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Related Experiment Video

Updated: Mar 14, 2026

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Prioritizing vaginal hysterectomy: a stepped algorithm with vNOTES support for benign indications.

Sezin Eda Karsli1, Yusuf Ziya Kizildemir2, Sibel Sak2

  • 1Department of Obstetrics and Gynecology, Şanlıurfa Training and Research Hospital, Şanlıurfa, Türkiye.

Frontiers in Medicine
|March 13, 2026
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Summary

A "vaginal-first" surgical approach for non-descensus uteri achieved 95.2% success without abdominal incisions. This method effectively utilizes vaginal hysterectomy (VH) and transvaginal NOTES (vNOTES) to maximize minimally invasive benefits.

Keywords:
conversion to laparoscopyminimally invasive surgerynon-descensus uterussurgical algorithmvNOTESvaginal hysterectomy

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Area of Science:

  • Minimally Invasive Surgery
  • Gynecologic Surgery
  • Surgical Algorithms

Background:

  • The management of non-descensus uteri often involves hysterectomy, with varying degrees of invasiveness.
  • Optimizing surgical approaches to minimize patient morbidity and maximize recovery is a key goal in gynecologic surgery.

Purpose of the Study:

  • To evaluate the clinical outcomes of a standardized "vaginal-first" surgical algorithm for hysterectomy in patients with non-descensus uteri.
  • To assess the role of transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) as a supportive technique within this algorithm.

Main Methods:

  • A prospective, single-center cohort study of 165 patients undergoing hysterectomy for benign indications.
  • Implementation of a stepwise algorithm: primary vaginal hysterectomy (VH), secondary vNOTES, and tertiary laparoscopy/laparotomy.
  • All procedures performed by a single surgeon to minimize variability.

Main Results:

  • Vaginal completion was achieved in 95.2% of patients (157/165).
  • Pure VH success rate was 87.9%, with 7.3% requiring vNOTES support and 4.8% converted to laparoscopy/laparotomy.
  • High success rates were observed in high-risk subgroups (obesity, prior Cesarean sections), and a learning curve demonstrated improved VH rates and decreased vNOTES use over time.

Conclusions:

  • A "vaginal-first" approach is recommended as the standard of care for hysterectomy in non-descensus uteri.
  • vNOTES serves as an effective "educational bridge" and "safety valve," enhancing surgical skills and preventing abdominal conversions.
  • This stepped strategy optimizes resource use and maximizes the benefits of minimally invasive surgery.