Outcomes of Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) for Uterosacral Ligament Suspension in Apical Compartment Prolapse: A Systematic Review.

Introduction and hypothesis: This systematic review is aimed at assessing the efficacy and safety of transvaginal natural orifice transluminal endoscopic surgery-uterosacral ligament suspension (vNOTES-USLS) based on current evidence.

Methods: A comprehensive search of PubMed and Web of Science was conducted for studies published up to 31 December 2024. Original studies on vNOTES-USLS were included, whereas reviews, abstracts, and publications not in the English language were excluded. No restrictions were placed on sample size or publication date.

Results: Nine studies with 336 patients met the criteria, including 1 randomized controlled trial, 3 prospective, and 5 retrospective studies. Operative time ranged from 17.4 ± 6.4 to 29.7 ± 8.2 minutes. Hemoglobin reduction varied between 1.12 ± 0.83 and 1.80 ± 1.57 g/dl. Hospital stays ranged from 1.0 ± 0.5 to 3.7 ± 1.1 days. Intraoperative complications occurred in 2.1% (7 out of 336), with bladder injury being the most common (3 cases). One patient required conversion to vaginal USLS, but no laparotomy conversions were reported. Ureteral kinking occurred in 1 case (0.3%) and was resolved intraoperatively. Postoperative complications were reported in 7.4% (25 out of 336), with urinary tract infection being the most frequent (10 cases). Over 1-37 months of follow-up, 1 patient required reoperation for anterior prolapse recurrence.

Conclusion: vNOTES-USLS appears to be a promising option for apical prolapse, with favorable short-term outcomes. However, small sample sizes, short follow-ups, and study design variations limit current evidence. Larger prospective studies with longer follow-ups and direct comparisons with established procedures are needed to assess long-term safety and effectiveness.