Comparison of conventional multiport laparoscopy, single-port laparoscopy, and vNOTES for the management of large adnexal masses (≥ 10 cm): a retrospective cohort study

OBJECTIVE: We compared the surgical outcomes and quality of recovery of conventional multiport laparoscopy (CML), Single-port laparoscopy (SPL), and vaginal natural orifice transluminal endoscopic surgery (vNOTES) for managing large adnexal masses. METHODS: This multicenter, retrospective cohort study included 87 patients who underwent salpingo-oophorectomy for benign adnexal masses ≥ 10 cm between January 2020 and December 2025 (CML: n = 38, SPL: n = 26, vNOTES: n = 23). The evaluated parameters included surgical timing (port setup, total operation, and specimen removal times), early postoperative pain using the Visual Analog Scale (VAS) and Faces Pain Scale Revised (FPS-R), and overall quality of recovery using the QoR-40 questionnaire at 24 h postoperatively. The secondary outcomes included cosmetic scar satisfaction and sexual function. RESULTS: CML demonstrated the shortest port setup time (2.5 ± 0.5 min) and total operation time (61.0 ± 14.7 min) among the groups. In contrast, vNOTES and SPL provided significantly faster specimen removal times than CML (6.1 ± 1.8 min and 6.6 ± 1.3 min vs. 9.3 ± 2.2 min, respectively; P < 0.001). The vNOTES group reported significantly lower VAS and FPS-R scores across all early postoperative time points (6, 12, and 24 h) and achieved the highest overall QoR-40 score (153.5 ± 9.7, P = 0.004). Multivariate logistic regression identified the vNOTES approach as the only independent predictor of excellent recovery (QoR-40 ≥ 150) (odds ratio [OR]: 1.8, 95% confidence interval [CI]: 1.1-3.1, P = 0.012). No significant differences were observed in terms of estimated blood loss, intraoperative complications, or long-term sexual function among the three groups. CONCLUSION: CML, SPL, and vNOTES are safe and effective minimally invasive approaches for large adnexal masses. While CML is the fastest overall, vNOTES appeared to offer benefits including efficient specimen extraction, reduced postoperative pain, and enhanced quality of recovery. Given the retrospective design, the modest sample size, and the patient-preference-based allocation, these findings should be considered hypothesis-generating and confirmed in adequately powered prospective studies.