Extraperitoneal vaginal natural orifice transluminal endoscopic pelvic reconstruction for multi compartment pelvic organ prolapse

We describe a novel extraperitoneal vaginal natural orifice transluminal endoscopic surgery (vNOTES) approach for pelvic reconstruction in women with multicompartment pelvic organ prolapse (POP). This retroperitoneal technique enables direct exposure of the presacral area, allowing secure fixation of a Y-shaped mesh to the anterior longitudinal ligament and comprehensive restoration of anterior, middle, and posterior compartment support. From April to December 2024, 118 patients underwent extraperitoneal vNOTES pelvic reconstruction. The mean age was 61.1 ± 6.6 years, the mean body mass index was 24.5 ± 2.6 kg/m², the mean operative time was 103.3 ± 25.7 minutes, and the mean estimated blood loss was 97.7 ± 47.7 ml. During a median follow-up of 6.9 months (range: 4.1-11.2 months), all patients experienced significant improvement in anatomic and functional outcomes, with no recurrence, mesh exposure, or reoperation. Three patients (2.5%) developed retroperitoneal hematomas that resolved with conservative management. These early results suggest that extraperitoneal vNOTES pelvic reconstruction is a feasible and safe technique, with the potential to reduce operative complexity and intra-abdominal risks compared with conventional transperitoneal approaches.