Intra- and Postoperative Complications in 4565 vNOTES Hysterectomies: International Registry Cohort Study.

Objective

To present the rates of intra- and postoperative complications and conversions in a large cohort of unselected vNOTES hysterectomies, performed by surgeons with different levels of expertise.

Design

International register-based cohort study.

Setting

Hysterectomies in the iNOTESs registry, 2015 to January 2024, performed by 201 surgeons from multiple countries.

Population

4565 patients undergoing vNOTES hysterectomy.

Methods

Descriptive data are presented in frequencies (n) and percent (%).

Main outcome measure

Intra- and postoperative complications. Conversions.

Results

Intraoperative and postoperative complication rates were 3.2% (n = 144) and 2.5% (n = 115), respectively. Conversions occurred in 1.6% (n = 72), of which 10 (0.2%) to laparotomy, and 82% of the conversions occurred within the first 50 cases of the surgeon's learning curve. The most common intraoperative complication was cystotomy, occurring in 1.3%, and almost half were performed by inexperienced surgeons. Other intraoperative organ injuries occurred in 20 cases (0.44%). Postoperatively, the most common complications were haemorrhage (n = 28), vault complications (n = 26) including 11 infected vault hematomas, cystitis (n = 18) and non-specific infections (n = 14). The vNOTES hysterectomies were performed by 201 surgeons, of which 9.5% had performed more than 50 vNOTES cases, representing 70% of the registered cases in the registry. The remaining 30% of the hysterectomies mainly represent learning curve data from 90% of the included surgeons. The complication rate decreased with increasing surgical experience.

Conclusions

The largest study population of vNOTES hysterectomies is presented, including both learning curve data and data from experienced surgeons, with acceptable rates of intra- and postoperative complications. No implication was found of vNOTES being inferior to other minimally invasive methods.

References:

• “QuickStats: Percentage* of Women Aged ≥50 Years Who Have had a Hysterectomy,† by Race/Ethnicity and Year – National Health Interview Survey, United States, 2008 and 2018§,” MMWR: Morbidity and Mortality Weekly Report 68, no. 41 (2019): 935.
• S. Housmans, A. Stuart, J. Bosteels, J. Deprest, and J. Baekelandt, “Standardized 10‐Step Approach for Successfully Performing a Hysterectomy via Vaginal Natural Orifice Transluminal Endoscopic Surgery,” Acta Obstetricia et Gynecologica Scandinavica 101, no. 6 (2022): 649–656.
• J. F. Baekelandt, P. A. De Mulder, I. Le Roy, et al., “Hysterectomy by Transvaginal Natural Orifice Transluminal Endoscopic Surgery Versus Laparoscopy as a Day‐Care Procedure: A Randomised Controlled Trial,” BJOG: An International Journal of Obstetrics and Gynaecology 126 (2019): 105–113.
• J. Baekelandt and S. Kapurubandara, “Benign Gynaecological Procedures by Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES): Complication Data From a Series of 1000 Patients,” European Journal of Obstetrics, Gynecology, and Reproductive Biology 256 (2021): 221–224.
• C. D. Dindo, N. Demartines, and P. A. Clavien, “Classification of Surgical Complications: A New Proposal With Evaluation in a Cohort of 6336 Patients and Results of a Survey,” Annals of Surgery 240 (2004): 205–213.