Concomitant Hysterectomy and vNOTES-Assisted Sacrocolpopexy: A Feasible and Safe Scarless Approach for Apical Prolapse Repair

<b>Background/Objectives:</b> Durable apical support after hysterectomy is crucial to prevent subsequent vaginal vault prolapse. Abdominal sacrocolpopexy remains the gold standard but carries risks of visceral injury and wound morbidity. The vaginal natural orifice transluminal endoscopic surgery (vNOTES) approach provides a scarless, minimally invasive alternative, but data on vNOTES-assisted sacrocolpopexy (vNOTES-SC) performed concurrently with hysterectomy remain limited. <b>Methods:</b> A retrospective cohort of 30 women with stage II uterine prolapse underwent concomitant hysterectomy and vNOTES-assisted sacrocolpopexy between January 2023 and January 2024. Anatomical outcomes were evaluated using the Pelvic Organ Prolapse Quantification (POP-Q) system preoperatively and at 12 months postoperatively. The primary endpoint was anatomical success (C ≤ -1 cm); the secondary endpoint used the IUGA criterion (C < -TVL/2). Complications were graded using the Clavien-Dindo classification. Statistical analyses included Wilcoxon signed-rank tests, effect-size estimation, ROC analysis, logistic regression, and Spearman correlation. <b>Results:</b> Mean operative time was 100.2 ± 11.7 min, mean blood loss 155.3 ± 74.8 mL, and mean hospital stay 1.5 ± 0.7 days. Significant improvements were seen in Aa, Ba, C, and Bp points (<i>p</i> < 0.001). Anatomical success (C ≤ -1 cm) was achieved in 73.3% and clinical success in 93.3% of patients. Two patients exhibited anatomical recurrence (6.7%), whereas one patient reported symptomatic recurrence (3.3%). Using the IUGA definition, anatomical success increased to 83.3%. The difference between strict success (C ≤ -1 cm) and IUGA success (C < -TVL/2) reflects definitional sensitivity, particularly in post-hysterectomy vaginal length. All complications were minor (Grade I-II). ROC analysis showed age as a weak predictor (AUC = 0.67). Effect sizes were large for apical and anterior compartments (Cohen's d = 1.84 for C-point). <b>Conclusions:</b> Concomitant hysterectomy with vNOTES-assisted sacrocolpopexy is a feasible, safe, and effective scarless approach for apical support restoration. The procedure provides significant anatomical correction and rapid recovery with low morbidity. Patients had symptomatic stage II prolapse with risk factors for early failure after native-tissue repair, supporting the selection of sacrocolpopexy for durable apical support. Larger prospective trials are needed to confirm long-term efficacy and functional outcomes.