Comparative Analysis of Hysterectomy Outcomes: Robotic Single-Port vs. Traditional Transvaginal NOTES Approaches

Qiannan Yang¹Daniel Y Lovell¹Juliana Wu²Chunhua Zhang^3*Xiaoming Guan^1*

• ¹Baylor College of Medicine, Houston, United States
• ²University of Texas Medical Branch at Galveston, Galveston, Texas, United States
• ³Second Affiliated Hospital, Nanjing Medical University, Nanjing, Jiangsu Province, China

Introduction: This study was to explore the feasibility and safety of robotic single port vaginal natural orifice transluminal endoscopic surgery (RSP-vNOTES) hysterectomy when compared with traditional vaginal natural orifice transluminal endoscopic surgery (T-vNOTES) hysterectomy. Methods: In this study, the clinical data of 135 patients who underwent RSP-vNOTES or T-vNOTES hysterectomy performed by a single minimally invasive gynecologic surgeon from January 2017 to September 2024 were retrospectively analyzed. Clinical characteristics, surgical outcomes, perioperative complications, and postoperative pain scores were collected and analyzed. Results: Seventy-nine patients underwent T-vNOTES hysterectomy, and 56 patients underwent RSP-vNOTES hysterectomy. Compared with the T-vNOTES group, the RSP-vNOTES group demonstrated a lower median body mass index (27 vs. 30 kg/m², P = 0.04), fewer vaginal deliveries (0 vs. 1, P = 0.02), and a lower median uterine weight (90 vs. 175 g, P = 0.001). In terms of concomitant procedures, the RSP-vNOTES group more frequently underwent interventions related to endometriosis management—including excision of endometriotic lesions, lysis of adhesions, ovarian cystectomy, oophoropexy, bowel shaving, and bowel oversewing (all P < 0.05). Multiple linear regression analysis was performed to adjust for these differences. After adjustment, there were no significant differences between groups in hysterectomy time, total operative time, estimated blood loss, or postoperative pain scores. Conversion to laparoscopy or laparotomy occurred in six cases in the T-vNOTES group and in one case in the RSP-vNOTES group, although this difference did not reach statistical significance. Similarly, no significant differences were observed in intraoperative or postoperative complications between the groups. Discussion: When compared with T-vNOTES hysterectomy, RSP-vNOTES hysterectomy appears feasible and safe to surgery, especially in cases involving concurrent endometriosis resection, and warrants further consideration as a skillset in a gynecologic surgeon's toolbox. Large multicenter studies involving multiple surgeons and longer follow-up are needed to fully establish the safety and feasibility of this approach.