Stage-Specific outcomes of robotic transvaginal NOTES hysterectomy in endometriosis: A comparative study

The objective was to assess outcomes of robotic-assisted transvaginal natural orifice transluminal endoscopic surgery (RA-vNOTES) performed for hysterectomy and endometriosis excision. We conducted a retrospective case series across two hospitals belonging to the same academic tertiary institution in Houston, Texas, USA. From August 2019 to April 2025, RA-vNOTES hysterectomy with endometriosis resection was performed in 274 patients with stage I-IV disease, classified according to the revised American Society for Reproductive Medicine (rASRM) system. Of the 274 patients, 131 were classified as stage I, 56 as stage II, 46 as stage III, and 41 as stage IV endometriosis. Hysterectomy time, total operative time, and estimated intraoperative blood loss were associated with stage of endometriosis (all p < 0.05). Median total operative time was 132 min for stage I, 147 min for stage II, 166 min for stage III, and 222 min for stage IV disease. Through a RA-VNOTES approach, we could address an obliterated posterior cul-de-sac and complete all necessary procedures for excision of endometriosis, including lysis of adhesions, retrograde ureterolysis, complete peritonectomy, cystectomy of endometriomas, appendectomy, bowel shaving, and bowel discoid excision. Three cases were converted to abdominal robotic surgery for bowel resection and reanastomosis, ureteral reimplantation, and excision of diaphragmatic endometriosis. All patients had a significant improvement in VAS pain score pre- to post-surgery. Overall complication rates were low. RA-vNOTES offers a safe and practical method for endometriosis excision while providing the patient with the profits of the most minimally invasive approach - with complications being rare.