Intra- and Postoperative Complications in 4565 vNOTES Hysterectomies: International Registry Cohort Study

To present the rates of intra- and postoperative complications and conversions in a large cohort of unselected vNOTES hysterectomies, performed by surgeons with different levels of expertise.

International register-based cohort study.

Hysterectomies in the iNOTESs registry, 2015 to January 2024, performed by 201 surgeons from multiple countries.

4565 patients undergoing vNOTES hysterectomy.

Descriptive data are presented in frequencies (n) and percent (%).

Intra- and postoperative complications. Conversions.

Intraoperative and postoperative complication rates were 3.2% (n = 144) and 2.5% (n = 115), respectively. Conversions occurred in 1.6% (n = 72), of which 10 (0.2%) to laparotomy, and 82% of the conversions occurred within the first 50 cases of the surgeon's learning curve. The most common intraoperative complication was cystotomy, occurring in 1.3%, and almost half were performed by inexperienced surgeons. Other intraoperative organ injuries occurred in 20 cases (0.44%). Postoperatively, the most common complications were haemorrhage (n = 28), vault complications (n = 26) including 11 infected vault hematomas, cystitis (n = 18) and non-specific infections (n = 14). The vNOTES hysterectomies were performed by 201 surgeons, of which 9.5% had performed more than 50 vNOTES cases, representing 70% of the registered cases in the registry. The remaining 30% of the hysterectomies mainly represent learning curve data from 90% of the included surgeons. The complication rate decreased with increasing surgical experience.

The largest study population of vNOTES hysterectomies is presented, including both learning curve data and data from experienced surgeons, with acceptable rates of intra- and postoperative complications. No implication was found of vNOTES being inferior to other minimally invasive methods.