A Structured Two-Phase Workflow for Transvaginal Natural Orifice Transluminal Endoscopic Sacrocolpopexy: A 24-Case Consecutive Feasibility Series.

Abstract

Study objective: To describe the feasibility, perioperative outcomes, and short-term follow-up of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) sacrocolpopexy performed with a structured two-phase workflow.

Design: Retrospective consecutive case series.

Setting: Single tertiary academic institution.

Participants: Twenty-four consecutive intended vNOTES-SC/RvNOTES-SC cases in a selective single-surgeon program for stage II-IV apical prolapse (April 2019-December 2025).

Interventions: The operation was organized into an endoscopic phase (presacral dissection, retroperitoneal tunneling, sacral fixation of the Y-mesh long arm, and peritonealization) and a direct-vision vaginal phase (vaginal-wall preparation, short-arm fixation, and cuff closure); robotic assistance, when used, was confined to the endoscopic phase. The first 10 cases used a previous multi-phase technique and the subsequent 14 the structured two-phase workflow.

Measurements and main results: Sacrocolpopexy was completed in 23 of 24 patients (one intraoperative conversion). Over a median follow-up of 12.2 months (range 5.9-83.9), no mesh-related complications, recurrences, or reoperations for prolapse occurred. One patient had vaginal cuff inflammation (resolved with oral antibiotics; Clavien-Dindo grade II) and two had mild stress urinary incontinence managed conservatively. Total operative time was shorter in the later period (138.1 ± 19.3 vs 190.0 ± 25.6 minutes), but because the periods were chronological this could not be separated from a learning-curve effect or increasing robotic use.

Conclusion: vNOTES sacrocolpopexy with a structured two-phase workflow was feasible, with a low complication profile and no mesh-related complications during short-term follow-up. Comparative effectiveness and long-term outcomes require prospective study; operative-time findings are hypothesis-generating.