Extraperitoneal vaginal natural orifice transluminal endoscopic pelvic reconstruction for multi compartment pelvic organ prolapse

Abstract

We describe a novel extraperitoneal vaginal natural orifice transluminal endoscopic surgery (vNOTES) approach for pelvic reconstruction in women with multicompartment pelvic organ prolapse (POP). This retroperitoneal technique enables direct exposure of the presacral area, allowing secure fixation of a Y‐shaped mesh to the anterior longitudinal ligament and comprehensive restoration of anterior, middle, and posterior compartment support. From April to December 2024, 118 patients underwent extraperitoneal vNOTES pelvic reconstruction. The mean age was 61.1 ± 6.6 years, the mean body mass index was 24.5 ± 2.6 kg/m², the mean operative time was 103.3 ± 25.7 minutes, and the mean estimated blood loss was 97.7 ± 47.7 ml. During a median follow‐up of 6.9 months (range: 4.1–11.2 months), all patients experienced significant improvement in anatomic and functional outcomes, with no recurrence, mesh exposure, or reoperation. Three patients (2.5%) developed retroperitoneal hematomas that resolved with conservative management. These early results suggest that extraperitoneal vNOTES pelvic reconstruction is a feasible and safe technique, with the potential to reduce operative complexity and intra‐abdominal risks compared with conventional transperitoneal approaches.

In our study, we aimed to assess whether pelvic reconstruction (PRC) is feasible via extraperitoneal vaginal natural orifice transluminal endoscopic surgery (vNOTES) and has shorter operation time and safer surgical approach than transperitoneal vNOTES.^{[ 1 ]}

This is a new retroperitoneal PRC approach for multi compartment pelcic organ prolapse (POP), the technique is explained step‐by‐step using videos and pictures.

The study was approved by the Ethics Committee of Obstetrics and Gynecology Hospital of Fudan University (file number 2024‐56‐X1) in China, written informed consent was obtained from all participants.

The patient was a 66‐year‐old woman with a Pelvic Organ Prolapse Quantification System (POP‐Q) stage III/III/II.

The posterior vaginal fornix was opened after injecting a diluted methylene blue solution into the posterior vaginal fornix and paravaginal space, and the pararectal space is bluntly dissected. A transvaginal single‐port device (ACCESS SYSTEM, HTKD Medical™) was established, and dissection was performed in the direction of the sacral promontory to expose the presacral area. A Artisyn® Y‐mesh (Johnson & Johnson, New Brunswick, NJ) was trimmed into the appropriate length, with the tail end fixed to the anterior longitudinal ligament of S1‐S2. Then a vaginal hysterectomy was performed, and the peritoneum was closed. The posterior limb of the Y‐shaped mesh was fixed to the posterior vaginal wall near the introitus, while the anterior limbs are fixed to the fascia on the surface of the bilateral pubic rami. This procedure reconstructs the support of the anterior, middle, and posterior compartments at three levels (The specific surgical steps are shown in Figure 1).

FIGURE 1.

vNOTES extraperitoneal pelvic reconstruction procedures. Surgical procedures: (a) The patient was placed in the lithotomy position. Hydrodissection was performed in the rectovaginal and right pararectal space. (b) A 3 cm transverse incision was made at the posterior vaginal fornix. The rectovaginal space around the incision was fully dissected, followed by blunt dissection toward the ischial spine. (c) A single‐port device (Port) was inserted, ensuring the inner ring tightly adhered to the vaginal wall to prevent gas leakage. (d) The pararectal loose connective tissue was bluntly dissected along the ischial spine direction. After identifying the sacral curvature, dissection continued rightward and upward along the midline until reaching the presacral space, establishing an extraperitoneal pathway. (e) Two non‐absorbable sutures were placed at the anterior longitudinal ligament of S1‐S2 to fix the tail end of the “Y”‐shaped mesh, after which the single‐port device was withdrawn. (f) After the vaginal hysterectomy, the peritoneum was closed. (g) The uterosacral ligament stump was reinforced with non‐absorbable sutures (to prevent mesh exposure into the pelvic cavity). The mesh length was adjusted, and the posterior arm of the “Y” mesh was exteriorized and fixed bilaterally to the lower posterior vaginal wall. (h) A 2‐cm longitudinal incision is made on the lower anterior vaginal wall, and the vesicovaginal space was dissected. The anterior arm of the “Y” mesh was fixed bilaterally to the fascia of the descending pubic rami. (i) The sacrouterine ligament stump was reinforced again with non‐absorbable sutures (to prevent mesh exposure into the vagina), and the vaginal cuff was closed. (j) The vaginal cuff was suspended and repositioned by anchoring it to the mesh bifurcation using absorbable sutures and a vaginal gauze pack was placed.

From April to December 2024, a total of 118 patients underwent extraperitoneal vNOTES‐PRC, The mean age of the patients was 61.1 ± 6.6 years, the mean body mass index (BMI) was 24.5 ± 2.6 kg/m², the mean operation time was 103.3 ± 25.7 min, and the intraoperative mean blood loss was 97.7 ± 47.7 mL. The median follow‐up period of 6.9 months (range: 4.1–11.2 months), all patients gained a signifcant improvement in anatomical and objective outcomes during the follow‐up. No relapse and mesh erosion, and no one needed repeat surgery, but there were 3 (2.5%) cases of significant retroperitoneal hematoma, which improved and recovered after symptomatic treatment.

Our initial experience showed that the extraperitoneal pelvic reconstruction is feasible via vNOTES, and it provide faster access to the presacral area than transperitoneal approach.

AUTHOR CONTRIBUTIONS

Concept and design: Yisong Chen; Data acquisition and interpretation: Junwei Li; Data analysis: Jing Peng; Manuscript drafting: Jing Peng; Surgical performance: Yisong Chen; Supervision: Keqin Hua.

FUNDING INFORMATION

This work was supported by Shanghai Municipal Health Commission Seed Program for Medical New Technology Research and Translation (Grant No. 2024ZZ1020).

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

Supporting information

Video S1. vNOTES Extrarperitoneal Pelvic Reconstruction.

Data S1.

DATA AVAILABILITY STATEMENT

The datasets generated during this study are available upon reasonable request, subject to institutional review and compliance with ethical requirements.