Feasibility and safety of the vNOTES approach in patients with concomitant endometriosis: a prospective study of 105 consecutive cases.

INTRODUCTION This study evaluates the surgical feasibility, safety and early perioperative outcomes of Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) for benign gynecological conditions in patients with histologically confirmed concomitant endometriosis.

Methods

This prospective, single-center cohort study evaluated 105 consecutive patients who underwent vNOTES for benign gynecological pathologies with concomitant endometriosis at Valais Hospital between June 2021 and June 2025. Exclusion criteria included a negative "sliding sign", known or suspected posterior deep infiltrating endometriosis (DIE), and a history of major pelvic surgery or pelvic radiotherapy. Data analyzed included demographic characteristics, intraoperative details (e.g., rASRM score, operative time, estimated blood loss, Clavien-Dindo complications, length of stay).

Results

The mean age was 46.2 ± 11.2 years, and the mean body mass index was 26.2 ± 5.5 kg/m2. Among the 105 patients included, a history of endometriosis was present in 34 (32.4%) patients. Mean operative time and blood loss were 57.3 ± 26.1 min and 61.9 ± 69 mL, respectively. Intraoperative complications occurred in 4 patients (3.8%), while postoperative complications were observed in 24 (22.9%), most commonly cystitis (n = 7, 6.7%) and surgical site infections (n = 6, 5.7%). According to the Clavien-Dindo classification, 21 patients (20.0%) experienced Grade II complications and 3 patients (2.9%) had Grade III. The conversion rate to conventional laparoscopy was 3.8% (n = 4). The mean hospital stay was 1.9 days. According to the rASRM classification, 60 patients (57.1%) were Stage I, 32 (30.5%) Stage II, 9 (8.6%) Stage III, and 4 (3.8%) Stage IV.

Conclusion

The vNOTES approach is a feasible and safe alternative to conventional laparoscopy for patients with benign gynecological conditions and concomitant endometriosis in the absence of preoperative evidence of severe posterior compartment involvement and pouch of Douglas obliteration.