Pregnancy Outcome After Vaginal Natural Orifice Transluminal Endoscopic Surgery: A Follow-Up Retrospective Observational Cohort Study

Study objective Vaginal natural orifice transluminal endoscopic surgery (vNOTES) is a minimally invasive surgical technique, with improved cosmetic results, reduced operation time, and reduced postoperative pain as its main advantages. The aim of the study was to assess pregnancy outcomes and the safety of vaginal delivery after fertility-sparing vNOTES procedures. Methods A retrospective, observational, single-centre cohort study was performed between January 2014 and March 2023. Fertility-sparing surgeries performed by vNOTES, including salpingostomy, salpingectomy, cystectomy, unilateral adnexectomy, and myomectomy for benign indications, were included. A total of 191 patients underwent vNOTES procedures, of whom 42 subsequently became pregnant, resulting in 52 pregnancies with deliveries between November 2015 and February 2024. Results The population consisted of an obstetrical high-risk population undergoing fertility-sparing surgery, mainly secondary to infertility or ectopic pregnancies. Among the 42 patients who became pregnant after a vNOTES procedure, 32 pregnancies occurred within the first year after vNOTES (76.2%). Assisted reproductive treatment was performed in 23.1% of all 52 pregnancies. Four patients delivered preterm, but the indication could not be linked to previous vNOTES procedures. Vaginal delivery occurred in 35 (67.3%) cases, and caesarean section (CS) was performed in 17 (32.7%) cases. A high percentage (21.2%) of these CS were elective, and none were a result of previous vNOTES procedures. Trial of labour after caesarean (TOLAC) was observed in four (7.7%) pregnancies, resulting in two uncomplicated vaginal deliveries and two CS due to cephalopelvic disproportion or foetal distress. Among patients with vaginal delivery, no tearing of the posterior colpotomy scar was described, and no grade 3 or 4 perineal ruptures were observed. Conclusions This is the largest known cohort evaluating the safety of pregnancy and vaginal delivery after vNOTES in a high-risk population. No pregnancy-related complications were reported as a result of previous vNOTES surgery. The posterior colpotomy, necessary for performing vNOTES, appears to be safe for a full-term pregnancy and during vaginal delivery. Therefore, previous vNOTES is not an indication for an elective CS.