Transvaginal Natural Orifice Transluminal Endoscopic Hysterectomy and Apical Suspension of the Vaginal Cuff to the Utero-Sacral Ligament Learning Curve: Our Experience with the First 30 Cases

Abstract

Study Objective The objective of this study is to describe our experience with Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) utero-sacral ligament apical suspension and to evaluate the learning curve of mastering the skills to operate this procedure. Design A retrospective multicenter study of the first 30 vNOTES hysterectomy and USLS surgeries performed between October 2018 and April 2019 at Rambam Health Care Campus (Israel) by a single surgeon (L.L) and Imelda Hospital (Belgium) by (J.B). Setting Retrospective study Patients or Participants Women who underwent sutero-sacral ligament suspension for treatment of uterovaginal or vaginal apical prolapse Interventions Vaginal hysterectomy and utero-sacral ligament suspension Measurements and Main Results The primary outcomes were hysterectomy and USLS times. Secondary outcomes included intra-operative bleeding, length of hospitalization, post-operative pain and need for analgesia. Sociodemographic and clinical data were retrieved from patients’ electronic charts. Patients` median age was 55 years (range 40-81); Median hysterectomy time was 38 minutes (range 15-55) from first cut to completion of hysterectomy; Median USLS time was 17 minutes (range 14-27). The median estimated intra-operative blood loss was 20 ml (range 20-250). Length of hospital stay was 2 days (2-3). Comparisons between median USLS time in the first 15 and in the 15 sequential procedures demonstrated a significant decrease: 25 minutes (range 18-39) vs. 15 minutes (range 13-28) respectively (P=0.03). The median estimated intraoperative blood loss decreased from 70 ml (range 40-100) in the first 15 suspensions to 20 ml (range 10-70) in the 15 sequential procedures (P=0.011) Conclusion vNOTES hysterectomy followed by USLS is a feasible procedure with an marked improvement in surgical performance in a short period as expressed by the improvement in surgical times with minor associated perioperative complications. This technique allows surgeon to expose the ureter well and lower the risk of ureter injury. Outcomes of long-term follow-up should be investigated.