vNOTES vs Total Laparoscopic Hysterectomy: A Randomized Controlled Trial of Pain, Opioid Use, and Quality of Recovery

To compare postoperative pain, opioid use, and recovery outcomes between Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) and total laparoscopic hysterectomy (TLH).

Prospective randomized controlled trial.

Tertiary care university-affiliated hospital.

Ninety female patients (18-75 years, ASA I-II) undergoing elective hysterectomy for benign indications.

Patients were randomized to undergo hysterectomy via vNOTES (n = 45) or TLH (n = 45) under standardized anesthesia and analgesia protocols.

Pain scores were significantly lower in the vNOTES group (p < .001), with median NRS scores of 3 vs 7 at 12 hours and 2 vs 4 at 24 hours (both p < .001). No participants in the vNOTES group received postoperative rescue opioids, whereas all TLH patients did (p < .001); median tramadol consumption was 0 (0-0) mg vs 200 (200-300) mg (p < .001). Recovery was faster with vNOTES, including earlier return of bowel function, oral intake, mobilization (p = .001), and shorter hospital stay (all p ≤ .001). QoR-15 scores were higher (adjusted mean difference 10.8, 95% CI 5.9-15.7; p < .001), while fatigue scores were lower (-3.9; p < .001). Hemoglobin decrease was slightly greater in the vNOTES group (-1.92 ± 0.64 vs -1.65 ± 0.55 g/dL; p = .045), although this difference was not considered clinically significant. Postoperative nausea, shoulder pain, and respiratory distress were less frequent, with similar complication rates.

vNOTES was associated with lower postoperative pain scores, reduced postoperative rescue opioid use, and improved immediate postoperative recovery compared with TLH, supporting its potential as a patient-centered minimally invasive approach.