Comparable Hysterectomy Outcomes Achieved With Robotic Single-Port and Traditional vNOTES Approaches

Robotic single-port vNOTES may facilitate minimally invasive management of complex endometriosis surgery

Key Points

Highlights:  

• Robotic single-port vaginal natural orifice transluminal endoscopic surgery(RSP-vNOTES) hysterectomy achieved perioperative outcomes comparable to traditional vNOTES despite being used more frequently in complex surgical cases.
• Endometriosis excision, adhesiolysis, ovarian cystectomy, bowel shaving, and bowel repair were substantially more common in the robotic group.
• After adjustment for case complexity and baseline differences, operative outcomes and complication rates were similar between approaches.

Importance: 

• Robotic single-port technology may expand the applicability of transvaginal natural orifice surgery to more complex gynecologic procedures, including advanced endometriosis surgery.
• The study provides early evidence supporting incorporation of robotic single-port vNOTES into the minimally invasive gynecologic surgical armamentarium

What’s done here:

• This is a retrospective comparative cohort study evaluating outcomes of robotic single-port vaginal natural orifice transluminal endoscopic surgery (RSP-vNOTES) versus traditional vNOTES (T-vNOTES) hysterectomy.
• Clinical data from 135 women undergoing hysterectomy between January 2017 and September 2024 were analyzed.
• Seventy-nine patients underwent traditional vNOTES and 56 underwent robotic single-port vNOTES.
• Surgical characteristics, perioperative outcomes, postoperative pain scores, conversion rates, and complications were compared.
• Multivariable regression analyses were performed to adjust for differences in patient characteristics, uterine size, and concomitant surgical procedures.

Key results:

• Patients undergoing robotic single-port vNOTES more frequently required endometriosis excision, adhesiolysis, ovarian cystectomy, oophoropexy, bowel shaving, and bowel repair.
• Unadjusted analyses showed longer operative times but lower blood loss in the robotic group.
• After adjustment for baseline and procedural differences, no significant differences were observed in hysterectomy time, total operative time, estimated blood loss, postoperative pain scores, conversion rates, or complications.
• Intraoperative and postoperative complication rates were similar between groups.
• Conversion to laparoscopy or laparotomy occurred in six traditional vNOTES cases and one robotic single-port case, although the difference was not statistically significant.

Strengths and Limitations:

• Strengths are the direct comparison of robotic single-port and traditional vNOTES hysterectomy and the use of multivariable analyses to account for substantial differences in surgical complexity between groups.
• Limitations are the retrospective single-center design, performance of all procedures by a highly experienced single surgeon, and the non-contemporaneous nature of the cohorts, which may limit generalizability

From the Editor-in-Chief – EndoNews

"The evolution of minimally invasive gynecologic surgery has largely been driven by efforts to reduce surgical morbidity while maintaining procedural effectiveness. Vaginal natural orifice transluminal endoscopic surgery (vNOTES) represents one of the most recent developments in this progression, combining the advantages of vaginal surgery with endoscopic visualization while avoiding abdominal incisions. The incorporation of robotic single-port technology into this platform represents a further attempt to extend the applicability of vNOTES to increasingly complex pelvic procedures.

Importantly, the principal finding of the present study is not that robotic single-port vNOTES is superior to traditional vNOTES. Rather, the study demonstrates that comparable perioperative outcomes were achieved despite the robotic cohort undergoing substantially more complex procedures, including endometriosis excision, extensive adhesiolysis, ovarian surgery, and bowel-related interventions. This observation suggests that robotic assistance may help overcome some of the technical limitations traditionally associated with transvaginal surgery.

The findings are particularly relevant to endometriosis surgery, where distorted anatomy, fibrosis, adhesions, and the need for meticulous dissection frequently challenge conventional minimally invasive approaches. As surgical management of endometriosis continues to evolve, technologies that facilitate complex pelvic dissection while preserving the benefits of minimally invasive surgery are likely to attract increasing interest.

At the same time, caution is warranted when interpreting these results. The study reflects the experience of a single highly specialized surgeon at a high-volume center, and outcomes achieved under such circumstances may not be readily generalizable to broader clinical practice. Furthermore, the retrospective design precludes conclusions regarding comparative effectiveness, learning curves, cost considerations, patient-reported outcomes, or long-term surgical success.

Nevertheless, this study provides important preliminary evidence that robotic single-port vNOTES may expand the technical scope of transvaginal surgery without compromising perioperative safety. Whether this approach ultimately translates into measurable advantages for patients, surgeons, and healthcare systems remains an important question for future prospective multicenter investigation."

Lay Summary

Hysterectomy performed using robotic single-port vaginal natural orifice transluminal endoscopic surgery (RSP-vNOTES) achieved perioperative outcomes comparable to those of traditional vNOTES (T-vNOTES), despite being used more frequently in patients undergoing complex concomitant procedures, including endometriosis excision, according to a new study published in Frontiers in Medicine.

vNOTES is a minimally invasive surgical approach that allows access to the pelvic cavity through the vagina, thereby avoiding abdominal incisions. More recently, robotic single-port technology has been incorporated into this technique with the aim of facilitating technically demanding pelvic procedures.

To evaluate the safety and feasibility of robotic single-port vNOTES, a team led by Dr. Xiaoming Guan from the Division of Minimally Invasive Gynecologic Surgery at Baylor College of Medicine retrospectively analyzed 135 patients who underwent hysterectomy between January 2017 and September 2024. Seventy-nine women underwent traditional vNOTES and 56 underwent robotic single-port vNOTES. All procedures were performed by a single experienced gynecologic surgeon.

The investigators compared patient characteristics, surgical complexity, perioperative outcomes, postoperative pain scores, and complications between the two approaches. Women undergoing robotic single-port vNOTES more frequently required additional procedures, including endometriosis excision, adhesiolysis, ovarian cystectomy, oophoropexy, bowel shaving, and bowel repair.

Although operative complexity differed substantially between groups, multivariable analyses demonstrated no significant differences in operative time, estimated blood loss, postoperative pain scores, conversion rates, or perioperative complications after adjustment for baseline and procedural differences.

Conversion to laparoscopy or laparotomy occurred in six women undergoing traditional vNOTES and in one woman undergoing robotic single-port vNOTES, although this difference did not reach statistical significance. Rates of intraoperative and postoperative complications were also similar between groups.

According to the authors, these findings suggest that robotic single-port vNOTES may facilitate more complex gynecologic procedures while maintaining perioperative outcomes comparable to those achieved with traditional vNOTES. They emphasize that larger multicenter studies involving multiple surgeons and longer follow-up will be required to define the role of this approach in contemporary minimally invasive gynecologic surgery.

Research Source: https://pubmed.ncbi.nlm.nih.gov/41244775/