vNOTES hysterectomy for patients with large uteri: Initial experience in the largest Tertiary Centre in Singapore

Vaginal natural orifice transluminal endoscopic surgery (vNOTES) is a novel, minimally invasive surgical method that has been increasingly used in gynaecological surgeries, especially hysterectomies. It has been shown to reduce operating time, post-operative recovery time and post-operative pain. However, in patients with large uteri, vNOTES hysterectomy may be more challenging due to the difficulty in mobilising the uterus and poor visualisation of the pelvic structures. Our study aims to evaluate the feasibility and outcomes of patients with large uteri undergoing vNOTES hysterectomy.

This was a single-centre retrospective study of patients who underwent vNOTES hysterectomy in KK Women's and Children's Hospital (KKH), Singapore's largest gynaecological tertiary care centre, between 15 April 2021 and 21 March 2024.

Demographic data and surgical outcomes were analysed for patients with large uteri, defined as uterine weight >280 g, based on the International Society of Gynaecological Endoscopy (ISGE) guidelines. Our subgroup analysis compared surgical outcomes for patients with uterine weight >280 g and uterine weight <280 g. Both groups were compared using the Student t-test and Fisher Exact test for quantitative and qualitative data, respectively. Pearson's correlation coefficient was used to study the association between uterine weight, estimated blood loss and operative time.

Among the 176 patients who underwent vNOTES hysterectomy during this period, 58 patients fit the criteria for a large uterus. There was one patient with intra-operative conversion to laparoscopy due to difficulty in entering the Pouch of Douglas. There were five post-operative complications (2.8 %). In our subgroup analysis, patients with uterine weight >280 g had significantly longer operative time (126.2 ± 48.4 min vs 101.6 ± 39.9 min, p < 0.01) and higher estimated blood loss (271.7 ± 264.9 ml vs 110.8 ± 93.1 ml, p < 0.01) compared to patients with uterine weight <280 g.

VNOTES hysterectomy is a safe and feasible approach for patients with large uteruses with low rates of complications and conversion. However, patients should also be counselled on the potential risks of increased operative time and bleeding. Further studies are needed to validate our findings.