Analyzing the learning curve of vnotes sacrocolpopexy by the cumulative summation test: a cohort study

The learning curve of transvaginal natural orifice transluminal endoscopic sacrocolpopexy (vNOTES-SC) in the treat of pelvic organ prolapse (POP) is critical yet underexplored. Our objective is to describe the learning curve and surgical complications of vNOTES-SC, taking into account the factors that affect operative time and evaluate the long-term follow-up outcomes of this surgery.

We conducted a hospital-based cohort study involving patients who underwent vNOTES-SC from June 2017 to May 2024. All surgeries were performed by a single surgeon with over 20 years of surgical experience. This study employed cumulative summation test (CUSUM) analysis to quantify the learning curve for vNOTES-SC by operative time. Perioperative outcomes, postoperative complications, and long-term follow-up outcomes were systematically collected and analyzed.

The CUSUM analysis revealed a sharp inflection at the 11th case, marking the transition from the learning improvement phase to the mature stable phase, with a corresponding reduction in mean operative time from 241.6 ± 45.1 to 184.3 ± 31.5 minutes. Operative time was driven by surgeon proficiency during the learning improvement phase but by uterine volume in the stable experience phase. After the surgeon passed through the learning curve, the conversion rate and postoperative stay decreased significantly, while there was no significant change in the occurrence of intraoperative and postoperative complications. During the median follow-up of 73 months, the anatomical cure rate was 91%, while mesh exposure was noted in three cases (3.8%). Postoperative pelvic organ prolapse quantitation scores exhibited improvement across all measures except point perineal body. The Pelvic Floor Impact Questionnaire-7 and Pelvic Floor Distress Inventory-20 demonstrated significant improvement compared to preoperative values.

vNOTES-SC is a feasible and durable approach for POP treatment with a short learning curve, rapid postoperative recovery, and favorable long-term follow-up outcomes thereby establishing it as a safe and viable surgical option even during learning improvement phase.