopic USLS cases (including 11 and 15 hysteropexies respectively). Baseline demographics in the two groups were similar. There were no differences in operative outcomes and no instances of ureteral injury. The vNOTES technique allowed for the use of significantly more sutures per side (2.0 [2.0-4.0] vs 1.0 [1.0-1.0], p = 0.001). Postoperative complications within 6 weeks demonstrated no significant differences. Both groups exhibited comparable rates of baseline subjective POP symptoms (100% vs 96.2%, p = 1.00) which improved significantly at 6 weeks (4.3% vs 11.1%, p = 0.282). At 6 weeks, anatomical success was achieved by significantly more patients with vNOTES (93.5% vs 78.6%, p = 0.042). Baseline and 6-week POP symptoms in the hysterectomy and hysteropexy subgroups were similar.
CONCLUSIONS: Both vNOTES and laparoscopic USLS demonstrated comparable subjective success rates at 6 weeks postoperatively. The vNOTES approach demonstrated improved anatomical success at 6 weeks, but the difference was not significant after adjusting for operative factors.

UNASSIGNED: To identify the learning curve in ovarian cystectomy by vaginal natural orifice transluminal endoscopic surgery.
UNASSIGNED: Data consist of consecutively ordered patients who underwent ovarian cystectomy via vaginal natural orifice transluminal endoscopic surgery between May 2020 and June 2023. The learning curve of ovarian cystectomy via vaginal natural orifice transluminal endoscopic surgery was measured in terms of the operating time adjusted by multivariate linear regression. A cumulative sum analysis was performed to establish the learning curve. Patients\' characteristics and surgical outcomes were compared based on the inflection points of this curve.
UNASSIGNED: The learning curve was divided into two unique phases: phase 1 (1-26 patients), and phase 2 (27-40 patients). The expected operating time in phase 2 was shorter than in phase 1 (86.4 ± 11.2 min vs. 102.0 ± 22.7 min, p = 0.021). The time to first postoperative flatus was shorter in phase 2 compared with phase 1 (14.6 ± 6.5 h vs. 20.6 ± 6.3 h, respectively, p = 0.008). No significant differences were observed in terms of patient\'s age, BMI, tumor size, parity, bilateral ovarian tumor, pathological diagnoses, estimated blood loss, postoperative pain score, or perioperative complications between the two phases.
UNASSIGNED: Proficiency in ovarian cystectomy by vaginal natural orifice transluminal endoscopic surgery was achieved after 26 surgeries based on cumulative sum analysis. These findings may provide insight for structured training programs of ovarian cystectomy via vaginal natural orifice transluminal endoscopic surgery.

Vaginal natural orifice transluminal endoscopic surgery (vNOTES) for colorectal cancer utilizes transvaginal access for bowel mobilization, vascular pedicle ligation, oncological resection, and bowel anastomosis, along with subsequent transvaginal natural orifice specimen extraction (NOSE), reducing or eliminating the need for transabdominal access. In this report, we describe the technique of vNOTES right hemicolectomy for cecal cancer, with intracorporeal anastomosis and transvaginal NOSE, including a step-by-step operative video. The patient was a 59-year-old Chinese female (body mass index 32.0 kg/m2) with a cT3N0M0 3 cm cecal adenocarcinoma. Posterior colpotomy was created with insertion of a dual-ring wound protector. vNOTES D2 right hemicolectomy with a fully stapled intracorporeal anastomosis was performed via a homemade transvaginal glove port, using extra-long rigid instruments. A 10 mm, 30° rigid laparoscope was used for operative visualization through a transumbilical port, without additional percutaneous trocars. Operative difficulties pertained to suboptimal instrument reach, lack of triangulation, and frequent clashing within the restricted access space. Surgical duration was 300 min, with 50 ml of blood loss. There was minimal postoperative pain. Return of bowel function occurred on postoperative day 2, with discharge from hospital on postoperative day 3. The patient resumed normal daily activities and regular diet by 1-week post-surgery. Self-reported cosmetic satisfaction score was excellent. No operative complications were observed at 2 months\' follow-up. vNOTES right hemicolectomy with intracorporeal anastomosis is safe and feasible in highly selected colon cancer patients. Operators should be proficient in conventional laparoscopic colectomy and transvaginal NOSE. More experience with the vNOTES technique is required to ascertain best practices.

UNASSIGNED: Vaginal assisted Natural Orifice Transluminal Endoscopic Surgery (NOTES) combines the benefits of vaginal and endoscopic surgery. This study presents the results of the first vaginal assisted NOTES hysterectomies (VANH) in The Netherlands.
UNASSIGNED: A prospective cohort study was performed in two non-academic teaching hospitals in The Netherlands. Data was collected from patients who underwent a VANH for benign indications between August 2019 and April 2023. Baseline characteristics and data of intra- and postoperative surgical outcomes were recorded and analysed. The VANHs were performed by four experienced vaginal and endoscopic gynaecological surgeons.
UNASSIGNED: A total of 200 patients underwent a VANH. Indications were dysfunctional menstrual bleeding (61 %; n = 122), abnormal cervical cytology (15.5 %; n = 31), abdominal pain (11.5 %; n = 23), post ablation/sterilization pain syndrome (3.5 %; n = 7), uterine fibroids (5.0 %; n = 10), atypical endometrial hyperplasia (2.5 %; n = 5) and Lynch or BRCA gene mutation carriers (1.0 %, n = 2). The mean surgical time was 61.4 min ( ± 22.8 min) with a mean blood loss of 88 mL ( ± 89 mL) and a mean uterine weight of 150 g ( ± 112 g). In 2.0 % (n = 4) of the cases a conversion was necessary. Same day discharge (SDD) was feasible in 80.2 % (n = 105) of the patients planned in day-care. In 2.0 % (n = 4) an intra-operative complication and in 9.0 % (n = 18) a post-operative complication occurred.
UNASSIGNED: This study shows vNOTES to be a safe and feasible surgical technique and can be safely implemented with appropriate patient selection and skilled surgeons. It highlights the importance of surgeon awareness of the challenges inherent in the initial stages of the implementation of a new surgical technique when performing their first vNOTES procedures. Additional randomized clinical trials are needed to show superiority of vNOTES compared to traditional surgery.

UNASSIGNED: To evaluate safety, efficacy, pre- and postoperative outcomes of vNOTES hysterectomy compared to conventional laparoscopic (CL) hysterectomy.
UNASSIGNED: This prospective study was conducted on patients who underwent CL or vNOTES hysterectomy for benign gynecological indications between January and July 2021. Sociodemographic, clinical, and surgical data were collected. Health-related quality of life (HRQoL) outcomes were evaluated using the EQ-5D-5L questionnaire.
UNASSIGNED: A total of 228 patients (CL vs. vNOTES: 147 vs. 81) were included. No significant differences were observed between the two groups in terms of blood loss, uterine weight, complications, length of hospital stay, and readmission rate. Patients in the vNOTES group experienced significantly less postoperative pain and required less analgesia compared to those who underwent CL hysterectomy (p < 0.001). The CL group had a shorter operative time (p < 0.001). There was a significant difference between the two groups in the EQ-5D-5L pain/discomfort dimension (p = 0.047).
UNASSIGNED: This research showed that vNOTES has various advantages, such as less postoperative pain, reduced analgesic usage, and better HRQoL outcomes three months after surgery.

BACKGROUND: Vaginal hysterectomy (VH) rate is declining despite being considered as the optimal minimally invasive option for hysterectomy with reduced operative time and length of stay compared with laparoscopic hysterectomy (LH). Vaginal assisted natural orifice transluminal endoscopic surgery hysterectomy (VANH) combines the advantages of both vaginal and endoscopic approach to surgery.
OBJECTIVE: To report feasibility and early experience of a single surgeon adopting VANH at a tertiary Australian hospital.
METHODS: Prospective review of the first 20 VANH cases with complete data set collected retrospectively including patient demographics, indication for surgery and perioperative outcomes.
RESULTS: The median age of the first 20 participants was 51.5 years (47-57 years of age) and the median body mass index was 33.5 kg/m2 (27.8-38.3 kg/m2). The predominant indication was complex hyperplasia with atypia (12/20, 60%). The median parity was two (1-3) where four patients were nulliparous. The median blood loss was 125 mL (100-200 mL) with an operative time of 149 min (138-198 min) and median weight of the specimen of 181.5 g (66.5-219 g). The mean length of stay was 1.4 days (1-2 days). Five cases had conversion to laparoscopy and the majority (80%) occurred within the first ten cases.
CONCLUSIONS: VANH is feasible but there is a learning curve to achieve competence in this technique, which requires adequate training in the early stages of adoption with careful case selection. Until further robust data is available to determine the clinical benefit and safety profile of VANH, patients should be carefully counselled and the decision on mode of hysterectomy be individualised.

BACKGROUND: To explore the possibility of treatment with VNOTES sentinel lymph node dissection concept in patients with endometrial cancer.
METHODS: Patients who underwent VNOTES sentinel lymph node biopsy with the Comba modification were compared to patients who underwent conventional laparoscopic sentinel lymph node biopsy performed by the same surgical team. A total of 38 patients who underwent sentinel lymph node biopsy + total laparoscopic hysterectomy and bilateral salpingo-oophorectomy (BSO) were compared with 19 patients who underwent VNOTES retroperitoneal sentinel lymph node biopsy + hysterectomy and BSO. Surgical steps were described.
RESULTS: The average operation time, perioperative blood loss, the number of sentinel lymph nodes, presence of complications, and preoperative-postoperative hemoglobin-hematocrit differences, tumor stages, grades, largest tumor diameter, depths of invasion, and histological subtypes were similar in both the VNOTES and conventional laparoscopy groups. The postoperative pain scores were lower and the hospital stay was shorter in the VNOTES group than in the conventional laparoscopy group. No disease recurrence had been detected in either group at the time of writing.
CONCLUSIONS: Compared to conventional laparoscopy, sentinel lymph node biopsy with the VNOTES technique provides similar surgical results and is more advantageous in terms of postoperative pain and hospital length of stay.

BACKGROUND: There is a scarcity of prospective clinical research evidence regarding the utilization of transvaginal natural orifice translumenal endoscopic surgery (vNOTES) as a treatment option for ovarian cysts. The objective of this study was to assess the feasibility and safety of employing vNOTES for the management of ovarian cysts.
METHODS: Our study included women between the ages of 18 and 70 who intended to undergo surgical intervention for benign lesions. Stratified blocked randomization was employed to allocate participants into groups. The main objective was to assess whether the assigned group adhered to the recommended surgical technique for ovarian cystectomy or adnexectomy, without any deviation to alternative surgical methods.
RESULTS: A total of 196 patients were included in the study, with all surgeries in each group being conducted according to the assigned procedures. Among them, the ovarian cystectomy layer included 58 cases in the vNOTES group and 58 cases in the conventional laparoscopy (CL) groups. The adnexectomy layer included 40 cases in the vNOTES group and 40 cases in the CL group. Utilizing a sensitivity analysis, the two-sided 95% lower confidence limit was determined to be 5.5% for the disparity in proportions between the vNOTES groups and CL groups. These lower limits fell below the predetermined non-inferiority margin of 10%.
CONCLUSIONS: The study findings demonstrate that vNOTES was not inferior to CL in terms of adnexectomy or ovarian cystectomy. vNOTES can be considered a more minimally invasive surgical approach, as it results in reduced postoperative pain, faster recovery, and absence of visible incisions. Overall, vNOTES proves to be a safe, feasible, and less invasive treatment option.
BACKGROUND: This study retrospectively registered with the China Clinical Trial Registry with the registration number ChiCTR2100052223(22-10-2021).

Urinary incontinence affects 25-45 % of women with the gold standard surgical approach being placement of mid-urethral synthetic slings; tension-free vaginal tape (TVT) and trans-obturator tape (TOT). Due to the controversies regarding vaginal mesh the last decade, an increasing demand has evolved for incontinence treatment without vaginal synthetic mesh. The short term results of autologous rectus fascia sling for TOT surgery have shown similar success rates compared to those after the use of synthetic mesh, but the harvesting of the mesh is less minimally invasive and is associated with longer surgical time. vNOTES is a combination of a vaginal entrance to the abdomen and endoscopy via the vagina. The aim with the video is to show a new surgical technique with a fully vaginal, scarless vNOTES approach for harvesting the posterior rectus fascia for TVT and TOT procedures.