ORIGINAL RESEARCH article
Front. Med.
Sec. Obstetrics and Gynecology
This article is part of the Research TopicInnovations in Abdomino-Pelvic SurgeryView all 4 articles
Prioritizing Vaginal Hysterectomy: A Stepped Algorithm with vNOTES Support for Benign Indications
Provisionally accepted
YUSUF ZIYA KIZILDEMIR1*
Sibel Sak1Muhammed Erdal Sak1Hacer Uyanikoglu1Mehmet Incebiyik1
Helin Kalir1
Sezin Eda Karsli2Işil Işik Okuyan2Merve Civelek2Cagri Kutlugun Emral2
Bekir Kahveci2- 1Faculty of Medicine, Harran University, Şanlıurfa, Türkiye
- 2TC Saglik Bakanligi Sanliurfa Egitim ve Arastirma Hastanesi, Şanlıurfa, Türkiye
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Objective: This prospective study aimed to evaluate the clinical outcomes of a standardized surgical algorithm adopting a "vaginal-first" approach in patients with non-descensus uteri. It sought to redefine vNOTES as an "educational bridge" and a "safety valve" within this framework. Materials and Methods: This single-center, prospective cohort study included 165 consecutive patients scheduled for hysterectomy for benign indications. A standardized stepwise algorithm was implemented: pure vaginal hysterectomy (VH) as the primary target; transition to vNOTES (second tier) in case of failure to progress; and laparoscopy or laparotomy as a final resort. All procedures were performed by a single surgeon. Results: Vaginal completion without abdominal incision was achieved in 157 patients (95.2%). Pure VH was successful in 87.9% (n=145), while 7.3% (n=12) required vNOTES support, and 4.8% (n=8) were converted to laparoscopy/laparotomy. High success rates were maintained in high-risk subgroups, including obesity (93.1%) and previous cesarean sections (96.0%). Learning curve analysis showed a significant increase in pure VH rates (81.7% to 93.9%; p=0.018) and a decrease in vNOTES utilization (11.0% to 3.6%; p=0.045). Multivariable regression identified uterine weight as the sole independent predictor of pure VH failure. Conclusion: A "vaginal-first" approach should be the standard of care for non-descensus uteri. vNOTES functions not just as a routine method, but as an educational catalyst that enhances surgical proficiency and a critical safety valve that prevents abdominal conversion. This stepped approach optimizes resource utilization while maximizing minimally invasive benefits.
Keywords: Conversion to Laparoscopy, minimally invasive surgery, Non-Descensus Uterus, Surgical algorithm, Vaginal hysterectomy, vNOTES
Received: 19 Dec 2025; Accepted: 11 Feb 2026.
Copyright: © 2026 KIZILDEMIR, Sak, Sak, Uyanikoglu, Incebiyik, Kalir, Karsli, Işik Okuyan, Civelek, Emral and Kahveci. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
* Correspondence: YUSUF ZIYA KIZILDEMIR
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