Extraperitoneal Pelvic and Para-Aortic Lymphadenectomy via Vaginal Natural Orifice Transluminal Endoscopic Surgery in...

To demonstrate extraperitoneal pelvic and para-aortic lymphadenectomy for endometrial cancer staging using vaginal natural orifice transluminal endoscopic surgery (vNOTES).

Minimally invasive surgery is widely used for endometrial cancer staging [1,2]. vNOTES is a scarless minimally invasive approach, although its oncologic role remains under investigation [3]. This video demonstrates extraperitoneal vNOTES pelvic and para-aortic lymphadenectomy in 11 steps, with diagrams that clarify transvaginal entry, retroperitoneal orientation, and para-aortic dissection.

A 64-year-old woman with grade 2 endometrioid endometrial carcinoma and suspicious pelvic and para-aortic lymph nodes on preoperative positron emission tomography-computed tomography. (Institutional permission was obtained for the publication of this surgical video. The patient provided written informed consent for the surgical procedure and for the use of anonymized clinical and video material for scientific publication. The patient's identity has been protected throughout the manuscript and video. Documentation of institutional permission/IRB exemption is provided in the submission files).

Total hysterectomy, bilateral salpingo-oophorectomy, and extraperitoneal pelvic and para-aortic lymphadenectomy were performed using vNOTES (Fig. 1). Blue dye was injected into the cervix for sentinel lymph node mapping; however, no stained sentinel lymph nodes were identified. Retroperitoneal access was obtained through the right lateral fornix into the extraperitoneal parametrial space. The paravesical and pararectal spaces were developed, followed by pelvic lymphadenectomy and para-aortic lymphadenectomy up to the renal vein (Figs. 2-3). This route allowed direct caudal-to-cranial access with minimal bowel interference and no abdominal incision, offering improved exposure, reduced abdominal wall trauma, less postoperative pain, and scarless surgery [4]. Potential disadvantages include a steep learning curve, limited working space, instrument collision, and difficulty managing major vascular injuries; therefore, emergency preparedness and appropriate surgical expertise are essential. The procedure was completed without complications, and the patient was discharged on postoperative day 2. Pathology showed a 3-cm grade 2 endometrioid carcinoma with less than half myometrial invasion. A total of 12 pelvic and 8 para-aortic lymph nodes were removed.

This video illustrates the feasibility of extraperitoneal pelvic and para-aortic lymphadenectomy via vNOTES in selected patients. Adequate lymph node yield was achieved, but comparative studies are needed before conclusions regarding equivalence or non-inferiority to laparoscopy can be drawn. With further experience, extraperitoneal vNOTES may have future applications in selected gynecologic oncologic staging procedures. VIDEO ABSTRACT.