Abstract
Objective:
This study evaluated the impact of uterine size on surgical outcomes in vaginal natural orifice transluminal endoscopic surgery (vNOTES) hysterectomy and compared perioperative outcomes with conventional laparoscopic hysterectomy (LH) in patients with large uteri.
Methods:
This single-center, retrospective cohort study included 812 patients who underwent hysterectomy between January 2024 and January 2026. Patients were categorized into 3 groups: vNOTES with small uteri (n = 102), vNOTES with large uteri (n = 87), and LH with large uteri (n = 623). Primary outcomes were operative time, estimated blood loss, conversion rates, and complications. Secondary outcomes included postoperative complications, hospitalization period, postoperative hemoglobin change, uterine weight and pain scores assessed using the visual analogue scale (VAS) at 12 and 24 hours postoperatively.
Results:
There were no statistically significant differences among 3 groups regarding operative time, hemoglobin drop or estimated blood loss (P > .05). Uterine weights were significantly higher in the large uterus groups (vNOTES: 385 ± 89.6 g; LH: 420 ± 107.2 g) compared to the small uterus group (135 ± 45 g, P < .001). Conversion to laparotomy was significantly higher in the LH group (5.3%) than the vNOTES groups (0% and 1.15%, P = .015). VAS at 12 hours were significantly lower in the vNOTES small uterus group (P = .006), whereas 24-hour scores and complication rates were comparable across all groups.
Conclusion:
vNOTES hysterectomy is a safe and feasible approach for patients with enlarged uteri, demonstrating noninferiority to conventional laparoscopy. vNOTES may offer lower risk of conversion to laparotomy compared to laparoscopy in cases of uterine enlargement.
Keywords: Laparoscopic hysterectomy, Large uterus, Minimally invasive surgery, Surgical outcomes, vNOTES
INTRODUCTION
Hysterectomy is one of the most commonly performed surgical procedures in gynecology and is primarily indicated for benign conditions such as uterine fibroids, abnormal uterine bleeding, and adenomyosis.1–3 Over the past decades, there has been a clear shift toward minimally invasive surgical techniques because they are associated with improved perioperative outcomes, including reduced postoperative pain, shorter hospital stay, faster recovery, and lower morbidity compared with abdominal hysterectomy.3–5
Vaginal natural orifice transluminal endoscopic surgery (vNOTES) has recently emerged as an innovative minimally invasive approach that combines the advantages of conventional vaginal surgery with the visualization and instrumentation capabilities of laparoscopy. By providing transvaginal endoscopic access to the peritoneal cavity, vNOTES enables hysterectomy to be performed without abdominal incisions while maintaining adequate visualization of pelvic anatomy.6,7 Several studies have demonstrated that vNOTES hysterectomy is a feasible and safe technique and may offer advantages such as reduced postoperative pain, shorter hospitalization, and improved cosmetic outcomes compared with conventional laparoscopic surgery.8,9
Despite these advantages, performing hysterectomy in patients with an enlarged uterus remains technically challenging regardless of the surgical approach. Increased uterine size may limit surgical exposure, reduce instrument maneuverability, and complicate uterine mobilization within the pelvic cavity. Moreover, the definition of “large uterus” remains inconsistent in the literature, with several studies defining it as a uterine weight exceeding approximately 280 g or a uterine size corresponding to more than 12 weeks of gestation.10
Recent studies have investigated the feasibility of vNOTES hysterectomy in patients with enlarged uteri and reported encouraging results with acceptable complication and conversion rates.7,11–13 Furthermore, comparative studies evaluating vNOTES and conventional laparoscopic hysterectomy (LH) in enlarged uterus cases suggest that vNOTES may achieve similar or even favorable perioperative outcomes in selected patients.14,15
However, the influence of uterine size on surgical outcomes in vNOTES hysterectomy has not been sufficiently clarified. In addition, data comparing vNOTES with conventional LH specifically in patients with enlarged uteri remain limited.
Therefore, the aim of this study was 2-fold: first, to evaluate the effect of uterine size on surgical outcomes in patients undergoing vNOTES hysterectomy by comparing normal-sized and enlarged uteri; and second, to compare perioperative outcomes between vNOTES hysterectomy and conventional LH in patients with enlarged uteri.
MATERIALS AND METHODS
Study Design
This single-center, retrospective cohort study was conducted at a tertiary center. The study aimed to assess the safety and feasibility of vNOTES for hysterectomy in patients with large uteri (≥280 g).10 Data were collected from all consecutive patients who underwent hysterectomy between January 2024 to January 2026. The reporting of this observational study adheres to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement guidelines.
The study included patients undergoing vNOTES hysterectomy, as well as a comparison group of LH patients with large uteri. The primary objective was to compare operative outcomes, including operative time, blood loss, conversion rates, complication rates, and postoperative recovery between these groups.
A total of 3268 patients were initially identified for inclusion. Of these, 174 patients (5.3%) were excluded due to loss to follow-up, 213 patients (6.5%) due to incomplete clinical data, and 2069 patients (63.3%) due to pelvic organ prolapse exceeding grade 2 or other exclusion criteria. After applying these criteria, the final cohort included 812 patients, comprising 189 patients (23.3%) who underwent vNOTES hysterectomy and 623 patients (76.7%) who underwent laparoscopy (Figure 1).
Figure 1.
Flow diagram of patient selection and group allocation.
The choice of surgical technique was based on patient-related factors (e.g., age, body mass index [BMI], parity, previous abdominal surgeries, and uterine size), gynecological pathology, and the surgeon’s clinical judgment. Surgical decisions were made in accordance with institutional guidelines, but the final choice of technique was determined by the operating surgeon based on intraoperative findings and the patient’s specific clinical needs.
All procedures were performed by experienced gynecologic surgeons, with no participation from residents or fellows in the primary surgical role. The study was approved by the Institutional Review Board (Approval number: 2024/242). All procedures adhered to the ethical standards of the Declaration of Helsinki.
Patient Data
Patient data were retrospectively collected from the institutional electronic medical record system. Demographic characteristics, clinical history, perioperative variables, and postoperative outcomes were reviewed for all eligible patients. The following baseline demographic and clinical variables were recorded: age, BMI, parity, menopausal status, history of previous abdominal or pelvic surgery, and relevant comorbidities.
Preoperative uterine assessment was performed through routine gynecological examination and imaging studies. A detailed pelvic examination, including speculum and bimanual examination, was conducted to evaluate uterine size, mobility, and vaginal capacity, as well as to identify potential contraindications for vaginal surgical approaches. All patients underwent transvaginal ultrasonography (Voluson S10, GE Healthcare) as part of the standard preoperative evaluation to determine uterine size, uterine pathology, and the presence of adnexal masses. Uterine size was measured in the longitudinal, sagittal, and transverse planes. Pelvic magnetic resonance imaging (MRI) was performed selectively in patients with suspected adenomyosis, large myomas, or complex pelvic pathology.
The final uterine weight, used for study grouping, was determined based on the histopathological examination of the surgical specimen after hysterectomy. In accordance with the International Society for Gynecologic Endoscopy (ISGE) guidelines and prior literature, a large uterus was defined as a uterine weight ≥280 g.10
Perioperative data collected included operative time, estimated blood loss, change in hemoglobin levels, intraoperative findings, type of concomitant adnexal procedures, and the need for conversion to another surgical approach. Postoperative outcomes such as length of hospital stay, perioperative complications, and final pathological diagnosis were also recorded. All data were anonymized before analysis to ensure patient confidentiality.
Outcome Measures
The aim of this study was to evaluate the safety and feasibility of vNOTES hysterectomy in patients with large uteri. The primary outcome measures included intraoperative complications, conversion to another surgical approach, estimated blood loss, and operative time. Intraoperative complications were defined as any injury to adjacent organs, including the bladder, ureter, or bowel, or any surgical event occurring during the procedure that required additional intervention. Conversion was defined as the need to change the surgical approach to laparoscopy or laparotomy.
The secondary outcome measures included postoperative complications occurring after surgery, length of hospital stay, postoperative hemoglobin change and final uterine weight. Postoperative hemoglobin change was calculated as the difference between the preoperative hemoglobin value and the hemoglobin value measured on the 6th hour after surgery.
Final uterine weight was determined based on histopathological examination of the surgical specimen. The final pathological diagnosis was also recorded for each patient to identify the underlying uterine pathology.
Surgical Technique
All surgical procedures were performed under general anesthesia with the patient positioned in the dorsal lithotomy position. Prophylactic antibiotics were administered intravenously 30 minutes prior to incision, consisting of cefazolin 2 g or clindamycin 900 mg in patients with penicillin allergy.
A Foley catheter was inserted after induction of anesthesia. Additional antibiotic doses were administered intraoperatively in cases of excessive blood loss (>1000 mL) or prolonged operative time, according to institutional protocols.
vNOTES hysterectomy.
The initial steps of the procedure were identical to those of conventional vaginal hysterectomy until entry into the peritoneal cavity was achieved. After colpotomy, a transvaginal wound retractor (Alexis-O) was inserted, followed by placement of a GelPoint V-Path transvaginal single-port access platform (Applied Medical, Rancho Santa Margarita, California, USA).
The patient was then placed in a Trendelenburg position of approximately 20–25°, and CO2 pneumoperitoneum was established at 12 mmHg. A 10-mm 30° laparoscope was introduced through the port, along with a 5-mm vessel sealing device (Voyant, Applied Medical) and atraumatic graspers.
Under endoscopic visualization, the uterine pedicles and supporting ligaments were coagulated and transected sequentially. Following completion of the hysterectomy, the uterus was removed transvaginally. Nonmechanical vaginal morcellation was performed when required to facilitate extraction of larger specimens.
After confirmation of adequate hemostasis, the transvaginal access device was removed. The vaginal cuff was closed with a continuous absorbable suture with a mild Trendelenburg position (∼10°) was applied during the procedure.
LH.
LH was performed using a 4-port technique consisting of a 10-mm umbilical trocar and 3 additional 5-mm accessory ports placed in the lower abdominal quadrants.
Pneumoperitoneum was established using a Veress needle, maintaining an intra-abdominal pressure of up to 15 mmHg. The patient was positioned in approximately 20° Trendelenburg.
The round ligaments were coagulated and divided, followed by transection of the adnexal structures when adnexectomy was indicated. The uterine arteries were sealed and divided using the Voyant vessel sealing system.
After bladder mobilization, a circumferential colpotomy was performed laparoscopically. The uterus was subsequently removed through the vaginal canal. Nonmechanical laparoscopic and vaginal morcellation was performed when required to facilitate extraction of larger specimens. Vaginal cuff closure was performed laparoscopically using absorbable Vicryl 0 sutures. Irrigation and suction were performed as required to clear blood and tissue debris, assess hemostasis, and maintain adequate visualization. Normal saline was used as the irrigation fluid.
All trocar sites were closed with Vicryl 3-0 or 4-0 sutures using a subcuticular technique.
Statistical Analysis
Statistical analyses were performed using JASP (version 0.19.1; JASP Team, 2024). The normality of the data distribution was assessed using visual methods (histograms and Q-Q plots) and analytical methods (Shapiro-Wilk test).
Continuous variables were presented as mean ± standard deviation (SD) or median (range) based on their distribution patterns. Categorical variables were expressed as frequencies and percentages (n, %). For the comparison of continuous variables among the 3 groups (vNOTES small uterus, vNOTES large uterus, and laparoscopic large uterus), One-way ANOVA was used for normally distributed data, while the Kruskal-Wallis test was employed for non-normally distributed data. To identify the source of significant differences between specific groups, posthoc pairwise comparisons (e.g., Tukey’s or Dunn’s test) were performed, and these differences were indicated in the tables using superscript letters (a, b).
Categorical data, such as conversion rates and complications, were compared using the χ2 test or Fisher’s exact test, as appropriate. A P-value of <.05 was considered statistically significant for all analyses.
RESULTS
A total of 3268 patients were initially assessed for eligibility. After applying the predefined exclusion criteria, the final study population consisted of 812 patients, including 102 patients (12.5%) in the vNOTES small uterus group, 87 patients (10.8%) in the vNOTES large uterus group, and 623 patients (76.7%) in the LH group.
Baseline Characteristics
Patients in the vNOTES small uterus group were significantly older compared to the other groups (P = .018). There were no statistically significant differences among the groups in terms of BMI, parity, nulliparity rate, menopausal status, or comorbidities (Table 1).
Table 1.
Demographic Data
| Variable | vNOTES Hysterectomy, Small Uteri (102, 12.5%) |
vNOTES Hysterectomy, Large Uteri (87, 10.8%) |
Laparoscopic Hysterectomy, Large Uteri (623, 76.7%) | P-Value |
|---|---|---|---|---|
| Age (years) | 61.4 ± 6.2a | 47.6 ± 4.1a,b | 47.6 ± 5.3b | .018 |
| BMI (kg/m²) | 25.3 ± 4.7a | 24.7 ± 4.6b | 25.7 ± 4.8a,b | .127 |
| Nulliparity (%) | 4 (3.9%) | 2 (2.3%) | 42 (6.8%) | .463 |
| Parity (median, range) | 2 (0–7) | 2 (0–3) | 2 (0–4) | .978 |
| Delivery Type | <.001 | |||
| C-section | 9 (8.8%) | 9 (10.3%) | 262 (42.1%) | |
| Vaginal | 89 (87.3%) | 73 (83.9%) | 325 (52.2%) | <.001 |
| Menopausal status | 53 (52%) | 24 (27.6%) | 262 (42.1%) | .298 |
| Previous abdominal surgery (%) | 21 (20.6%)a | 21 (24.1%)a | 354 (56.8%)b | <.001 |
| Preoperative hemoglobin (g/dL) | 13.1 ± 1.6a | 12 ± 1.3a,b | 11.8 ± 1.1b | .024 |
| Surgical indications | 38 (37.3%)a | 29 (33.3%)a | 199 (30.1.%)a | .001 |
| Abnormal Uterine | 22 (21.5%)a | 44 (50.6%)b | 348 (55.8%)b | |
| Bleeding | 42 (41.2%)a | 14 (16.1%)b | 87 (14.0%)b | |
| Myoma uteri | ||||
| Other | ||||
| Comorbidities (any), n (%) | 29 (28.4%) | 21 (24.1%) | 183 (29.4%) | .537 |
a,bStatistically significant differences between groups (P < .05) as determined by post hoc pairwise comparisons. Groups sharing the same letter are not significantly different from each other.
The history of previous abdominal surgery was significantly more common in the laparoscopic group compared to both vNOTES groups (P < .001). Similarly, the distribution of delivery type differed significantly between groups, with a lower rate of vaginal delivery observed in the laparoscopic group (P < .001).
Preoperative hemoglobin levels were significantly higher in the vNOTES small uterus group compared to the laparoscopic group (P = .024).
Regarding surgical indications, myoma uteri was more frequent in the large uterus groups, whereas abnormal uterine bleeding was more evenly distributed across all groups. A statistically significant difference was observed in the distribution of surgical indications between groups (P = .001).
Intraoperative Outcomes
There were no statistically significant differences among the groups in terms of operative time, hemoglobin level drop, or estimated blood loss (Table 2).
Table 2.
Intraoperative Outcomes
| Variable | vNOTES Hysterectomy, Small Uteri (102, 12.5%) |
vNOTES Hysterectomy, Large Uteri (87, 10.8%) |
Laparoscopic Hysterectomy, Large Uteri (623, 76.7%) | P-Value |
|---|---|---|---|---|
| Operative time (minutes) | 69.2 ± 15.7 | 74.3 ± 18.9 | 81.7 ± 20.6 | .299 |
| Hemoglobin drop (g/dL) | 1.25 ± 0.3 | 1.72 ± 0.61 | 1.77 ± 0.51 | .409 |
| Estimated blood loss, cc | 100 (50–300) | 130 (50–500) | 140 (100–600) | .461 |
| Uterus weight (gr) | 135 ± 45a | 385 ± 89.6b | 420 ± 107.2b | <.001 |
| Adnexectomy | 69 (47.6.%) | 60 (68.9%) | 519 (64.7%) | .705 |
| Conversion to laparoscopy | 1 (0.98%) | 2 (2.3%) | - | .469 |
| Conversion to laparotomy | 0 | 1 (1.15%) | 33 (%5.3) | .015 |
| Additional surgery | 38 (37.5%) | 28 (32.1%) | 189 (30.3%) | .894 |
a,bStatistically significant differences between groups (P < .05) as determined by post hoc pairwise comparisons. Groups sharing the same letter are not significantly different from each other.
As expected, uterine weight was significantly higher in both large uterus groups compared to the small uterus group (P < .001), with no significant difference between the vNOTES and laparoscopic large uterus groups.
The rate of adnexectomy and frequency of additional surgical procedures did not differ significantly between the groups. Conversion to laparoscopy was comparable between vNOTES groups. However, conversion to laparotomy was significantly higher in the laparoscopic group compared to the vNOTES groups (P = .015).
Postoperative Outcomes and Complications
The length of hospital stay was comparable between groups (Table 3). At 12 hours, pain scores were significantly lower in the vNOTES small uterus group compared to the other groups (P = .006). However, at 24 hours, pain scores were low across all groups, and no statistically significant difference was observed (P = .188).
Table 3.
Postoperative Complications
| Variable | vNOTES Hysterectomy, Small Uteri (102, 12.5%) |
vNOTES Hysterectomy, Large Uteri (87, 10.8%) |
Laparoscopic Hysterectomy, Large Uteri (623, 76.7%) | P-Value |
|---|---|---|---|---|
| Length of hospital stay, days | 1.51 ± 0.7 | 1.66 ± 0.23 | 1.88 ± 0.33 | .363 |
| Postoperative VAS scores, mean ± std | ||||
| 12 hours | 3.1 ± 1.82 | 3.8 ± 2.14 | 3.9 ± 2.02 | .006 |
| 24 hours | 1.5 ± 0.91 | 1.7 ± 1.07 | 1.8 ± 1.13 | .188 |
| Postoperative complications | ||||
| Pain (I)a | 3 (2.9%) | 2 (2.29%) | 18 (3.4%) | .950 |
| Transfusion (II) | 3 (2.9%) | 6 (6.9%) | 47 (7.5%) | .235 |
| Cuff hematoma (II) | 0 | 1 (1.15%) | 4 (0.64%) | .594 |
| Cuff dehiscence (IIIa) | 0 | 0 | 3 (0.48%) | .633 |
| Visceral injury | 1 | .317 | ||
| Bladder injury (IIIb) | 0 | 2 (2.29%) | 3 (2.09%) | |
| Uretral injury (IIIb) | 0 | 0 | 2 (0.32%) | |
| Intestinal injury (IIIb) | 0 | 1 (1.15%) | 5 (0.8%) | |
| Vesicovaginal fistula (IIIb) | 0 | 0 | 3 (0.48%) | .663 |
| Rehospitalization | 1 (0.98%) | 2 (2.29%) | 17 (2.73%) | .569 |
Postoperative complications are graded according to the Clavien-Dindo classification. VAS, visual analogue scale. aTo avoid circularity, pain-related events (Grade I pain requiring additional analgesia) were analyzed separately from other postoperative complications.
Overall postoperative complication rates were low and comparable between groups. There were no statistically significant differences in rates of pain requiring additional treatment, transfusion, cuff hematoma, cuff dehiscence, visceral injuries or rehospitalization.
Major complications, including bladder, ureteral, and intestinal injuries (Clavien–Dindo grade IIIb), were rare and showed no significant difference between groups. Similarly, the incidence of vesicovaginal fistula did not differ significantly.
DISCUSSION
Hysterectomy constitutes the most surgical intervention in gynecology, encompassing various approaches. Patients with enlarged uteri are frequently recommended to undergo abdominal hysterectomy due to the challenges of vaginal and laparoscopic techniques, such as restricted operative visibility, limited instrument maneuverability, and difficulties in specimen extraction.10,11,14 The present study contributes to the evolving understanding of minimally invasive hysterectomy techniques by providing a robust comparison of vNOTES and laparoscopic approaches, particularly focusing on uterine size as a key variable influencing surgical outcomes. Our study demonstrated that vNOTES hysterectomy is a safe and effective option for patients with large uteri, and also noninferior to vNOTES hysterectomies performed in patients with small uteri and to LHs performed in patients with large uteri.
In our cohort, patient characteristics were largely comparable across the groups, except for the vNOTES small uterus group being significantly older which is aligns with literature reports on vNOTES hysterectomies, where patients, particularly those with small uteri, are often older due to postmenopausal status. The rates of previous abdominal surgery and cesarean delivery were significantly higher in the laparoscopic group, consistent with findings from the existing literature.8,15,16 This observation underscores the clinical practice of tailoring surgical approaches based on individual patient histories, potentially mitigating complications associated with altered anatomical planes in previously operated abdomens.17,18 Differences in surgical indications were observed between the groups, with myoma uteri being more prevalent in those with larger uteri—an expected finding reflecting the underlying pathology driving the need for hysterectomy. Consistent with these indications, preoperative hemoglobin levels were significantly lower in the laparoscopic group, potentially linked to the higher prevalence of abnormal uterine bleeding in this cohort. Comorbidities across the groups showed no notable discrepancies. However, literature reviews indicate mixed findings regarding discrepancies in comorbidity profiles across various populations.8,19–21
This study's intraoperative outcomes, demonstrating no significant differences in operative time, blood loss, or hemoglobin level drop across vNOTES and laparoscopic groups, even with varied uterine sizes, further support the expanding applicability of minimally invasive techniques. Although no statistically differences in operative time were observed among the groups, mean operative durations were longer in the vNOTES large uterus and laparoscopic groups compared to the vNOTES small uterus group, consistent with the anticipated greater blood loss associated with larger uteri. This finding aligns with previous studies indicating that increased uterine size is associated with longer operative times and greater blood loss due to the technical challenges of manipulating and extracting larger specimens.13,21,22 No significant differences were observed between the groups in terms of adnexectomy rates and additional surgical procedures, such as antiprolapse surgeries, consistent with the literature.11,12 In the vNOTES small uterus group, conversion to laparoscopy was required in one case due to a bladder complication during hysterectomy. Similarly, 2 cases in the vNOTES large uterus group required conversion to laparoscopy. In one of these cases, a bladder injury occurred due to adequate visualization and adhesions resulting from prior surgeries; in the other, it was necessitated by the need to control bleeding that occurred during intraligamentary myoma dissection. Conversion rates to laparoscopy did not differ significantly between the groups. However, when comparing the vNOTES group with the laparoscopic group, the conversion to laparotomy was notably higher in the latter, a finding consistent with other research on hysterectomy approaches.23 The single case of conversion to laparotomy in the vNOTES large uterus group involved a rectal serosa injury and an obliterated Douglas pouch, which was repaired by a general surgeon. In the laparoscopic group, conversion to laparotomy was required in 33 patients, a finding consistent with the literature.24 In our cohort, major organ injuries were identified in 20 patients, all classified as Clavien-Dindo grade IIIb. Notably, not all of these injuries required conversion to laparotomy, of these 20 major organ injuries, 5 bladder injuries, 2 ureteral injuries, and 4 intestinal injuries necessitated conversion to laparotomy, whereas the remaining 11 were successfully managed laparoscopically. The additional conversions to laparotomy (22 patients) were primarily due to intraoperative technical challenges, such as inadequate visualization, dense adhesions, or uncontrolled hemorrhage.
According to postoperative outcomes, the length of hospital stay was comparable across all groups, although patients undergoing LH had a slightly longer duration of hospitalization, which is consistent with findings in other comparative studies.12,15 In our cohort, visual analogue scale (VAS) scores at the 12th hour were significantly lower in the vNOTES groups compared to the laparoscopic group, Aiob et al17 and Güngördük et al12 also reported significantly lower postoperative pain scores in vNOTES patients compared to those undergoing LH, particularly in the immediate postoperative period.12,17,21,25 Our findings regarding the safety profile of vNOTES in large uteri are further supported by a synthesis of current literature, which demonstrates strong evidence for the feasibility of this approach (Table 4). However, unlike most studies in the literature, no significant difference in VAS scores was observed at 24 hours in our cohort. This may be attributable to the routine use of simple analgesics during postoperative treatment at our hospital. Although rehospitalization rates were higher in the large uterus groups compared to the small uterus vNOTES group, this difference was not found statistically significant. Postoperative complication rates, including those classified as Clavien-Dindo grade IIIb, also showed no significant differences among the groups, further reinforcing the safety profile of vNOTES hysterectomy even in cases with larger uteri.13,26–28 This finding contrasts with some literature suggesting a higher complication rate in larger uteri due to increased technical difficulty and potential for increased bleeding.29 Despite this, the comparable complication rates in our study might suggest improvements in surgical techniques and patient selection criteria, enabling the safe application of vNOTES to a broader range of uterine sizes.28
Table 4.
Key Claims and Support Evidence for vNOTES in Enlarged Uteri
| Claim | Evidence Strength | Reasoning | Key References |
|---|---|---|---|
| vNOTES hysterectomy is safe/feasible for enlarged/very large uterus | Strong | Multiple cohort studies show low complication/conversion rates even at >1 kg uterine weight. | 7,11–13,15,26–28 | |
| Complication rate is comparable/lower than laparoscopy | Strong | Comparative studies show similar or fewer complications versus conventional laparoscopy. | 5,8,16,17,20,21 |
| Operative time/blood loss increase with uterine size | Moderate | Larger uterus leads to longer surgery and more bleeding, but not necessarily higher major complication rates. | 13,22,29 |
| Surgeon experience reduces risk | Moderate | Learning curve analyses indicate significantly improved outcomes after approximately 20 cases. | 6 |
| Ureteral/bladder injury risk not increased versus other routes | Moderate | Large series report rare urinary tract injuries, comparable to other minimally invasive routes. | 6,7,12 |
| Generalizability outside expert centers remains uncertain | Moderate | Most data originate from high-volume expert centers; less evidence is available from community settings. | 14 |
The robust methodology employed, including a comprehensive analysis of intraoperative and postoperative outcomes across distinct uterine size categories and surgical approaches, represents a significant strength of this study. Specifically, the comparison between vNOTES and LH for large uteri, coupled with the granular examination of different uterine sizes within the vNOTES approach, provides novel insights into the clinical applicability and safety of these techniques. Although uterine weight is an important determinant of surgical difficulty, it should not be considered the sole criterion for selecting patients for vNOTES hysterectomy. Future studies should investigate whether uterine mobility, vaginal accessibility, the presence and location of large or intra ligamentary myomas, obliteration of the posterior cul-de sac, dense pelvic adhesions, and previous abdominal or pelvic surgery are independent predictors of conversion. However, as with any study, the present study has several limitations. The primary limitations include its retrospective design, single-center data collection, and relatively small sample size, which may limit the generalizability of the findings.
In conclusion, this study underscores the feasibility and comparable safety of vNOTES hysterectomy across varying uterine sizes, presenting a viable alternative to traditional laparoscopic approaches for benign indications. Moreover, this research highlights that uterine volume is not a contraindication for vNOTES hysterectomy, advocating for its consideration even in cases with substantial uterine enlargement. Nonetheless, future multicenter, prospective randomized controlled trials with larger cohorts are imperative to validate these findings and to further delineate long-term outcomes.
Footnotes
Data availability statement: Data are available from the authors upon reasonable request.
Institutional Review Board approval: This study was reviewed and approved by the Institutional Review Board of İzmir City Hospital (Approval number: 2024/242).
Conflict of interests: none.
Disclosure: none.
Funding sources: none.
Contributor Information
Ahkam Göksel Kanmaz, Department of Obstetrics and Gynecology, İzmir City Hospital, İzmir, Türkiye. (Drs. Kanmaz, Akbaş, Töz, Kandemir, and Akpak).
Özgün Akbaş, Department of Obstetrics and Gynecology, İzmir City Hospital, İzmir, Türkiye. (Drs. Kanmaz, Akbaş, Töz, Kandemir, and Akpak).
Emrah Töz, Department of Obstetrics and Gynecology, İzmir City Hospital, İzmir, Türkiye. (Drs. Kanmaz, Akbaş, Töz, Kandemir, and Akpak).
Çağla Ezgi Uğuz Kandemir, Department of Obstetrics and Gynecology, İzmir City Hospital, İzmir, Türkiye. (Drs. Kanmaz, Akbaş, Töz, Kandemir, and Akpak).
Yaşam Kemal Akpak, Department of Obstetrics and Gynecology, İzmir City Hospital, İzmir, Türkiye. (Drs. Kanmaz, Akbaş, Töz, Kandemir, and Akpak).
Jan Baekelandt, Department of Obstetrics and Gynecology, Imelda Hospital Bonheiden, Bonheiden, Belgium; and Department of Development and Regeneration, University of Leuven, Leuven, Belgium. (Dr. Baekelandt).
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