Outcomes of first 60 vaginal myomectomies by one gyn surgeon with 20 years of extensive vaginal surgical expertise

Abstract

Introduction

This retrospective single-center study based on prospectively collected data aimed to evaluate changes in operative performance during the initial experience with vaginal myomectomy.

Methods

Sixty consecutive patients who underwent VM between January 2021 and December 2023 were included. Demographic features, FIGO-classified myoma characteristics, operative variables, and postoperative outcomes were recorded prospectively. To assess the LC, patients were divided chronologically into four groups of 15 cases. The primary objective was to evaluate changes in operative performance across consecutive cases. Operative time, estimated blood loss, hematocrit decrease, and hospitalization duration were used as measurable indicators of surgical progression, while the occurrence of major complications was assessed as a safety outcome. Groups were compared in terms of preoperative characteristics, intraoperative parameters, and postoperative outcomes.

Results

The mean age and BMI of the patients were 38.1 years and 28.2 kg/m², respectively. Myoma number, diameter, and FIGO-based localization were similar across all groups (p > 0.05). No major intraoperative or postoperative complications occurred. Hematocrit drop and estimated blood loss were significantly higher in the first 15 cases compared to subsequent groups (p = 0.033 and p = 0.005). Operative time significantly decreased after the first 30 cases (p = 0.001), while length of hospital stay significantly shortened after the first 15 cases (p = 0.001). Transfusion rates did not differ between groups (p = 0.923).

Conclusion

The findings suggest that improvements in bleeding parameters and hospitalization duration became apparent after approximately 15 procedures, whereas operative efficiency improved and appeared to stabilize after approximately 30–34 procedures. These observations should be interpreted within the context of the initial experience of an experienced vaginal surgeon rather than as universally applicable thresholds.

Introduction

Vaginal myomectomy (VM) is a surgical alternative developed to prevent the potential intra-abdominal dissemination and parasitic myoma formation associated with power morcellation in laparoscopic myomectomy, as well as the abdominal surgical morbidity encountered in abdominal (laparotomic) myomectomy. In addition, VM represents a significant minimally invasive approach that aims to overcome the anatomical access limitations of hysteroscopic myomectomy and to eliminate its life-threatening intraoperative complications, including fluid overload and electrolyte imbalances [1]. Recent evidence suggests that the optimal surgical approach for myomectomy should be individualized according to myoma characteristics, patient factors, and surgeon expertise [2]. Untreated uterine myomas (UM) may result in abnormal uterine bleeding, abdominal and/or pelvic discomfort, bowel and/or bladder dysfunction, infertility and pregnancy loss [3]. Previous reports showed the efficacy and safety of VM for the treatment of UM. Plotti et al. analyzed outcomes of VM, and the authors concluded that VM was a safe procedure with short hospital stay and low complication rate [4]. Concerns regarding specimen extraction and procedure-related complications have further stimulated interest in alternative minimally invasive approaches for myoma surgery [5].

The learning curve (LC) in surgery is characterized as the graphical curve of case and/or duration in which a surgeon gains sufficient skills to perform surgery with acceptable success and complication rates [6]. Previous reports emphasized that each surgery has unique LC. Lee and colleagues evaluated the LC of single-port laparoscopic myomectomy, and the authors stated that proficiency was gained after 45 cases [7]. In another study, Wang et al. tried to determine LC for transvaginal natural orifice transluminal endoscopic hysterectomy. The study findings revealed that 20 procedures were enough to obtain surgical competence for transvaginal natural orifice transluminal endoscopic hysterectomy [8].

Unlike conventional vaginal procedures, vaginal myomectomy requires identification, mobilization, enucleation, and reconstruction of the uterus through a limited vaginal access route. These technical challenges, together with variations in myoma size, number, and localization, may result in a learning process that differs from other vaginal and minimally invasive gynecologic procedures. Although previous studies investigated outcomes of VM and LC of different procedures other than VM in gynecology practice, to our knowledge, no research has evaluated operative performance during the initial experience with vaginal myomectomy. Recent advances in transvaginal surgery have expanded the range of minimally invasive approaches available for the management of benign gynecologic diseases. Natural orifice transluminal endoscopic surgery (NOTES) and vaginal natural orifice transluminal endoscopic surgery (vNOTES) have been increasingly utilized for hysterectomy, adnexal surgery, and myomectomy, demonstrating favorable perioperative outcomes and rapid postoperative recovery. These developments further highlight the growing role of transvaginal approaches in contemporary gynecologic surgery. The purpose of the present study was to evaluate the impact of the learning curve on vaginal myomectomy outcomes, a topic that has received limited attention in the literature. We hypothesized that increasing surgical experience would be associated with improvements in operative efficiency and perioperative outcomes, resulting in measurable changes in operative time, blood loss, and hospitalization duration over consecutive cases.

Methods

This retrospective study based on prospectively collected surgical data was conducted at the Department of Obstetrics and Gynecology of Istanbul Sancaktepe Ilhan Varank Training and Research Hospital. Sixty consecutive patients who underwent vaginal myomectomy between January 2021 and December 2023 performed by the same senior gynecologic surgeon, who had approximately 20 years of experience in gynecologic surgery and extensive expertise in advanced vaginal procedures, were included. The aim of the study was to evaluate the surgical learning curve (LC) of VM by assessing consecutive cases. Indications for VM included symptomatic uterine myomas causing pelvic pain, abnormal uterine bleeding, or other myoma-related clinical complaints. All patients were informed in detail 24 h before surgery about the natural course of UM, the purpose of VM, possible treatment alternatives, potential complications, and postoperative follow-up, and written informed consent was obtained.

Surgical and clinical data were collected prospectively as part of routine clinical practice. The learning-curve analysis and study design were developed retrospectively after completion of patient enrollment. Therefore, ethical approval for retrospective analysis of the anonymized dataset was obtained from the Ethics Committee of Istanbul Sancaktepe Ilhan Varank Training and Research Hospital on July 16, 2025 (Approval No. 241). The study was conducted in accordance with the Declaration of Helsinki. All procedures were performed by the same senior surgeon (HS), who had approximately 20 years of experience in gynecologic surgery and extensive experience in advanced vaginal procedures, including vaginal hysterectomy, vaginal prolapse surgery, and vaginal reconstructive procedures. However, prior to the study period, the surgeon had not performed vaginal myomectomy. Therefore, the present series represented the surgeon’s initial experience with vaginal myomectomy using the STVEC technique, while not representing the acquisition of basic vaginal surgical skills. The present series represented the surgeon’s first 60 consecutive vaginal myomectomy cases performed using the Sahin Transvaginal Extracorporeal (STVEC) technique. Residents and assistants participated only in supportive roles and did not perform the key operative steps. A detailed medical history and gynecological examination were performed for each patient. Preoperative characteristics including age, body mass index (BMI), UM-related primary symptoms, gravidity, parity, smoking status, and previous cesarean section or myomectomy were recorded. All myomas were evaluated by ultrasonography, and their number and locations were classified according to the FIGO leiomyoma classification. Although hysteroscopic myomectomy is generally considered the standard approach for FIGO type 0–2 submucosal myomas, selected patients in the present series underwent vaginal myomectomy because concomitant myoma characteristics and uterine accessibility were considered suitable for the STVEC technique. In patients with multiple myomas, FIGO classification was assigned according to the dominant myoma, defined as the largest surgically treated lesion. Infertility was not considered an isolated indication for vaginal myomectomy. Surgical treatment was offered based on established clinical indications related to uterine myomas, whereas infertility was documented as an accompanying patient characteristic when present. Hospitalization duration was calculated from completion of surgery to actual hospital discharge. Hospitalization duration was recorded in hours rather than days to provide a more precise assessment of postoperative recovery and discharge timing, particularly because most patients were discharged within the first 48 h after surgery. Patients were discharged when pain was controlled, ambulation was achieved, oral intake was tolerated, and no postoperative complications were observed.

Exclusion criteria included uterine anomalies, coagulopathy, age under 18 years, active urinary or genital tract infection, contraindications to vaginal surgery, uterine size exceeding that of a 16-week pregnancy, and a history of pelvic radiotherapy or pelvic cancer surgery. Intraoperative variables such as operative time, hematocrit decrease, estimated blood loss, number of erythrocyte suspension units transfused, and length of hospital stay were recorded. All patients received intravenous 1 g cefazolin 30–60 min before surgery as prophylaxis against infection.

The primary outcome of the study was change in operative performance over consecutive cases, assessed using operative time, estimated blood loss, hematocrit decrease, and hospitalization duration. Major intraoperative and postoperative complications were recorded separately as safety outcomes. Because major complications are relatively infrequent events and may not adequately reflect incremental changes in surgical proficiency within a limited sample size, they were not used as the primary endpoint for assessment of operative performance. For descriptive comparisons, the 60 consecutive cases were divided chronologically into four groups of 15 patients each. Because chronological grouping alone may not fully characterize changes in operative performance over time, a cumulative sum (CUSUM) analysis based on operative time was additionally performed to provide a continuous graphical assessment of surgical adaptation. Estimated blood loss was calculated intraoperatively by subtracting the volume of irrigation fluid from the total volume collected in the suction canister and adding the blood volume estimated from the weight difference of surgical sponges before and after use.

Procedure technique

All vaginal myomectomy procedures were performed under epidural or general anesthesia. After exposure of the posterior vaginal fornix, posterior colpotomy was performed between the uterosacral ligaments and extended laterally as needed. A vaginal retractor was then placed to improve visualization. The uterus and myoma were mobilized toward the colpotomy site using Allis clamps. The uterus was temporarily exteriorized through the vaginal incision to allow extracorporeal myomectomy using the Sahin Transvaginal Extracorporeal (STVEC) technique. After infiltration of the serosal surface overlying the myoma with diluted adrenaline and lidocaine solution, a midline vertical uterine incision was made. The myoma was then enucleated along the pseudocapsular plane and extracted. The myometrial defect was closed in two layers using 2 − 0 polyglycolic acid sutures, and the serosa was closed with 3 − 0 polydioxanone sutures. After uterine reconstruction, the uterus was returned to its anatomical position within the pelvic cavity, and the peritoneum and colpotomy incision were closed. (Figure 1).

Fig. 1.

Surgical steps of the Sahin Transvaginal Extracorporeal (STVEC) vaginal myomectomy technique. A Posterior colpotomy. B Placement of the vaginal retractor. C Exteriorization of the uterus through the posterior colpotomy. D Exposure of the uterine myoma. E Extracorporeal enucleation of the myoma. F Reconstruction of the uterine wall following myomectomy. G Repositioning of the reconstructed uterus into the pelvic cavity and closure of the posterior colpotomy

Statistical analysis

The Statistical Package for the Social Sciences version 27 (SPSS IBM Corp., Armonk, NY, USA) program was used. Distribution of continuous variables was assessed using the Kolmogorov–Smirnov test together with visual inspection of histograms and Q–Q plots. The ANOVA test was done for comparison of normally distributed variables, and the Kruskal-Wallis test was used for non-normally distributed parameters. The Tukey test and Games-Howell test were performed for post hoc analysis to compute pairwise comparisons. Categorical variables were classified using the χ2 test or Fisher’s exact test. Quantitative data are shown as mean ± standard deviation or median (IQR) values. Although chronological grouping was used to facilitate comparison of perioperative outcomes across different phases of experience, cumulative sum (CUSUM) analysis based on operative time was additionally performed because it is a well-established method for evaluating changes in surgical performance over consecutive cases. The CUSUM analysis was used to identify potential inflection points and transitions from the adaptation phase to a more stable performance phase. The data were analyzed at 95% confidence level and P value of less than 0.05 was accepted as statistically significant. No formal sample size calculation was performed because this study included all consecutive patients who underwent vaginal myomectomy during the study period. The study should therefore be considered exploratory and hypothesis-generating.

Results

Demographic characteristics of all patients and postoperative outcomes are presented in Table 1. A total of 60 patients were included in the study, with a mean age of 38.1 years and a mean BMI of 28.2 kg/m². Pelvic pain was present in 30 patients (50%), heavy menstrual bleeding in 49 patients (81.7%), and infertility in 2 patients (3.3%). The mean myoma diameter was 7.0 cm. The requirement for erythrocyte suspension transfusion was 16.7%. The mean operative time was 59.2 min, and the mean duration of hospitalization was 38.8 h. No major intraoperative or postoperative complications (including neurovascular injury, organ damage, or infection) occurred in any patient. The comparison of preoperative demographic characteristics between the groups is shown in Table 2. There were no significant differences in age (p = 0.442), BMI (p = 0.798), gravidity (p = 0.399), parity (p = 0.255), smoking status (p = 0.436), history of previous myomectomy (p = 0.244), or previous cesarean section (p = 0.835). Symptom distribution and myoma characteristics are summarized in Table 3. Rates of pelvic pain (p = 0.966), heavy menstrual bleeding (p = 0.329), and infertility (p = 0.558) were statistically similar among the groups. Myoma localization based on the FIGO leiomyoma classification (submucosal FIGO 0–2, intramural FIGO 3–4, subserosal FIGO 5–7, and transmural FIGO 2–5) also showed no significant differences between groups (p = 0.836). Similarly, the number of myomas (p = 0.418) and mean myoma diameter (p = 0.722) were comparable across all groups. Operative and postoperative parameters are summarized in Table 4. Hematocrit decrease and estimated blood loss were significantly higher in the first group compared with the other three groups (p = 0.033 and p = 0.010, respectively). However, neither the need for erythrocyte suspension units (p = 0.412) nor the overall transfusion rates (p = 0.923) differed significantly among the groups. The mean operative time was significantly longer in the first 30 cases than in the last 30 cases (p = 0.001). The duration of hospitalization was 52.8 h in the first 15 cases, which was significantly longer than in subsequent cases (p = 0.001). These findings indicate a marked improvement in surgical efficiency after the first 15–30 procedures, reflecting the progression of the learning curve for vaginal myomectomy. When the first 30 cases were compared with the last 30 cases, the mean operative time decreased by 11.4 min (95% CI, 6.4–16.4 min), corresponding to a large effect size (Cohen’s d = 1.16). Similarly, hospitalization duration decreased by 12.0 h (95% CI, 4.8–19.2 h), also demonstrating a large effect size (Cohen’s d = 0.84). Improvements were not strictly monotonic across all outcomes; however, the most pronounced changes occurred after the first 15–30 procedures.

Table 1.

Demographic and postoperative data for all patients

	n = 60
Age (years)*	38.1 ± 7.4
BMI (kg/m²)*	28.2 ± 5.1
Gravidity**	2.0 (1.0–3.0)
Parity**	2.0 (1.0–2.0)
Symptom, n (%)
Pelvic pain  HMB  Infertility	30 (50%) 49 (81.7%) 2 (3.3%)
Number of UM, n (%)	1.0 (1.0–2.8)
UM diameter (cm)*	7.0 ± 2.6
Hematocrit decrease**	2.4 (1.5–3.0)
Amount of bleeding (ml)**	185.0 (130.0–420.0)
Units of ES transfusion**	10 (16.7%)
Blood transfusion, n (%)	0 (0–1.0)
Operation time (min)*	59.2 ± 11.3
Hospitalization (hours)*	38.8 ± 15.4

*mean ± standard deviation, ** median (IQR), ES Erythrocyte suspension, BMI Body mass index, UM Uterine myomas

Table 2.

Comparison of preoperative demographic data between the groups

	Group 1 (n = 15)	Group 2 (n = 15)	Group 3 (n = 15)	Group 4 (n = 15)	P value
Age (years)*	39.2 ± 7.7	36.7 ± 6.1	40.1 ± 8.3	36.4 ± 7.3	0.442
BMI (kg/m²)*	27.6 ± 5.4	27.6 ± 5.2	28.5 ± 4.5	29.2 ± 5.5	0.798
Gravidity**	2.0 (2.0–3.0)	2.0 (1.0–3.0)	2.0 (1.0–3.0)	1.0 (0–3.0)	0.399
Parity**	2.0 (2.0–3.0)	2.0 (1.0–2.0)	1.0 (1.0–3.0)	1.0 (0–2.0)	0.255
Smoking status, n (%)	4 (26.7%)	4 (26.7%)	6 (40.0%)	2 (13.3%)	0.436
Previous myomectomy, n (%)	1 (6.7%)	2 (13.3%)	5 (33.3%)	4 (26.7%)	0.244
Previous cesarean section, n (%)	5 (33.3%)	5 (33.3%)	7 (46.7%)	5 (33.3%)	0.835

*mean ± standard deviation, ** median (IQR), BMI Body mass index

Table 3.

Comparison of symptoms and characteristic of myomas between the groups

	Group 1 (n = 15)	Group 2 (n = 15)	Group 3 (n = 15)	Group 4 (n = 15)	P value
Symptom, n (%)
Pelvic pain  HMB  Infertility	8(73.3%) 12(46.7%) 1 (13.3%)	7(66.7%) 10(46.7%) 0 (26.7%)	8(46.7%) 14(26.7%) 0 (46.7%)	7 (40.0%) 11(26.7%) 1 (53.3%)	0.966 0.329 0.558
Location of UM, n (%)
Submucosal (FİGO 0–2)  Intramural (FİGO 3–4)  Subserosal (FİGO 5–7)  Transmural (FİGO 2–5)	1 (6.7%) 7 (46.7%) 3 (20.0%) 4 (26.7%)	1 (6.7%) 6 (40.0%) 3 (20.0%) 5 (33.3%)	- 9 (60.0%) 2 (13.3%) 4 (26.7%)	- 5 (33.3%) 5 (33.3%) 5 (33.3%)	0.836
Number of UM, n (%)	1.0 (1.0–4.0)	1 (1.0–2.0)	1 (1.0–3.0)	1 (1.0–1.0)	0.418
UM diameter (cm)*	7.2 ± 2.5	6.8 ± 2.9	6.5 ± 1.8	7.6 ± 3.1	0.722

UM Uterine myomas

*mean ± standard deviation, ** median (IQR)

Table 4.

Comparison of operation data and postoperative results between the groups

	Group 1 (n = 15)	Group 2 (n = 15)	Group 3 (n = 15)	Group 4 (n = 15)	P value
Hematocrit decrease*	4.2 (1.5–8.0)a	1.8 (1.2–2.7)b	2.1 (1.5–2.4)b	2.4 (1.0–2.7)b	0.033
Amount of bleeding (ml)*	200.0 (166–414)a	180.0 (142–258)b	160.0 (136–254)b	180.0 (50–320)b	0.010
Blood transfusion *	0 (0–1.0)	0 (0–1.0)	0 (0–0)	0 (0–0)	0.412
Units of ES transfusion, n (%)	3 (20.0%)	3 (20.0%)	2 (13.3%)	2 (13.3%)	0.923
Operation time (min)*	66.5 ± 9.0a	63.4 ± 10.1a	55.1 ± 11.7b	52.0 ± 8.3b	0.001
Hospitalization (hours)*	52.8 ± 13.4a	36.8 ± 15.3b	33.6 ± 12.2b	32.0 ± 11.7b	0.001

Lower-case letters are used to define the group that makes the difference. The same letters (such as a-a) indicate that there is no difference, different letters (such as a-b) indicate that there is a difference

*mean ± standard deviation, ES: erythrocyte suspension

To further evaluate the learning curve, a cumulative sum (CUSUM) analysis of operative time was performed. The CUSUM curve demonstrated a progressive increase during the initial phase of surgical experience, reaching a peak at approximately the 34th procedure, followed by a sustained downward trend. This inflection point suggests that surgical proficiency in vaginal myomectomy was achieved after approximately 34 cases and supports the findings of the grouped chronological analysis, which showed significant reductions in operative time after the first 30 procedures (Fig. 2).

Fig. 2.

CUSUM learning curve based on operative time for vaginal myomectomy. The cumulative sum (CUSUM) curve demonstrates progressive improvement in operative performance, with an inflection point at approximately the 34th consecutive case, indicating the transition from the learning phase to a stable proficiency phase

Discussion

Evaluating operative performance during the initial implementation of a new surgical procedure is important to identify case numbers required to perform surgery with acceptable success and complication rates. Defining LC can also play an important role in organizing resident training and in gaining an idea about how many cases a fellow should complete during clinical visits. VM is an established minimally invasive surgical option for selected patients with uterine myomas. Thus, we conducted this study to clarify the impact of LC on VM outcomes. Our findings revealed that amount of bleeding and length of hospital stay were significantly decreased following 15 cases, and operative time decreased and appeared to stabilize after approximately 30 procedures.

Prolonged operative time may result in increases in anesthesia complications, decreases in surgeon attention during surgery, and prolonged recovery time, while higher surgical experience of a specific procedure may shorten the operative time. Catanzarite et al. found significant correlations between prolonged operative time and increased 30-day perioperative complications after laparoscopic and robotic hysterectomy [9]. Sharma and colleagues analyzed the LC for non-descent vaginal hysterectomy with regards to surgical time, and the authors found that operative time decreased from 89 min to 70.5 min after 20 cases, which was significantly shorter in favor of cases after 20 [10]. In another study by de Yoo et al., the impact of LC for robotic single-site surgery in benign gynecologic diseases was examined by dividing 626 patients into three groups (157 patients, 225 patients and 244 patients). The authors found significant decreases in operative time in the second and third groups in comparison with the first group [11]. In the present study, we achieved significantly shorter operative time after 30 cases. We believe that with the increasing number of cases, better knowledge of the area where the operation is performed and the surgical steps by the surgeon and the team, and their increased decision-making skills in the face of undesirable situations are crucial in shortening the operative time. The results of the CUSUM analysis were consistent with the grouped comparison approach. The CUSUM curve reached its peak at approximately the 34th case, indicating the transition from the learning phase to a more stable proficiency phase. This finding closely corresponds to the reduction in operative time observed after the first 30 procedures.

Comparison with other minimally invasive gynecologic procedures provides additional context for interpretation of the present findings. In single-port laparoscopic myomectomy, Lee et al. reported that approximately 45 cases were required to achieve procedural proficiency, whereas the present study demonstrated stabilization of operative performance after approximately 30–34 vaginal myomectomy procedures [7]. Similarly, studies evaluating robotic gynecologic surgery have reported learning curves ranging from 30 to more than 50 procedures, depending on procedure complexity and surgeon experience. In transvaginal natural orifice transluminal endoscopic surgery (vNOTES), Wang et al. identified a learning phase of approximately 20 cases for hysterectomy [8]. These differences likely reflect variations in technical demands, instrumentation, visualization, and previous surgeon experience. Unlike laparoscopic and robotic procedures, vaginal myomectomy is performed through a natural orifice and relies heavily on preexisting expertise in vaginal surgery, which may partly explain the relatively shorter adaptation period observed in the present study.

Bleeding during operations obstructs the definition of anatomical landmarks, decreases success, increases blood transfusion rate and prolongs recovery. Studies investigating correlations between LC and amount of bleeding have controversial results. Wang et al. did not find any correlation between LC and blood loss during transvaginal natural orifice transluminal endoscopic hysterectomy [8]. However, Sahan et al. analyzed the impact of LC on bleeding during kidney stone surgery, and the authors concluded that the amount of bleeding significantly decreased after 30 procedures [12]. In the present study, significantly less bleeding was found after 15 VM cases, but erythrocyte suspension requirements were similar between the four groups. This can be explained as being due to the rate of erythrocyte suspension use not changing while the amount of bleeding decreases, with bleeding during VM often at tolerable amounts.

Length of hospital stay is important for patients returning to daily life and the cost of healthcare systems [13]. Dou et al. compared the first 15 cases and cases between 16 and 44 who underwent laparo-endoscopic single-site radical hysterectomy, and the authors did not find a significant relationship between LC and length of hospital stay [14]. Similarly, Wang et al. did not show any correlation between the LC for transvaginal natural orifice transluminal endoscopic hysterectomy and hospitalization period [8]. However, the present study outcomes demonstrated that hospital stay following VM was significantly shortened after 15 cases. There are two explanations for this result. First, the aforementioned studies evaluated the duration of hospital stay in ‘days’, whereas in this study we considered the hospitalization duration in ‘hours’. Secondly, each country’s hospital stay charges may vary, and surgeon discharge trends may differ.

Our findings are generally consistent with previous reports demonstrating favorable perioperative outcomes following vaginal myomectomy. Plotti et al. reported low complication rates and short hospital stays after vaginal myomectomy [4]. Although this study did not specifically evaluate the learning curve, the progressive improvements observed in the present study are in line with the overall feasibility and minimally invasive nature of the vaginal approach.

The present findings should also be interpreted in the context of the expanding literature on transvaginal minimally invasive surgery. Lee et al. described NOTES myomectomy as a feasible transvaginal approach for selected patients with uterine myomas, demonstrating the potential of natural-orifice surgery in myoma management [15]. Similarly, Lee et al. and Futcher et al. reported favorable outcomes with transvaginal endoscopic hysterectomy procedures, while Kaya et al. demonstrated the feasibility of NOTES techniques across a variety of gynecologic procedures [16–18]. Although the present study evaluated conventional vaginal myomectomy using the STVEC technique rather than endoscopic transvaginal surgery, these reports collectively support the concept that transvaginal approaches can be performed safely and effectively by appropriately trained surgeons. The similarities and differences between these approaches may be relevant when interpreting procedure-specific adaptation and operative performance.

The present findings may have implications for surgical training programs. Based on the observed learning curve, trainees with prior experience in basic and advanced vaginal surgery may require approximately 30–34 supervised vaginal myomectomy procedures to achieve a stable level of operative efficiency. However, because the present study reflects the experience of a single surgeon with extensive vaginal surgical expertise, these findings should not be interpreted as a definitive training requirement. Structured mentorship, stepwise progression of surgical responsibility, and careful patient selection during the early learning phase are likely important components of successful training in vaginal myomectomy. The observed improvements over time may not be attributable solely to increasing technical proficiency of the surgeon. Progressive familiarity of the operating room team with the STVEC technique, optimization of workflow, and refinement of patient selection may also have contributed to the observed reductions in operative time and hospitalization duration.

Several limitations of this study should be acknowledged. First, this study reflects the experience of a single surgeon with approximately 20 years of gynecologic surgical experience and extensive expertise in advanced vaginal surgery. Consequently, the observed improvements may not be generalizable to surgeons with different levels of experience, particularly those in the early stages of vaginal surgical training. Second, although all consecutive patients were included, the relatively small sample size may have limited statistical power for subgroup analyses. Third, while surgical data were collected prospectively, the learning-curve analysis was performed retrospectively, introducing limitations inherent to retrospective study designs. In addition, patient selection may have evolved during the study period as surgical experience increased, potentially introducing selection bias. The study also focused exclusively on perioperative outcomes and did not evaluate mid-term or long-term clinical results. Furthermore, several factors that may influence operative complexity, including myoma localization, uterine mobility, pelvic adhesions, obesity severity, and details of previous pelvic surgery, were not analyzed separately because of the limited sample size. Finally, cost analysis was not performed. Future multicenter studies with larger patient populations and longer follow-up are needed to validate the proposed learning-curve patterns and further evaluate clinical outcomes.

In conclusion, the present findings suggest that vaginal myomectomy may be performed with acceptable perioperative outcomes during the learning process when undertaken by an experienced vaginal surgeon. Improvements in bleeding parameters and hospitalization duration were observed after approximately 15 cases, whereas operative time decreased and reached a stable proficiency phase after approximately 30–34 cases. Given the absence of a comparison group, the relatively small sample size, and the lack of long-term follow-up data, these findings should be interpreted cautiously. Larger prospective studies are needed to validate the proposed learning-curve thresholds and to further evaluate clinical outcomes.

Author contributions

E.A.S: Conceptualization, study design, data collection, manuscript writing. T.S: Data analysis and interpretation. S.Ö.A: Surgical procedures and data acquisition. A.B.T: Literature review and manuscript revision. H.S: Supervision, critical revision, and final approval of the manuscript.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The study was approved by the Clinical Research Ethics Committee of Sancaktepe İlhan Varank Training and Research Hospital (Approval No: 241, Date: July 16, 2025), and was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from all participants.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.