Mid-Term Oncological Outcomes of Vaginal Natural Orifice Transluminal Endoscopic Surgery Compared with Total Laparoscopic Hysterectomy for Early-Stage Endometrial Cancer: A Single-Center Retrospective Study

Background/Objectives: Vaginal natural orifice transluminal endoscopic surgery (vNOTES) is increasingly being used to avoid abdominal incisions; however, its mid-term oncological safety in endometrial cancer remains unclear. Methods: This single-center retrospective cohort study included patients with International Federation of Gynecology and Obstetrics (FIGO) clinical stage IA endometrioid endometrial carcinoma undergoing simple hysterectomy between January 2014 and December 2023. Patients were treated with either total laparoscopic hysterectomy (TLH) or vNOTES. Patients who underwent lymph node assessment were excluded. Follow-up assessed mid-term oncological outcomes. Recurrence-free survival (RFS) was evaluated using the Kaplan–Meier method and compared between the groups, and Cox proportional hazards models were used to identify prognostic factors for RFS. Results: In total, 130 patients were included: 109 underwent TLH and 21 vNOTES. The median follow-up period was 48 and 33 months in the TLH and vNOTES groups, respectively. Postoperative adjuvant therapy was more frequent in the vNOTES group. The operative time was significantly shorter with vNOTES. Postoperative complications were low and similar between the groups. The 3-year RFS was 92.8% and 94.4% in the TLH and vNOTES groups, respectively, without a significant difference (p = 0.874). Lymphovascular space invasion was significantly associated with worse RFS, whereas surgical approach was not significantly associated with RFS. Conclusions: No statistically significant difference in mid-term RFS was observed between vNOTES hysterectomy and conventional TLH in this highly selected low-risk cohort. However, the study was underpowered and subject to residual confounding; therefore, these findings should be considered preliminary and hypothesis-generating.