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Functional Outcomes After Vaginal Natural Orifice Transluminal Endoscopic Surgery Hysterectomy: A Systematic Review
Charlotte M Wignall1, Jane E McDonnell2, Batool Nadim3
1School of Medicine, The University of Notre Dame Australia, Sydney, New South Wales, Australia.
Introduction:
Vaginal hysterectomy is guideline-preferred for benign disease, yet uptake is declining. Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) offers enhanced visualisation while optimising recovery; however, impact on functional outcomes remains unclear.
Aims:
To evaluate sexual function and pelvic floor outcomes following vNOTES hysterectomy compared with minimally invasive alternatives.
Methods:
A systematic review was conducted per PRISMA 2020 and Cochrane guidelines (PROSPERO CRD420251247524). MEDLINE, Embase, Cochrane and Scopus were searched to February 2026. Comparative studies (≥ 25 vNOTES patients) reporting functional outcomes (Female Sexual Function Index [FSFI], Pelvic Floor Distress Inventory [PFDI], International Consultation on Incontinence Questionnaire [ICIQ], Pelvic Organ Prolapse Quantification [POP-Q]) were included. Non-comparative studies and those without validated measures were excluded. Risk of bias was assessed using RoB2 and Newcastle-Ottawa Scale. Results were synthesised narratively (SWiM).
Results:
Five studies (n = 526; one randomised trial, four cohort studies) were included. Sexual function was equivalent between vNOTES and laparoscopic approaches at 3-6 months. One study with variable follow-up extending beyond 6 months reported higher FSFI scores (p = 0.003), whereas others showed no difference (p > 0.05). Dyspareunia rates were comparable (2 studies). Pelvic floor outcomes (1 study) were limited, suggesting improved anterior compartment support (POP-Q Aa; p < 0.003), with similar apical and posterior support. Overall certainty of evidence was low.
Discussion:
vNOTES hysterectomy demonstrates comparable medium-term sexual and pelvic floor outcomes to laparoscopic approaches, with no signal of harm. Small samples, observational design and heterogeneity limited evidence, restricting definitive conclusions. Standardised long-term studies are required to define functional safety and guide counselling.
