Surgical Approach for Enlarged Uteri: Further Tailoring of vNOTES Hysterectomy

This article refers to:

Comparison of Surgical Outcomes of Total Laparoscopic Hysterectomy and vNOTES Hysterectomy for Undescended-Enlarged Uteri

Minimally Invasive Surgery (MIS) is a current surgical trend which aims to increase the efficiency of operative techniques in different fields. Gynecology is one of these surgical fields, very prolific for innovative techniques. In particular, the possibility to use vaginal route offers novel strategies for both surgical approach and specimen retrieval by culdotomy, even preserving the uterine integrity [1].

In this scenario, vaginally Assisted Natural Orifice Transluminal Endoscopic Surgery (vNOTES) is one of the most innovative surgical techniques which is currently under the spotlight. Apart from gynecological conditions, vNOTES was also used in a hybrid manner in other medical specialties, such as in case of nephrectomy [2]. As far as gynecological surgery is concerned, vNOTES hysterectomy is gaining continuous popularity. This technique provides the peculiar feature of combining the advantages of both vaginal hysterectomy (VH) and laparoscopic hysterectomy (LH). One of the most important benefits is the lack of visible scars, which results in an optimal cosmetic outcome. Moreover, vNOTES hysterectomy provides a shorter duration of surgery, as well as reduction of post-operative pain, due to the vaginal access route. Moreover, the use of endoscopic visualization helps to increase the safety of the procedure compared to “classic” VH, allowing the easy identification of uterine vessels and ligaments. However, this technique should be performed only after adequate training, since the transvaginal access could lead to specific complications. In particular, the pelvic cavity can be not accessed if the incision is too close to the uterus; in addition, the bowel and rectum could be injured; finally, the hypogastric plexus could be damaged during of transection of the uterosacral ligaments [3].

Every new surgical approach requires validation compared to previous available techniques and, subsequently, it should be appropriately tailored depending on the patient’s condition. For this reason, also vNOTES hysterectomy has undergone a strict validation pathway over the last decade. Recently, a metanalysis was performed by Housmans et al. [4], including the data retrieved from one RCT and five retrospective studies about vNOTES hysterectomy compared to Laparoscopic Assisted Vaginal Hysterectomy (LAVH) and Total Laparoscopic Hysterectomy (TLH). One the one hand, data analysis was in favor of the vNOTES approach in terms of surgery duration and blood loss; on the other hand, no significant differences were reported regarding intra- and post-operative complications, pain scores and modification of hemoglobin levels evaluated on postoperative day 1. Nevertheless, data should be interpreted taking into account that only benign gynecological diseases were included in the pooled analysis.

Therefore, the new target of clinical trials should be to assess the appropriateness of vNOTES hysterectomy in selected populations, with the aim of maximizing the potential benefits of this technique compared to other approaches. In this context, we recently highlighted the opportunity offered by vNOTES hysterectomy for obese patients, considering the impact of immediate and medium-term complications in this population [5]. Despite these encouraging elements, vNOTES feasibility and safety would need further validation, such as in case of very large uteri, which require adequate surgical expertise to be managed with minimally invasive approaches. Accumulating evidence suggests that TLH could be implemented even for very large uteri, using standardized approach [6], although some authors continue to prefer VH [7]. Although data are still not robust enough to draw firm conclusions for vNOTES hysterectomy, a recent study [8] on a limited cohort of women undergoing this technique for myomas or adenomyosis, with a mean uterine weight of 1141.8 gr, found that this approach seems feasible and safe. More recently, another retrospective study evaluated vNOTES hysterectomy in 114 women with enlarged uteri and benign gynecologic diseases, with a mean uterus weight of 559 gr [9]; in line with previous findings, the vNOTES approach has been found to be feasible, with only one conversion to laparotomy for specimen extraction and no conversions to laparoscopy [9].

Considering the paucity of data about the topic, we were glad to read the recent article published in Journal of Investigative Surgery, in which the authors performed vNOTES hysterectomy for undescended and enlarged uteri [10]. In this study, the inclusion criteria (enlarged uterus) were defined as the presence of a uterus weighing 280 gr or more on pathologic examination, as recommended by the guideline of the International Society of Gynecologic Endoscopy (ISGE); in addition, authors excluded women with uterine prolapse, based on Pelvic Organ Prolapse Quantification (POP-Q). Subsequently, the authors compared LH to vNOTES hysterectomy, with a cross-sectional approach. The LH and vNOTES groups did not show significant differences for blood loss, pain score after 6 hours, and postoperative total doses of analgesics consumed; conversely, the vNOTES approach was associated with a shorter duration of surgery and hospitalization, as well as lower pain score after 24 hours, compared to LH. Finally, we appreciated that the Authors provided for the first time a 1:1 propensity score match model, which confirmed the previous results in a more robust fashion.

The importance of such innovative studies relies on the identification of the most efficient surgical technique on selected population(s). In this scenario, we can consider vNOTES hysterectomy as a feasible approach for women with benign indications for hysterectomy, with enlarged and undescended uteri. Despite these promising data, we take the opportunity to solicit further studies aiming to select vNOTES indications for hysterectomy, which will provide a robust background to draw recommendations in future guidelines about gynecological MIS.

Authors’ contribution

All the authors conform the Journal and the International Committee of Medical Journal Editors (ICMJE) criteria for authorship, contributed to the intellectual content of the study and gave approval for the final version of the article.

Disclosure statement

The authors have no proprietary, financial, professional or other personal interest of any nature in any product, service or company. The authors alone are responsible for the content and writing of the paper.