Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) in Benign Gynaecology: A Systematic Review of Adnexal, Myomectomy and Prolapse Procedures.

Objective: Vaginal natural orifice transluminal endoscopic surgery (vNOTES) is utilised for gynaecological procedures globally, however evidence to support its application aside from hysterectomy is lacking. A systematic review to determine feasibility and safety profile of vNOTES for benign gynaecology was conducted.

Data Sources: A literature search of MEDLINE, EMBASE, CINAHL, SCOPUS and CENTRAL was conducted, including all types of studies reporting vNOTES for gynaecological indications. After excluding cases with concurrent hysterectomy, the review focuses on procedures for benign indications and oncological procedures are reported separately. Patient characteristics and perioperative outcomes were reported, with pooled analysis for sufficiently powered categories.

Methods Of Study Selection: 54 articles were analysed, including 7 comparative studies (n=439) and 1 RCT (n=34), reporting 2469 cases of vNOTES, including adnexal (tubal and/or ovarian) (43 articles, n=2261), myomectomy (10 articles, n=136) and prolapse repair (6 articles, n=72) in predominantly premenopausal women with BMI<30kg/m on pooled analysis.

Tabulation, Integration And Results: The overall conversion rate was low (1.38%, n=34) with procedure specific conversion rates of 0.45-6.8% for adnexal procedures, 1.47% for myomectomy and none reported for prolapse repair. Overall complication rates were low (3.44%, n=85) with no associated mortality. Five (0.20%) adhesion-related rectal injuries at colpotomy were noted, all repaired intraoperatively without long-term sequelae.

Conclusion: vNOTES appears feasible based on limited evidence, for uterine-sparing gynaecological indications, despite a notable rate of rectal injury at colpotomy. There is a negligible risk of rectal injury observed at conventional laparoscopy and robotically assisted surgery, but similar rate of entry-related gastrointestinal injury. This may be due to the learning-curve or suboptimal case selection, necessitating careful training, assessment, and appropriate patient selection. Surgeons should continue registering prospective vNOTES cases via iNOTESs, to evaluate emerging perioperative trends with global uptake of this novel technique.