Safety and Feasibility of Vaginal Natural Orifice Surgery Hysterectomy for Enlarged Uteri

This study evaluated the impact of uterine size on surgical outcomes in vaginal natural orifice transluminal endoscopic surgery (vNOTES) hysterectomy and compared perioperative outcomes with conventional laparoscopic hysterectomy (LH) in patients with large uteri.

This single-center, retrospective cohort study included 812 patients who underwent hysterectomy between January 2024 and January 2026. Patients were categorized into 3 groups: vNOTES with small uteri (n = 102), vNOTES with large uteri (n = 87), and LH with large uteri (n = 623). Primary outcomes were operative time, estimated blood loss, conversion rates, and complications. Secondary outcomes included postoperative complications, hospitalization period, postoperative hemoglobin change, uterine weight and pain scores assessed using the visual analogue scale (VAS) at 12 and 24 hours postoperatively.

There were no statistically significant differences among 3 groups regarding operative time, hemoglobin drop or estimated blood loss (P > .05). Uterine weights were significantly higher in the large uterus groups (vNOTES: 385 ± 89.6 g; LH: 420 ± 107.2 g) compared to the small uterus group (135 ± 45 g, P < .001). Conversion to laparotomy was significantly higher in the LH group (5.3%) than the vNOTES groups (0% and 1.15%, P = .015). VAS at 12 hours were significantly lower in the vNOTES small uterus group (P = .006), whereas 24-hour scores and complication rates were comparable across all groups.

vNOTES hysterectomy is a safe and feasible approach for patients with enlarged uteri, demonstrating noninferiority to conventional laparoscopy. vNOTES may offer lower risk of conversion to laparotomy compared to laparoscopy in cases of uterine enlargement.