Benton-Bryant Charlotte, Pour Nina Reza, Baekelandt Jan, Elhindi James, Ekanyake Kanchana, Kapurubandara Supuni
University of Sydney (Drs. Benton-Bryant and Kapurubandara), Sydney, New South Wales, Australia.
Sydney West Area Pelvic Surgical Unit (SWAPS) (Drs. Pour and Kapurubandara), Sydney, New South Wales, Australia; Department of Obstetrics and Gynaecology, Blacktown Hospital (Dr. Pour), Sydney, New South Wales, Australia.
J Minim Invasive Gynecol. 2025 Apr;32(4):318-351.e2. doi: 10.1016/j.jmig.2024.11.004. Epub 2024 Dec 6.
Vaginal natural orifice transluminal endoscopic surgery (vNOTES) is utilised for gynecological procedures globally, however evidence to support its application aside from hysterectomy is lacking. A systematic review to determine feasibility and safety profile of vNOTES for benign gynaecology was conducted.
A literature search of MEDLINE, EMBASE, CINAHL, SCOPUS, and CENTRAL was conducted, including all types of studies reporting vNOTES for gynecological indications. After excluding cases with concurrent hysterectomy, the review focuses on procedures for benign indications and oncological procedures are reported separately. Patient characteristics and perioperative outcomes were reported, with pooled analysis for sufficiently powered categories.
Fifty-four articles were analyzed, including 7 comparative studies (n = 439) and 1 RCT (n = 34), reporting 2469 cases of vNOTES, including adnexal (tubal and/or ovarian) (43 articles, n = 2261), myomectomy (10 articles, n = 136) and prolapse repair (6 articles, n = 72) in predominantly premenopausal women with BMI <30 kg/m on pooled analysis.
TABULATION, INTEGRATION AND RESULTS: The overall conversion rate was low (1.38%, n = 34) with procedure specific conversion rates of 0.45 to 6.8% for adnexal procedures, 1.47% for myomectomy and none reported for prolapse repair. Overall complication rates were low (3.44%, n = 85) with no associated mortality. Five (0.20%) adhesion-related rectal injuries at colpotomy were noted, all repaired intraoperatively without long-term sequelae.
vNOTES appears feasible based on limited evidence, for uterine-sparing gynecological indications, despite a notable rate of rectal injury at colpotomy. There is a negligible risk of rectal injury observed at conventional laparoscopy and robotically assisted surgery, but similar rate of entry-related gastrointestinal injury. This may be due to the learning-curve or suboptimal case selection, necessitating careful training, assessment, and appropriate patient selection. Surgeons should continue registering prospective vNOTES cases via iNOTESs, to evaluate emerging perioperative trends with global uptake of this novel technique.
阴道自然腔道内镜手术（vNOTES）在全球范围内用于妇科手术，然而除子宫切除术外，支持其应用的证据尚缺乏。开展了一项系统评价以确定vNOTES用于良性妇科疾病的可行性和安全性。
对MEDLINE、EMBASE、CINAHL、SCOPUS和CENTRAL进行文献检索，纳入所有报告vNOTES用于妇科适应证的各类研究。在排除同期行子宫切除术的病例后，本评价聚焦于良性适应证的手术，肿瘤手术单独报告。报告了患者特征和围手术期结局，并对有足够样本量的类别进行汇总分析。
分析了54篇文章，包括7项比较研究（n = 439）和1项随机对照试验（n = 34），报告了2469例vNOTES手术病例，汇总分析显示，主要为BMI<30kg/m²的绝经前女性，包括附件手术（输卵管和/或卵巢）（43篇文章，n = 2261）、子宫肌瘤切除术（10篇文章，n = 136）和脱垂修复术（6篇文章，n = 72）。
制表、整合与结果：总体中转率较低（1.38%，n = 34），附件手术的特定手术中转率为0.45%至6.8%，子宫肌瘤切除术为1.47%，脱垂修复术未报告中转情况。总体并发症发生率较低（3.44%，n = 85），无相关死亡病例。在阴道切开术中发现5例（0.20%）与粘连相关的直肠损伤，均在术中修复，无长期后遗症。
基于有限的证据，vNOTES对于保留子宫的妇科适应证似乎是可行的，尽管在阴道切开术中直肠损伤发生率较高。在传统腹腔镜手术和机器人辅助手术中观察到直肠损伤风险可忽略不计，但与穿刺相关的胃肠道损伤发生率相似。这可能是由于学习曲线或病例选择欠佳，需要进行仔细的培训、评估和合适的患者选择。外科医生应继续通过iNOTESs登记前瞻性vNOTES病例，以评估随着这项新技术在全球的应用而出现的围手术期新趋势。
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