Vaginal natural orifice transluminal endoscopic surgery versus conventional multiport laparoscopy for hemorrhagic ovarian cyst rupture with hemoperitoneum: a multicenter retrospective cohort study.

Abstract

Objective: To compare perioperative outcomes, postoperative pain, early recovery, and patient-reported sexual and cosmetic outcomes between vaginal natural orifice transluminal endoscopic surgery (vNOTES) and conventional multiport laparoscopy (CML) in hemodynamically stable women undergoing surgery for hemorrhagic ovarian cyst rupture with hemoperitoneum.

Methods: Design Multicenter retrospective cohort study (Canadian Task Force classification II-2).

Setting: Departments of Obstetrics and Gynecology of two tertiary referral centers, January 2020 to December 2025.

Participants: Forty-two non-pregnant women aged ≥18 years with imaging-confirmed hemoperitoneum from a ruptured ovarian cyst and clinical evidence of ongoing bleeding undergoing minimally invasive surgery.

Interventions: vNOTES via posterior colpotomy with a multichannel single-port device (n = 13) versus CML with a 10-mm umbilical and two or three 5-mm ancillary trocars (n = 29). Both arms used a standardized Enhanced Recovery After Surgery protocol.

Results: Primary outcomes were operative time, estimated blood loss, visual analog scale (VAS) pain at 6, 12, and 24 hours, length of stay, and Quality of Recovery-15 score at discharge. Secondary outcomes included complications (Clavien-Dindo), conversion, transfusion, additional analgesia, and Female Sexual Function Index (FSFI) and Female Genital Self-Image Scale (FGSIS) scores at 6 months. Baseline characteristics were comparable between groups. Operative time (44.6 ± 17.1 vs 49.1 ± 16.5 min; p = .20), blood loss (124.0 ± 116.3 vs 132.8 ± 127.1 mL; p = .72), transfusion (7.7% vs 6.9%; p = .92), and intraoperative complications (7.7% vs 6.8%; p = .93) did not differ, and no conversion to laparotomy occurred. VAS pain at 12 hours was lower after vNOTES (1.9 ± 0.7 vs 3.2 ± 1.1; p = .002). FGSIS favored vNOTES (24.28 ± 1.80 vs 22.31 ± 3.47; p = .009), whereas FSFI total and domain scores, including lubrication, were comparable between groups. There were no conversions from vNOTES to conventional laparoscopy or to laparotomy. Exploratory adjusted and IPTW sensitivity analyses were consistent with the primary unadjusted findings. Because approach selection was non-random, the pain and genital self-image differences cannot be causally attributed to the technique.

Conclusion: In hemodynamically stable women with hemorrhagic ovarian cyst rupture, vNOTES is feasible and safe, with hemostatic efficacy comparable to CML and advantages in 12-hour pain and genital self-image. Prospective studies are warranted to confirm these findings.