Three surgical approaches for retroperitoneal transvaginal natural orifice transluminal endoscopic surgery (vNOTES)

Objective: This study aimed to evaluate the safety, efficacy, advantages, and limitations of three surgical approaches performed through the anterior, lateral, and posterior vaginal fornix for retroperitoneal transvaginal natural orifice transluminal endoscopic surgery (vNOTES). Method: We included women who underwent vNOTES retroperitoneal surgery between January 2019 and September 2025. The anterior, lateral, and posterior vaginal fornix approaches were used for retroperitoneal vNOTES. Demographic data, operative characteristics, and perioperative outcomes were retrospectively evaluated. Results: A total of 89 patients successfully underwent vNOTES retroperitoneal surgery. The surgical approaches included 13 procedures via the anterior fornix, 16 via the lateral fornix, and 60 via the posterior fornix. The anterior fornix approach was primarily used for lateral suspension for pelvic organ prolapse (POP). All procedures were completed safely, with the longest follow-up exceeding 2 years, and no cases of mesh exposure were observed. Overall, three patients (23.08%) experienced Grade I complications. The lateral fornix approach was primarily used for lymphadenectomy, and all procedures were completed safely. A total of four cases (25.00%) of Grade I complications and one case (6.25%) of Grade II complications were recorded. The posterior fornix approach was primarily used for sacrocolpopexy and sacrospinous ligament fixation (SSLF), with all procedures completed safely. In the sacrocolpopexy group, three Grade I complications (30.77%) and one Grade III complication (7.69%) were observed. In the SSLF group, eight Grade I complications (17.02%) were recorded. Conclusion: In this retrospective study, retroperitoneal vNOTES was demonstrated to be a safe and feasible approach. By using different vaginal fornix incisions, it can be adapted to a wide range of procedures, including surgeries for POP and resection of both pelvic and para-aortic lymph nodes.