Endoscopic Hysterectomy Research Articles

Value of perineal Four-dimensional ultrasound imaging technique for follow up of patients undergoing endoscopic hysterectomy for myoma

Value of perineal Four-dimensional ultrasound imaging technique for follow up of patients undergoing endoscopic hysterectomy for myoma

Intraoperative bladder visualization by indocyanine green filling and subsequent washout in endoscopic hysterectomy: ICG-Washout method.

Despite a potential risk of bladder injury in laparoscopic hysterectomy (LH) and robot-assisted LH (RaLH), an intraoperative method for delineating the entire bladder with indocyanine green (ICG) has not been established. We conducted a preliminary experiment using porcine bladders to verify the appropriate amount of ICG for intraoperative bladder visualization. Afterward, intraoperative bladder visualization was tried in LH and RaLH in two patients suspected of having adhesions around the bladder after previous abdominal surgery. Although near-infrared (NIR) fluorescence was well observed through the wall of the porcine bladder filled with ICG solution at a concentration of 0.024 mg/mL, the subsequent replacement of the ICG solution with saline made the NIR fluorescence brighter. In both patients, the bladder was successfully delineated by NIR fluorescence after filling the bladder with ICG solution and the subsequent washout with saline. The ICG-Washout method for locating the bladder by NIR fluorescence could be useful in LH and RaLH.

Impact of COVID-19 pandemic on changing the ratio of abdominal, vaginal, and laparoscopic hysterectomies

Introduction/Objective. Coronavirus pandemic caused most hospitals in the world to suspend regular activities. The aim of this study was to analyze pandemic influence on patients who underwent hysterectomy with classical (abdominal) and minimally invasive surgery (laparoscopic and vaginal approach) at the Clinic for Gynecology and Obstetrics of the University Medical Centre of Serbia. Methods. There were 2446 hysterectomies for five-year period. The study analyzed number and types of hysterectomies before and during COVID-19 pandemic. Results. The total number of operated patients was most decreased in the first year of the pandemic. During pandemic, the number of vaginal and laparoscopic hysterectomies did not change, whereas there was an increase in the number of abdominal hysterectomies. Statistical significance (p < 0.01) was found between abdominal and vaginal as well as between abdominal and endoscopic hysterectomies. Conclusion. The global pandemic impact on care of symptomatic patients with COVID-19 has led to the redeployment of staff and resources, which has significantly reduced the total number of operations in many hospitals around the world.

VNOTEsHC : Hysterectomy by transvaginal natural orifice transluminal endoscopic surgery versus laparoscopic for large uteri: study protocol for a multicentre randomised controlled trial.

In France, 62,000 hysterectomies are performed per year, 70% of which are benign. The choice of approach (laparotomy, laparoscopy or vaginal route) is particularly important in the case of large uterus (> 280g) which are associated with a higher risk of complications. The current data are not sufficient to favour one or other approach. A new medical device, the vNOTES (Natural Vaginal Orifice Transluminal Endoscopy System), offers the advantage of both laparoscopic and vaginal route for pelvic surgery. To demonstrate the superiority in terms of intraoperative and postoperative complications of the use of a natural orifice transluminal endoscopic hysterectomy system (vNOTES) versus laparoscopic hysterectomy for benign pathologies on estimated large volume uteri (>280g). A randomised, double-blind, superiority trial will be performed at five hospital centres. Women with benign uterine pathology requiring hysterectomy and with a large uterus (> 280g) will be randomised to receive either laparoscopic or vNOTES hysterectomy. The primary outcome will be the occurrence of intraoperative and postoperative complications within 6 weeks of surgery. Secondary outcomes will be conversion during surgery, duration of surgery and hospitalisation, postoperative pain, postoperative complications, resumption of sexual life and satisfaction with the surgical team. 248 women will be randomised. This trial will provide a better understanding of the approach to large uteri optimise the care of these thousands of women undergoing hysterectomy. This trial will evaluate the vNotes for large uteri.

Learning curve analysis of transvaginal natural orifice transluminal endoscopic hysterectomy combined under the standard operating procedure.

To investigate the learning curve of transvaginal natural orifice transluminal endoscopic hysterectomy (tVNOTEH) when using a standard operating procedure (SOP). Seventy-nine patients were treated with tVNOTEH by a single surgeon. The SOP for tVNOTEH was created after the first eight cases. Patients' perioperative data were retrospectively reviewed. Operative time (OT) was regarded as a replaceable marker for surgical competency. The learning curve was drawn using the cumulative sum method. All patients completed surgeries without switching to other surgical paths. The overall mean OT was 90.23 ± 29.85 min. Four unique phases of the learning curve were identified: phase I (the exploring stage over eight cases), phase II (after adopting the SOP, acquirement of competence over 20 cases), phase III (post-learning of 19 cases, in which more difficult cases were introduced), phase IV (more adept at tVNOTEH), with OT 113.75 ± 43.07 min, 82.50 ± 25.88 min, 101.05 ± 27.83 min, 82.75 ± 25.53 min, respectively. No significant differences were found apart from OT, uterine size, and disease types. Our data demonstrated four distinct phases of the learning curve of tVNOTEH. For an experienced surgeon, surgical competence in tVNOTEH can be grasped after eight cases. With SOP, surgical competence could be rapidly acquired.

Evaluation of the learning curve and safety outcomes in robotic assisted vaginal natural orifice transluminal endoscopic hysterectomy: A case series of 84 patients.

To explore the learning curve and safety outcomes of robotic assisted transvaginal natural orifice transluminal endoscopic surgery (R-vNOTES) for hysterectomy in benign gynaecological diseases. A retrospective chart review of all patients undergoing R-vNOTES hysterectomy for benign gynaecological disease from 2019 to 2021. An academic tertiary care university hospital in Houston, TX, USA. 84 patients were identified that met the study requirements. The mean hysterectomy time was 77.27±2.89min. The median additional operation time was 63 (8-206)min. There were two conversions to robotic assisted single incision laparoscopy. Thirteen (15.48%) patients had an associated complication. Analysis of the learning curve suggests plateauing of hysterectomy time at approximately 10 cases and time for robot docking and port placement after 10-20 cases. R-vNOTES is a safe and effective route for hysterectomy. For a surgeon with experience in laparoscopic single site surgery and abdominal robotic surgery, they need to perform 10 cases of R-vNOTES hysterectomy and 10-20 cases in port placement and robotic docking to achieve proficiency.

Evaluating Surgical Complexity of Endoscopic Hysterectomy: An Inter-rater and Intra-rater Agreement Study of Novel Scoring Tool

Evaluate inter-rater and intrarater reliability of a novel scoring tool for surgical complexity assessment of endoscopic hysterectomy. Validation study. Academic medical center. Total of 11 academic obstetrician-gynecologists with varying years of postresidency training, clinical practice, and surgical volumes. Application of a novel scoring tool to evaluate surgical complexity of 150 sets of images taken in a standardized fashion before surgical intervention (global pelvis, anterior cul-de-sac, posterior cul-de-sac, right adnexa, left adnexa). Using only these images, raters were asked to assess uterine size, number, and location of myomas, adnexal and uterine mobility, need for ureterolysis, and presence of endometriosis or adhesions in relevant locations. Surgical complexity was staged on a scale of 1 to 4 (low to high complexity). Number of postresidency years in practice for participating surgeons ranged from 2 to 15, with an average of 8 years. A total of 8 obstetrician-gynecologists (72.7%) had completed a fellowship in minimally invasive gynecologic surgery. Six (54.6%) reported an annual volume of >50 hysterectomies. Raters reported that 95.4% of the images were satisfactory for assessment. Of the 150 sets of images, most were found to be stage 1 to 2 complexity (stage 1: 23.8%, stage 2: 41.6%, stage 3: 32.8%, stage 4: 1.8%). The level of inter-rater agreement regarding stage 1 to 2 vs 3 to 4 complexity was moderate (κ=0.49; 95%confidence interval [CI], 0.42-0.56). Moderate inter-rater agreement was also found between surgeon raters with an annual hysterectomy volume >50 (κ=0.49; 95%CI, 0.40-0.57) as well as between surgeon raters with fellowship experience (κ=0.50; 95%CI, 0.42-0.58). Intrarater agreement averaged 80.2% among all raters and also achieved moderate agreement (mean weighted κ=0.53; range, 0.38-0.72). This novel scoring tool uses clinical assessment of preintervention anatomic images to stratify the surgical complexity of endoscopic hysterectomy. It has rich and comprehensive evaluation capabilities and achieved moderate inter-rater and intrarater agreement. The tool can be used in conjunction with or instead of traditional markers of surgical complexity such as uterine weight, estimated blood loss, and operative time.

A case of transvaginal natural orifice transluminal endoscopic hysterectomy and uterosacral ligament suspension for apical support of the vaginal cuff

A case of transvaginal natural orifice transluminal endoscopic hysterectomy and uterosacral ligament suspension for apical support of the vaginal cuff

Modern approaches to endoscopic hysterectomy

The new method of radical uterine surgery combining endoscopic approachand minilaparotomy is represented. 105 operative invasions on the uterus were performed using this method. Characteristic features of the surgical method, which was elaborated, are minimum blood loss and tissue injury, simple technique, low requirement of analgetics, fast rehabilitation of patients activity and capacity for work, using common equipments and materials.

Evaluating Surgical Complexity of Endoscopic Hysterectomy: An Inter-Rater Agreement Study for Novel Scoring Tool

<h3>Study Objective</h3> Evaluate inter-rater reliability of a novel scoring tool for surgical complexity assessment of endoscopic hysterectomy. <h3>Design</h3> Validation study. <h3>Setting</h3> Academic medical center. <h3>Patients or Participants</h3> 11 academic OB/GYNS with varying years of post-training practice and surgical volumes <h3>Interventions</h3> Application of a novel scoring tool to evaluate surgical complexity of 150 sets of surgical images taken in a standardized fashion (global pelvis, anterior cul-de-sac, posterior cul-de-sac, right adnexa, left adnexa). Surgical complexity was staged on a scale of I-IV (low to high complexity). Raters were asked to assess uterine size, number and location of fibroids, adnexal and uterine mobility, need for ureterolysis, and presence of endometriosis or adhesions. <h3>Measurements and Main Results</h3> Number of post-residency years in practice for participating surgeons ranged from 2 – 15, with an average of 8 years. 8 (72.73%) OB/GYNs had completed a fellowship in minimally invasive gynecologic surgery. 6 (54.55%) reported annual volume of hysterectomy >50 cases. Raters reported 95.4% of images were satisfactory for assessment. Of the 150 sets of images, most were found to be Stage I-II complexity (Stage I: 46.4%, Stage II: 30.6%, Stage III: 16.4%, Stage IV: 6.6%). Level of inter-rater agreement regarding Stage I-II vs. III-IV complexity was moderate (k=0.493, CI [0.43-0.56]). Moderate inter-rater agreement persisted between surgeon raters with annual hysterectomy volume > 50 (k=0.484, CI [0.42-0.56]) as well as between surgeon raters with fellowship experience (k=0.498, CI [0.434-0.57]). <h3>Conclusion</h3> Current methods for assessment of surgical complexity for clinical and research purposes rely on seemingly objective markers like uterine weight, estimated blood loss, and operative time, which can be limited or flawed. In contrast, this novel scoring tool has rich and comprehensive evaluation capabilities and achieved moderate inter-rater agreement. The complexity scoring tool can be used in conjunction with or instead of traditional methods for assessment of surgical complexity of endoscopic hysterectomy.

Robotic Natural Orifice Transluminal Endoscopic Surgery Hysterectomy and Salpingo-Oophorectomy in a Porcine Model.

Purpose. The emergence of robotic-assisted surgical techniques has gained significant indications in terms of reduced trauma, shortened recovery, and higher patients' satisfaction. However, limitations by present surgical robotic systems used in natural orifice transluminal endoscopic surgery (NOTES) gynecology still exists, such as arm collisions, countertraction, instrument dexterity, and, in particular, space confinement due to the narrow pelvic anatomy. The current study evaluated the use of a miniaturized single-site surgical robotic system and its feasibility in performing robotic NOTES gynecological procedures using a live porcine animal model. Methods. Using a transrectal approach, the fully internalized robotic arms were deployed in a reverse configuration to access the lower pelvic cavity of the animals to perform NOTES gynecological procedures. Results. Robotic-assisted transrectal gynecological procedures were successfully performed using the new robotic system. A hemi-hysterectomy with unilateral salpingo-oophorectomy was completed in the first animal and a total hysterectomy with bilateral salpingo-oophorectomy in the second animal with an average docking time of 22.5minutes and console time of 63minutes and 58minutes, respectively. The overall blood loss for each procedure was estimated to be <20mL per animal with no intraoperative complications. Conclusions. The reverse configuration of the miniaturized surgical robotic system has demonstrated its capability to provide a potential solution to maintain clear visualization of the surgical field, optimal triangulation, and dexterity robotic NOTES gynecological procedures within the deep confined space of the pelvic cavity.

The Risk of Vaginal Cuff Dehiscence with Different Suture Types Following Endoscopic Hysterectomy

Study Objective To evaluate the rate of vaginal cuff dehiscence (VCD) after endoscopic hysterectomy using absorbable vs delayed absorbable suture. Design Retrospective cohort study. Setting Academic center, Mayo Clinic Phoenix, Arizona. Patients or Participants 586 consecutive patients undergoing endoscopic hysterectomy (499 robotic, 87 laparoscopic) with a specific cuff closure technique. Interventions Specific vaginal cuff closure technique with delayed absorbable (PDS and V-loc) or absorbable (Vicryl) suture. Measurements and Main Results The mean age was 50.8 years (SD 12.6) with a mean BMI of 30 kg/m2 (SD 8.4). Most patients were premenopausal (59%) and 4.6% were on or had previously received chemotherapy. Of the hysterectomies performed, 75% were for benign indications, 94.5% were simple hysterectomies and 5.5% were radical or modified radical hysterectomies. Mean estimated blood loss was 93.4 ml (SD 137.7ml). Vicryl was used in 152 patients, PDS in 161 patients and V loc in 273 patients. The 3 groups were similar in demographics except for uterine pathology (benign in 80.9% vs. 72.7% vs 73.2% respectively, p= 0.038), median blood loss (115.7 (SD 134.7) vs 87.9 (SD= 90.5) vs 96.9 (SD 161.2) ml respectively, p= 0.034). After a mean follow up period of 586.6 days (SD 725.7), vaginal cuff dehiscence occurred in 1.2% of patients (2.6% Vicryl, 0.6% PDS and 0.7% V loc, p= 0.165). VCD rate with delayed absorbable suture (PDS or V loc) vs absorbable suture (Vicryl), was 0.7% vs. 2.6%, p= 0.058. respectively. Logistic regression analysis revealed younger age and lower BMI are risk factors for VCD (OR: 0.91 95% CI 0.83-0.99 vs OR 0.76, 95% CI 0.61-0.94 respectively). Conclusion Delayed absorbable suture is preferable for vaginal cuff closure at endoscopic hysterectomy as compared to absorbable suture. Risk factors for vaginal cuff dehiscence are younger age and lower BMI.

Impact of a Revised Cuff Closure Technique on the Rate of Vaginal Cuff Dehiscence with Endoscopic Hysterectomy

Study Objective To evaluate the outcome of a specific vaginal cuff closure technique at endoscopic hysterectomy to reduce dehiscence. Design Retrospective cohort study. Setting Academic center, Mayo Clinic Phoenix, Arizona. Patients or Participants 434 consecutive patients undergoing endoscopic hysterectomy (363 robotic, 71 laparoscopic) with a revised cuff closure technique. Interventions Continuous vaginal cuff closure using delayed absorbable suture (PDS or V loc) with full thickness bites 5 mm away from the vaginal edge and 5 mm apart. Measurements and Main Results The mean age of the cohort was 51.4 years (SD 12.5) with a mean BMI of 30 kg/m2 (SD 8.1). Most hysterectomies (73%) were for benign conditions- 94.2% were simple hysterectomies and the remainder, 5.8%, were radical or modified radical. Mean estimated blood loss was 93.4 ml (SD 137.7). At a median follow up of 518.2 days (SD 673.7) vaginal cuff dehiscence (VCD) was observed in 0.7% of patients, as compared to our previous VCD rate of 4.1% (p= 0.00732) [1] with a previous cuff closure technique using polyglactin absorbable suture. There was a trend of a higher VCD among patients with a lower BMI (22.8 vs. 30.1 kg/m2, P= 0.066), and of patients receiving chemotherapy (33.3% vs 3.5%, P= 0.024). Conclusion The use of delayed absorbable suture and mass closure technique (5 mm away from the vaginal edge and 5 mm in between sutures) of the vaginal cuff reduced vaginal cuff dehiscence from 4.1% to 0.7%.

Transvaginal Natural Orifice Transluminal Endoscopic (vNOTES) Hysterectomy: A Novel Route for Uterus Removal

Study Objective To demonstrate the feasibility of Transvaginal Natural Orifice Transluminal Endoscopic (vNOTES) hysterectomy. Design Stepwise demonstration with narrated surgical video. Setting A university-affiliated center. Patients or Participants A 52-year-old gravida 2, para 2 woman with a 10 cm fibroid presented with a 2-year history of frequent micturition. Ultrasound showed fibroids and bilateral ovarian cysts. Interventions After injecting dilute vasopressin in the cervix, the vaginal mucosa was incised circumferentially. Posterior and anterior colpotomy was made. Then bladder pillars were clamped. Single-site port was successfully placed and pneumoperitoneum was established. After the survey of upper abdomen, progressive clamping from the cardinal ligaments to the level of the broad ligament was performed. Then the proper ligaments of ovary were clamped and bilateral oophorosalpingectomy was performed. The specimen was then delivered to the vagina. The vaginal cuff was closed with running stich. Measurements and Main Results The surgery was successfully conducted with operating time of 120 minutes and blood loss of 20 ml. The uterus weighed 410 g. The patient recovered well and had resolution of frequent micturition. Conclusion vNOTES is feasible for hysterectomy. Combined with traditional transvaginal colpotomy, vNOTES allows the access to the entire abdomen and completion of hysterectomy through a transvaginal single port. Transvaginal NOTES Hysterectomy benefits specimen removal and leads no abdominal incision.

Feasibility and Safety of Robotic Vaginal Natural Orifice Transluminal Endoscopic Hysterectomy for Benign Indications

Study Objective Hysterectomy, is mostly performed by an abdominal approach and to a lesser extent by a vaginal access, which has been proven to result in superior patients’ outcomes. The Hominis Surgical System is a novel robot-assisted system, designed specifically for robotic vaginal natural orifice transluminal endoscopic surgery (RvNOTES). In the current study we aimed to present our experience in the first 30 RvNOTES hysterectomies, and to assess the feasibility and safety of this revolutionary technology Design A two-center prospective study of RvNOTES hysterectomy for benign indications. Setting N/A Patients or Participants Thirty women aged 38 to 79 years, BMI 18-40 kg/m2. Interventions RvNOTES hysterectomy. Measurements and Main Results Intraoperative and postoperative complications, median blood loss, duration of surgery and postoperative pain. All procedures were completed successfully without conversions to open surgery. No intraoperative complications were observed. Median blood loss and procedure duration were 50 ml (range: 20-400) and 41 minutes (range: 24 to 88), respectively. Postoperative pain was minimal with a median VAS of 3 (range: 1-5) The vaginal cuff was fully healed in all women at the 6-week post-operative follow up visit. Conclusion This is the first publication regarding a robotic-assisted vaginal hysterectomy. The combined advantages of the vNOTES approach with robotic instrumentation have the potential to shift the trend from abdominal to RvNOTES approach for a wide variety of gynecological and non-gynecological surgical procedures.

Cost-effective minimally invasive gynecologic surgery: emphasizing surgical efficiency.

The United States has the highest healthcare costs among developed countries. This review evaluates surgical practices and equipment choices during endoscopic hysterectomy, highlighting opportunities for the gynecologic surgeon to reduce costs and maximize surgical efficiency. There are opportunities to economize at every step of the endoscopic hysterectomy. When surgeons are provided education about instrumentation costs, the cost of hysterectomy has been shown to decrease. Colpotomy has been found to be the rate-limiting step in laparoscopic hysterectomy; use of a uterine manipulator likely saves time and money. When evaluating the economic impact of route of surgery, the cost differential between laparoscopic and robotic-assisted hysterectomy has decreased. Robotic-assisted hysterectomy may be more cost-effective in some cases, such as for larger uteri. From a systems-level perspective, dedicating a specific operating room team to the gynecology service can decrease operative time. The gynecologic surgeon is best equipped to control surgery-related costs by making choices that improve surgical efficiency and decrease operating room time. If a costlier piece of equipment leads to a more efficient case, the choice may be more cost-effective. There are multiple systems-level changes that can be implemented to decrease surgery-related costs.

Is Hysterectomy a Risk Factor for Urinary Retention? A Retrospective Matched Case Control Study

Compare the rates of urinary retention in patients undergoing endoscopic hysterectomy with those of patients undergoing nonhysterectomy endoscopic gynecologic surgery. Retrospective case control study matched by operative time. Academic medical center. All patients undergoing endoscopic gynecologic surgeries between January 2013 and December 2018. Outpatient endoscopic gynecologic surgery. A total of 200 endoscopic hysterectomy cases were matched to endoscopic nonhysterectomy gynecologic surgery controls in a 1:1 ratio. The differences in baseline and operative characteristics between the 2 groups included age (48.6 years vs 45.7 years, p = .04), perioperative opioid administration (morphine milligram equivalents, 11.6 mg vs 7.6 mg, p = .01), and estimated blood loss (64.1 mL vs 31.8 mL, p = .001). The rate of urinary retention in the hysterectomy group was double that in the nonhysterectomy group (26.5% vs 13%, p = .01). In the hysterectomy group, age, perioperative opioids, operative time, and estimated blood loss did not differ between those who failed and those who passed the void trial. In the nonhysterectomy group, only operative time was significantly longer in those who failed the void trial (108 minutes vs 94.3 minutes, p = .04). After adjusting for perioperative opioid use and operative time, the relative risk of urinary retention in the hysterectomy group was 2.3 (p = .002, 95% confidence interval, 1.38-3.98). Hysterectomy appears to be an independent and major factor contributing to postoperative urinary retention. When compared with nonhysterectomy gynecologic surgical controls with similar operative times, the rate of urinary retention in patients who underwent hysterectomy was doubled.

Transvaginal Natural Orifice Transluminal Endoscopic Surgery Hysterectomy (VNOTES): A Walkthrough

Video Objective To present a thorough yet concise explanation of the methodology for the completion of a successful transvaginal hysterectomy via natural orifice transluminal endoscopic surgery. Design A narrated instructional video guide detailing each procedure (Canadian Task Force Classification III). Setting University Hospital, Baylor College of Medicine, Houston, Texas Patients Our patient is a 46-year-old G2P1011 who had two notable previous surgeries: a tubal ligation and an adnexa removal surgery. She possessed a narrow vagina and non-descent uterus while having a strong preference for maintaining a high level of cosmesis. Interventions A complete transvaginal hysterectomy utilizing solely natural orifice transluminal endoscopic surgery was performed on the patient. Transvaginal entry was established and with the gelpoint mini port in place we began circumferential dissection of the cervix anteriorly at the bladder fold. Utilizing the laparoscopic single tooth tenaculum, we hooked the anterior lip of the cervix for countertraction and hydro dissected the anterior cervix with 20 units of Vasopressin (Pitressin) in 20 ml of saline. Next, the monopolar hook was employed to cut the anterior colpotomy and begin the circumferential incision around the cervix. Following this, we used the LigaSure bipolar forceps to sever bilateral ureteral sacral ligament. The same strategy is used at the anterior cervix to separate the bladder from the uterus. Following bladder mobilization, the cardinal ligaments and uterine arteries were cauterized and transected by LigaSure. The right fallopian tube was removed utilizing the LigaSure first, before proceeding with the left fallopian tube; the pelvis was inspected with hemostasis noted throughout. Finally, the vaginal cuff was closed in traditional vaginal fashion after the deflation of the abdomen. Conclusion Despite certain drawbacks, utilizing pure natural orifice transluminal endoscopic surgery in hysterectomy is a safe and feasible procedure that maintains a high-level of cosmesis for patients while still offering the most minimally invasive route.

1942 Transvaginal Natural Orifice Transluminal Endoscopic (Vnotes) Hysterectomy Learning Curve: The Feasibility in the Hands of Skilled Gynecologists

1942 Transvaginal Natural Orifice Transluminal Endoscopic (Vnotes) Hysterectomy Learning Curve: The Feasibility in the Hands of Skilled Gynecologists

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

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.