Spatial Mapping of Pelvic Anatomy Focused on Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) Apical Suspension Prolapse Procedures.

Importance: Comprehensive understanding of anatomic landmarks is essential for safe and successful apical suspension during vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) procedures. However, detailed descriptions of these landmarks remain scarce in the current literature.

Objective: We aimed to delineate the anatomic relationships of key landmarks relevant to apical suspension procedures performed through vNOTES.

Study design: Ten embalmed female cadavers were dissected. A 9.5 cm Alexis retractor from the commercially manufactured vNOTES port was used. Distances were measured from the inner ring of the retractor to the following anatomic structures: the ischial spine (sagittal and transverse planes), S1 root, urethra, trigone, pubic crest, and iliac vessels.

Results: The mean distance from the retractor's inner ring to the ischial spine was 1.0 cm (range: 0.9-1.3, SD: 0.1) sagittally and 3.6 cm (range: 3.0-4.9, SD: 0.6) transversely. The S1 foramen was located 6.4 cm (range: 5.0-8.0, SD: 1.0) from the ring's midpoint. Sagittal measurements revealed a mean distance of 2.6 cm (range: 1.7-3.5, SD: 1.0) from the proximal urethra and 1.9 cm (range: 1.4-3.5, SD: 0.7) from the trigone. The external iliac vessels were 3.2 cm (range: 2.1-4.1, SD: 0.7) from the ring's edge, while the pubic crest was 2.7 cm (range: 1.6-3.3, SD: 0.5) away.

Conclusions: The spatial relationships described in this study provide crucial reference points for surgeons performing apical suspension during vNOTES. Knowledge of these relationships can enhance safety and provide a roadmap for future innovation and the advancement of complex gynecologic interventions.