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Poster: Comparing vNOTES & Vaginal Hysterectomy: Adnexal Removal & Postoperative Pain

Student: Dylan Becker

Faculty Advisor: Lieschen Quiroz, MD

Contributing Authors: Christine Aboseif, MD; Adam Hare, MD; Dylan Becker, MS3; Nidhi Desai, MD; Michael Machiorlatti, PhD, MS; Kenlee Claborn, MS3; Zachary Arnold, MS4; Rebecca M. Nuss, MD; Guimy R. Castor, MPH; Jameca Price, MD, MPH, MCR

Background

Vaginal hysterectomy is a well-established surgical approach for the management of benign gynecologic conditions. More recently, vaginal natural orifice transluminal endoscopic surgery or vNOTES has emerged as a minimally invasive alternative that may facilitate improved surgical outcomes. However, while comparative studies between vNOTES and conventional TVH are increasing, data specifically evaluating outcomes such as planned adnexal removal and early postoperative pain remains limited.

Methods

A multicenter prospective cohort study was conducted between June 2024 and March 2026 comparing patients undergoing vNOTES hysterectomy with those undergoing conventional vaginal hysterectomy. All patients aged 18 years and older with planned removal of fallopian tubes with or without oophorectomy at time of hysterectomy were included. Patients older than 65 years underwent cognitive screening using the Mini-Cog assessment. The surgical approach was determined by the operating surgeon based on clinical judgment and patient factors. Demographic, perioperative, and intraoperative data were obtained through electronic medical record review. Postoperative pain was assessed using a visual analog scale (VAS) 24 hours after surgery. Operative characteristics and postoperative recovery measures were recorded, and outcomes were compared between surgical approaches using independent samples t-tests and chi-square tests. RStudio was used for all analysis.

Results

Ninety-two patients were included: 52 underwent vNOTES hysterectomy and 40 underwent conventional vaginal hysterectomy. Successful planned adnexal removal was achieved in 96.2% of vNOTES cases (50/52) and 85.0% of conventional vaginal hysterectomy cases (34/40; p=0.41). Mean age was similar between groups (56.9 vs 58.0 years, p=0.71), while BMI trended higher in the vNOTES group (31.5 vs 28.9 kg/m², p=0.05). Pelvic organ prolapse was present in most patients (92.3% vs 100%, p=0.20). Twenty-four-hour postoperative pain scores were similar between groups (3.88 vs 4.18, p=0.49). Operative time (246 vs 187 minutes, p=0.0001) and anesthesia time (291 vs 231 minutes, p< 0.0001) were longer in the vNOTES group. Logistic regression showed no independent predictors of successful adnexal removal, and multiple regression demonstrated no independent predictors of 24-hour postoperative pain.

Conclusions

vNOTES hysterectomy achieved high rates of planned adnexal removal comparable to conventional vaginal hysterectomy, despite longer operative and anesthesia times. Similar early postoperative pain further supports vNOTES as a feasible minimally invasive option for hysterectomy with adnexal removal and concomitant prolapse repair in selected patients.