Comparative Outcomes of vNOTES Versus Other Minimally Invasive Hysterectomy Routes: A NSQIP Study

INTRODUCTION: vNOTES hysterectomy emerged as a new surgical approach in the United States. OBJECTIVE: To describe the national distribution of the different routes of minimally invasive hysterectomy. To compare perioperative outcomes between patients undergoing vaginal natural orifice surgery (vNOTES) and those undergoing traditional laparoscopic surgery (TLH), vaginal surgery (VH), and laparoscopy-assisted vaginal hysterectomy (LAVH). METHODS: Design: Retrospective cohort study of targeted hysterectomy data prospectively collected from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP). Setting: NSQIP Database. Patients or Participants: Women aged 18 years or older undergoing minimally invasive hysterectomy in 2022. Patients were further classified into four groups according to the route of surgery. We excluded patients who had cancer diagnosis or concurrent surgeries. Interventions: The variable including “operative approach” was utilized to stratify patients into groups. Patient demographics, medical history, and perioperative outcomes were collected. Composite morbidity outcomes were compared. RESULTS: A total of 38,737 hysterectomies were analyzed, with TLH being the most common approach (20,416; 52.7%), followed by RH (15,991; 41.3%), VH (1,783; 4.6%), and vNOTES (547; 1.4%). Median operative time by surgical approach was, however, the shortest in VH (125 min), compared to LH (146 min), vNOTES (134 min), and RH (172 min), p<0.001. After adjusting for the significant demographic differences, including age, race, BMI, diabetes, hypertension, and operative time, the composite morbidity was found to be similar in vNOTES (6.03%) and LH (6.84%) compared to VH (6.79%) and RH (5.57%). CONCLUSIONS: These findings suggest that vNOTES, although uncommon, can be performed with relatively low morbidity rates like more established minimally invasive techniques. This study provides valuable insights into the contemporary landscape of minimally invasive hysterectomy procedures and underscores the need for further research to optimize patient outcomes and inform clinical decision-making.