Outcomes of Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) for Uterosacral Ligament Suspension in Apical Compartment Prolapse: A Systematic Review

Introduction and HypothesisThis systematic review is aimed at assessing the efficacy and safety of transvaginal natural orifice transluminal endoscopic surgery-uterosacral ligament suspension (vNOTES-USLS) based on current evidence.MethodsA comprehensive search of PubMed and Web of Science was conducted for studies published up to 31 December 2024. Original studies on vNOTES-USLS were included, whereas reviews, abstracts, and publications not in the English language were excluded. No restrictions were placed on sample size or publication date.ResultsNine studies with 336 patients met the criteria, including 1 randomized controlled trial, 3 prospective, and 5 retrospective studies. Operative time ranged from 17.4 +/- 6.4 to 29.7 +/- 8.2 minutes. Hemoglobin reduction varied between 1.12 +/- 0.83 and 1.80 +/- 1.57 g/dl. Hospital stays ranged from 1.0 +/- 0.5 to 3.7 +/- 1.1 days. Intraoperative complications occurred in 2.1% (7 out of 336), with bladder injury being the most common (3 cases). One patient required conversion to vaginal USLS, but no laparotomy conversions were reported. Ureteral kinking occurred in 1 case (0.3%) and was resolved intraoperatively. Postoperative complications were reported in 7.4% (25 out of 336), with urinary tract infection being the most frequent (10 cases). Over 1-37 months of follow-up, 1 patient required reoperation for anterior prolapse recurrence.ConclusionvNOTES-USLS appears to be a promising option for apical prolapse, with favorable short-term outcomes. However, small sample sizes, short follow-ups, and study design variations limit current evidence. Larger prospective studies with longer follow-ups and direct comparisons with established procedures are needed to assess long-term safety and effectiveness.