Feasibility and Learning Curve of Transvaginal Natural Orifice Transluminal Endoscopic Surgery for Hysterectomy and Uterosacral Ligament Suspension in Apical Compartment Prolapse

OBJECTIVE: The aim of this study was to describe our experience with transvaginal natural orifice transluminal endoscopic surgery (vNOTES) uterosacral ligament suspension (USLS) and to evaluate the learning curve of mastering the skills to operate this procedure. METHODS: This is a prospective study of the first 35 vNOTES hysterectomy and USLS surgeries performed between October 2018 and April 2019 at Rambam Health Care Campus (Israel) (n = 26) and Imelda Hospital (Belgium) (n = 9). The primary outcome was surgical time. Secondary outcomes included intraoperative bleeding, length of hospitalization, pain during the first 24 hours postoperative pain, and the need for analgesia, intraoperative, and postoperative adverse events. RESULTS: The median age was 55 years (range, 40-81). The median operative time was 113 minutes (range, 89-233). For the procedures performed at Rambam, total operative time decreased from the first 13 to the following 13: from 149 minutes (range, 89-233 minutes) to 103 (89-170) (<0.001); Pearson correlation demonstrated a moderate negative significant correlation of surgery duration with surgeon experience (rho = -0.445, P < 0.001). The median estimated blood loss was 30 mL (20-200). The median hospital stay was 2 days (1-3). There were no intraoperative adverse events. The median visual analogue scale score for pain assessment during the first 24 hours after surgery was 1 (range, 1-3). CONCLUSIONS: vNOTES USLS is a feasible procedure that showed marked improvement in surgical performance in a short period, as evidenced by the decrease in surgical time and the low rate of minor associated perioperative complications. Outcomes of long-term follow-up should be investigated.