Extraperitoneal versus transperitoneal approach in vNOTES sacrocolpopexy: a comparative pilot study

This pilot study aimed to assess the feasibility, perioperative safety, and short-term outcomes of extraperitoneal versus transperitoneal vNOTES sacrocolpopexy.

Thirty-six patients with POP-Q stage III or higher who underwent simultaneous vNOTES hysterectomy, BSO, and sacrocolpopexy were retrospectively analyzed and categorized into extraperitoneal (Group A, n=14) and transperitoneal (Group B, n=22) groups. Anatomical success, quality of life, and recovery were evaluated using POP-Q, P-QOL, ICIQ-UI SF, QoR-15, and MESH-R scales.

Baseline characteristics were comparable between groups. Six-month anatomical success rates were similar (extraperitoneal 90.8% vs. transperitoneal 91.6%). The most notable procedural difference was Trendelenburg positioning: Group A was maintained at 10°-15° throughout, whereas Group B required 25°-30° during the sacrocolpopexy phase. Numerical trends favoring the extraperitoneal approach were observed in operative time (99.6 vs. 110.4 min; p=0.185) and time to first stool (27.7 vs. 34.5 h; p=0.552), but neither reached statistical significance. No rectal injuries or intraabdominal abscesses occurred in either group.

Extraperitoneal vNOTES sacrocolpopexy is feasible and safe, yielding anatomical outcomes equivalent to the transperitoneal approach at six months. Its most substantiated advantage is the reduced Trendelenburg angle, which may lower physiological burden in high-BMI patients. Remaining potential benefits require confirmation through larger prospective trials.