Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) for hysterectomy strategic repositioning of the vaginal route through technological evolution and emerging surgical variants.

Hysterectomy is one of the most commonly performed gynecologic surgical procedures worldwide. Over the past few decades, minimally invasive techniques, particularly laparoscopic and robotic hysterectomies, have become dominant surgical approaches [ 1 ]. Vaginal hysterectomy (VH), despite being the original natural-orifice technique, has well-established advantages, including shorter operative time (OT), faster recovery, and reduced healthcare costs [ 2 , 3 ], but it has experienced a significant global decline. This trend has been largely driven by limited surgical training during residency, increasing dependence on laparoscopic platforms, and the rising prevalence of complex uterine conditions [ 3 , 4 ]. Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) has emerged as a modern minimally invasive approach that integrates the scarless access of VH with the superior visualization, ergonomic control, and surgical precision of laparoscopy [ 5 – 9 ]. By overcoming many of the anatomical and technical limitations associated with conventional VH, vNOTES has expanded the indications for vaginal surgery and has demonstrated perioperative outcomes comparable to or superior to those of laparoscopic hysterectomy (LH), including reduced OT, less blood loss, and faster recovery. Recent technological advancements have led to the development of multiple vNOTES variants, including isobaric NOTES hysterectomy (iNH), total NOTES hysterectomy (TNH), and robotic vaginal NOTES hysterectomy (RvNH). These emerging surgical adaptations offer the potential to further enhance clinical applicability, particularly in challenging cases such as a narrow vagina, cardiopulmonary dysfunction, large uteri, pelvic adhesions, obesity, and complex endometriosis. This review comprehensively synthesizes the current evidence comparing vNOTES and LH and explores whether vNOTES may serve as a strategic opportunity to systematically reposition the vaginal route as a primary minimally invasive option. In addition, this review evaluates the evolving technological landscape of vNOTES, its potential for global scalability, and the critical role of structured training and procedural standardization in supporting its future dissemination.

All included studies were published between 2012 and 2025 and comprised randomized controlled trials (RCTs), prospective cohort studies, retrospective analyses, and relevant case series that directly evaluated the perioperative outcomes of vNOTES hysterectomy. The key characteristics of these comparative studies are summarized in Table 1 . The included studies encompassed diverse vNOTES subtypes, allowing for a detailed classification based on surgical workflow, uterine artery ligation timing, pneumoperitoneum use, and robotic assistance. vNOTES procedures can be categorized into five primary subtypes, each representing a distinct surgical innovation. A gasless transvaginal approach without CO 2 insufflation, typically applied in patients with large uteri, to potentially reduce cardiopulmonary risks. A fully endoscopic procedure performed entirely through the transvaginal ports without conventional vaginal dissection, providing a minimal-access solution. Endoscopic hysterectomy performed after transvaginal access and colpotomy, with uterine artery ligation conducted after port insertion. A hybrid technique in which uterine artery ligation is performed prior to port insertion, followed by laparoscopic dissection. A robot-assisted transvaginal approach utilizing wristed robotic instruments, primarily applied in endometriosis and other complex pelvic cases. Among the reviewed procedures, NAVH and vNH were the most frequently performed (eight studies each), followed by two TNH studies and one iNH. The distribution of each vNOTES subtype is summarized in Table 2 , and the relative frequencies are shown in Fig. 1 . Detailed surgical workflows for iNH, vNH, NAVH, and TNH are illustrated in Fig. 2 , highlighting the key differences in access strategies, pneumoperitoneum use, and stepwise procedural sequences. This typology not only reflects the procedural evolution of vNOTES but also offers a strategic framework for optimizing surgical selection, training, and global dissemination. This classification contributes to the repositioning of VH as a primary minimally invasive option in modern gynecologic surgery. The comparative clinical outcomes of vNOTES and laparoscopic hysterectomy in the included comparative studies are summarized in Table 3 . OT consistently favored vNOTES over LH, particularly for vNH and NAVH subtypes. Statistically significant reductions were reported in 12 studies [ 5 , 10 – 20 ]. Kim et al. [ 6 ] was the only study favoring LH, likely because of the use of multiport LAVH as a comparator. Conversion events were reported in six studies; however, no significant differences were observed between the groups. Kheirbek et al. [ 12 ] noted high conversion rates (vNOTES, 9.6%; LH, 7.4%) in cases with large uteri (≥500 g). Basol et al. [ 21 ] reported 10% conversion in TNH vs. 0% in LH. Thigpen et al. [ 11 ] reported low conversion rates in both groups (vNOTES, 0.6%; LH, 0.8%). LH showed higher conversion rates in studies by Baron et al. [ 14 ], Badiglian-Filho et al. [ 22 ], and Kim et al. [ 6 ]. Overall, vNOTES demonstrated low and acceptable conversion rates comparable to those of LH. Ten studies reported comparable or lower EBL in the vNOTES groups. Eight studies did not report EBL. Significant reductions were also observed by Yang [ 8 ], Kheirbek et al. [ 12 ], and Wang et al. [ 20 ]. The postoperative Hb decrease similarly favored vNOTES in studies by Kim et al. [ 6 ] and Yang [ 8 ]. Notably, Wang et al. [ 20 ] reported a significant Hb reduction in patients with uterine weights of >500 g. The perioperative transfusion rates were generally low. Wang et al. [ 20 ] found significantly higher transfusion rates in the LH group for uteri weighing >280 g. In the TNH cohort, Basol et al. [ 21 ] reported no transfusions in the vNOTES group, whereas two transfusions occurred in the LH group. In obese [ 16 ] and large uterus cases [ 15 , 20 ], both groups showed slightly higher transfusion rates, without statistical significance. Other studies [ 5 , 13 , 14 , 17 , 22 ] reported no transfusions in either group, indicating stable hemostasis. vNOTES was consistently associated with a shorter hospital stay. Yang et al. [ 23 ] and Yuan et al. [ 10 ] reported a 1-day reduction, while Thigpen et al. [ 11 ] noted same-day discharge in both groups. Some studies, including those by Kheirbek et al. [ 12 ] and Noh et al. [ 13 ], did not report on hospital stay. Overall, vNOTES hysterectomy demonstrated favorable trends toward shorter hospitalization and enhanced recovery. The overall complication rates were low across all studies. No complications occurred in the vNOTES groups as reported by Yang et al. [ 5 , 23 ], Yuan et al. [ 10 ], Park et al. [ 17 ], Badiglian-Filho et al. [ 22 ], and Kim et al. [ 6 ]. Notably, LH was associated with significantly higher complication rates in the studies by Basol et al. [ 21 ], Puisungnoen et al. [ 24 ], and Baekelandt et al. [ 19 ]. Other studies by Baron et al. [ 14 ], Yang et al. [ 25 ], and Wang et al. [ 20 ] also favored vNOTES. Bladder injury was reported in vNOTES by Baekelandt et al. [ 19 ] and Wang et al. [ 20 ], whereas ureteral occlusion was noted in LH. Noh et al. [ 13 ] reported ureter injury in vNOTES. Kim et al. [ 6 ] observed major complications only in LH patients. Overall, vNOTES demonstrated a favorable safety profile with a potential advantage over LH in terms of cumulative complication rates. Most studies have reported lower or comparable postoperative pain in patients undergoing vNOTES. Park et al. [ 17 ] were the only authors of an RCT to report higher vaginal pain on day one in vNOTES than in laparoendoscopic single-site. However, most studies reported lower or comparable pain with vNOTES. Yang et al. [ 5 ], Noh et al. [ 13 ], and Baron et al. [ 14 ] reported no significant differences in VAS scores. Yuan et al. [ 10 ], Thigpen et al. [ 11 ], Yang et al. [ 5 ], Kaya et al. [ 15 , 16 ], Basol et al. [ 21 ], Puisungnoen et al. [ 24 ], and Baekelandt et al. [ 19 ] reported reduced pain in vNOTES groups. Six studies [ 5 , 12 , 13 , 15 , 16 , 20 ] demonstrated successful vNOTES hysterectomy in large uteriand total vaginal NOTES (≥280 g). Kheirbek et al. [ 12 ] reported cases with mean uterine weights exceeding 500 g. Yang et al. [ 23 ] reported that iNH was feasible for large uteri. RvNH and TNH were primarily applied to smaller uteri (<200 g) because of technical limitations. Overall, vNOTES appears to be feasible even in large uteri, expanding its surgical indications. However, evidence for emerging vNOTES variants remains limited. Small-cohort studies have recently explored the iNH, TNH, and RvNH. Yang et al. [ 23 ] reported that iNH achieved outcomes comparable to those of LH while minimizing blood loss, even in patients with large uteri. Basol et al. [ 21 ] found that TNH offered shorter hospital stays but higher conversion rates than LH. Thigpen et al. [ 11 ] reported that RvNH demonstrated shorter OTs and less postoperative pain than RSSP hysterectomy, although it was mainly applied to smaller uteri. However, further large-scale studies are required to confirm the feasibility and safety of this method. Lee et al. [ 26 ] first attempted vNOTES in 2015 using the da Vinci S System (Intuitive Surgical, Sunnyvale, CA, USA) but faced inherent design limitations in arm mobility and instrument collisions. Yang [ 7 , 8 ] overcame these problems in 2021 by using a customized setup for the da Vinci Si System (Intuitive Surgical), enabling the first clinical RvNH. Based on these developments, Guan et al. [ 27 ] successfully applied the da Vinci SP System (Intuitive Surgical) to clinical practice. Advances in next-generation platforms, including the da Vinci 5 System (Intuitive Surgical), are expected to further improve RvNH. RvNH is applied in challenging cases such as large uteri, obesity, and endometriosis, supporting its versatility [ 28 , 29 ]. Recent studies suggest that RvNH may improve the postoperative quality of life compared to conventional robotic hysterectomy [ 30 ]. Continuous advancements in robotic platforms are expected to enhance the applications of RvNH. iNH offers a scarless approach with potential benefits in terms of hemodynamic stability and faster recovery. First introduced by Yang [ 7 ] in 2020 using a retractor-based platform without CO 2 insufflation, iNH reduces the risks associated with pneumoperitoneum, such as subcutaneous emphysema, cardiopulmonary dysfunction, and hypercapnia. Mei et al. [ 31 ] reported that gasless RvNH achieved comparable or better outcomes than conventional RvNH in blood loss, pain, and recovery. Preclinical studies confirmed its feasibility [ 32 ], and Yang et al. [ 23 ] successfully applied gasless vNOTES without robotic assistance. A randomized trial by Liu et al. [ 33 ] is currently comparing gasless and conventional vNOTES to determine whether gasless vNOTES can be established as an optimal surgical option for benign gynecological diseases. Broader adoption requires further evidence and optimized instruments. TNH is a scarless, minimally invasive hysterectomy technique developed based on the VAMIS concept [ 34 ]. Baekelandt [ 9 ] established TNH as a fully transvaginal laparoscopic procedure, demonstrating feasibility in five cases. In a subsequent randomized controlled trial, Baekelandt et al. [ 19 ] compared a mixed vNOTES cohort, including both vaginally assisted NOTES hysterectomy and total vaginal NOTES hysterectomy/TNH, with TLH and demonstrated that vNOTES was non-inferior to TLH, with advantages in operative time, same-day discharge, hospital stay, postoperative pain, analgesic use, and postoperative complications. TNH differs from vNH in that it fully replaces the vaginal steps with endoscopic dissection, including the anterior and posterior peritoneum and sacrouterine ligaments, making it suitable for nulliparous women and those with narrow vaginal canals. Basol et al. [ 21 ] reported shorter hospital stays, less pain, and fewer complications with TNH than with single-port laparoscopy. Although technically demanding, TNH shows promise as a minimal-access surgery. The application of vNOTES hysterectomy in special clinical conditions has been explored, including endometriosis, large uteri, and challenging patient populations, including nulliparous and virgin patients, individuals with a narrow vagina, obese patients, and those with significant pelvic adhesions, as well as cases involving earlier recovery of intestinal function. RvNH has shown feasibility for advanced endometriosis, including DIE involving the bowel [ 35 ]. Xu et al. [ 36 ] successfully treated stage IV endometriosis with RvNH even in an obliterated cul-de-sac. Zhang et al. [ 37 ] reported reduced postoperative pain and faster recovery with RvNH. Single-port RvNH using the da Vinci SP System (Intuitive Surgical) is effective in treating severe pelvic endometriosis [ 27 ]. Intraoperative intraoperative indocyanine green fluorescence improves ureteral safety in cases of complex pelvic anatomy [ 38 , 39 ]. Collectively, these results suggest that RvNH is a feasible option for managing complex endometriosis. vNOTES hysterectomy is feasible and effective for large uteri (≥280 g) [ 40 – 43 ]. Temtanakitpaisan et al. [ 40 ] demonstrated safe vNOTES in uteri weighing >1,000 g, although a larger size may increase OT and blood loss. Nulens et al. [ 41 ] reported a 99% completion rate in uteri ≥280 g, including patients with prior cesarean, obesity, and nulliparity. Wang et al. [ 42 ] confirmed the feasibility of extremely large uteri with auxiliary measures as needed. Tan et al. [ 43 ] emphasized the need to counsel patients about longer OTs and potential blood loss. These findings support vNOTES as a viable option in cases involving large uteri. vNOTES is feasible in challenging cases such as nulliparous and virgin patients, those with a narrow vagina, obesity, and pelvic adhesions [ 44 – 47 ]. Unlike conventional VH, vNOTES offers improved visualization and endoscopic surgical control. Nulens et al. [ 45 ] confirmed the safety of vNOTES in virgin women without increased morbidity. In obese patients, vNOTES showed favorable perioperative outcomes, although the OT and hospital stay may increase [ 46 ]. Liu et al. [ 29 ] successfully performed RvNH in a class III obese patient with a body mass index of 70. Kaya et al. [ 16 ] consistently reported shorter OTs and faster recovery in obese women. vNOTES provides excellent visualization and access in cases of pelvic adhesions, even after multiple prior abdominal surgeries [ 47 ]. The use of vNOTES has significantly expanded the indications for vaginal surgery in complex populations. The vNOTES hysterectomy offers procedural advantages beyond perioperative safety, including cost-effectiveness, faster recovery, and a relatively manageable learning curve. vNOTES typically uses standard laparoscopic instruments, making it a cost-efficient and globally scalable option, especially in low-resource settings [ 48 , 49 ]. Tang et al. [ 50 ] reported that vNOTES promotes earlier recovery of intestinal function and a faster return to work than LH. The learning curve for vNOTES has been reported to be relatively short. Mereu et al. [ 51 ] demonstrated surgical competence in five cases and proficiency in 25 cases. Lauterbach et al. [ 52 ] confirmed its feasibility for surgeons skilled in minimally invasive gynecologic procedures. These advantages make vNOTES an accessible, rapidly adoptable, efficient, and minimally invasive surgical option. VH is a minimally invasive surgery for benign gynecologic disease [ 2 ]. vNOTES has recently emerged as a modern evolution of VH; however, direct comparative studies remain scarce. Merlier et al. [ 53 ] conducted the only available comparative study and reported no significant differences in surgical outcomes or outpatient success rates between VH and vNOTES. However, vNOTES offers notable advantages, including superior surgical visualization and adnexal management, particularly in patients with limited vaginal access [ 53 , 54 ]. Additionally, vNOTES provides ergonomic benefits to surgeons, such as improved posture and enhanced instrument control, which may facilitate its broader adoption in complex clinical scenarios. Current evidence suggests that vNOTES may not only complement but also potentially extend the indications for VH. Large-scale prospective comparative studies are essential to establish clear selection criteria and define the respective clinical roles.

This review comprehensively synthesizes the current evidence comparing vNOTES and LH while exploring whether vNOTES may serve as a strategic pathway to systematically reposition the vaginal route as the primary minimally invasive option in gynecologic surgery. vNOTES hysterectomy consistently demonstrates favorable perioperative outcomes, including reduced OT, lower EBL, decreased postoperative pain, and shorter hospital stays [ 6 , 10 , 11 , 13 , 15 – 18 , 20 – 22 , 24 , 25 , 32 ]. These advantages have been repeatedly confirmed across multiple studies, reinforcing the safety and efficacy of vNOTES as a minimally invasive alternative [ 6 , 10 , 11 , 13 , 15 – 18 , 20 – 22 , 24 , 25 , 32 ]. In addition to these perioperative benefits, vNOTES offers faster recovery, earlier return to daily activities, cost-effectiveness, and a manageable learning curve, supporting its accessibility for a broad range of surgeons and patients [ 6 , 10 , 11 , 13 , 15 – 18 , 20 – 22 , 24 , 25 , 32 , 51 ]. Importantly, vNOTES shows particular utility in complex clinical scenarios where conventional VH and laparoscopic approaches may be limited [ 9 , 12 – 16 , 28 , 35 , 37 – 39 ]. These scenarios include patients with large uteri, obesity, nulliparity, narrow vaginal canals, pelvic adhesions, and DIE [ 9 , 12 – 16 , 28 , 35 , 37 – 39 ]. Robotic-assisted vNOTES provides enhanced visualization and precision in dissection, enabling safer procedures in these challenging pelvic environments [ 7 – 9 , 27 – 31 , 36 – 43 ]. The clinical versatility of vNOTES not only complements but also broadens the indications for minimally invasive gynecologic surgery, supporting its potential to expand the surgical armamentarium [ 7 – 9 , 27 – 31 , 36 – 43 ]. As the technological landscape of vNOTES continues to evolve, further advancements in conventional techniques-including iNH [ 23 ], TNH [ 9 ], and traditional transvaginal approaches-as well as RvNH [ 7 , 8 ] will be essential for achieving widespread global dissemination. The future success of vNOTES relies on refining surgical instruments, developing specialized platforms, and optimizing procedures tailored to each approach [ 7 , 8 , 23 , 29 , 31 , 43 ]. Although RvNH has demonstrated promising results in complex surgical scenarios, additional large-scale clinical studies are necessary to validate its role and further expand its indications [ 7 , 8 , 27 – 31 , 36 – 43 ]. To support the global scalability of vNOTES, region-specific strategies must address barriers such as limited access to specialized equipment and variations in surgical training infrastructure [ 51 – 54 ]. Establishing international collaborations, developing accessible and standardized training modules, and promoting global technology-sharing initiatives will be critical in overcoming these disparities [ 51 – 54 ]. Simulation-based education, stepwise credentialing processes, and the integration of vNOTES into residency training curricula may further accelerate proficiency acquisition and contribute to uniform worldwide adoption [ 51 – 54 ]. Limited surgical exposure to VH during residency, as outlined by the Accreditation Council for Graduate Medical Education guidelines, which require only 15 VH cases [ 55 ], has contributed to the continued decline in VH proficiency and utilization. vNOTES presents a pivotal opportunity to systematically revive the vaginal route as a primary minimally invasive approach [ 49 ]. Unlike conventional VH, vNOTES offers enhanced endoscopic visualization and ergonomic advantages, facilitating its rapid adoption by laparoscopically trained surgeons [ 49 ]. Lauterbach et al. [ 52 ] confirmed that vNOTES can be safely adopted after a short learning curve, whereas Guan et al. [ 56 ] emphasized its value as a rescue strategy when a standard vaginal approach is not feasible. Lerner et al. [ 49 ] proposed that vNOTES could play a key role in reestablishing the vaginal route as the preferred minimally invasive option in gynecologic surgery. Future technological innovations should prioritize the development of ergonomic instruments specifically designed for transvaginal access, the integration of advanced robotic assistance for complex cases, and the refinement of isobaric techniques to reduce learning curves and enhance surgical safety [ 7 , 8 , 23 , 29 , 31 , 43 ]. To facilitate safe and widespread clinical adoption, it will be essential to establish standardized procedural guidelines, competency-based training programs, and global accreditation systems [ 51 – 54 ]. Prospective complication registries and multi-institutional studies will also be necessary to ensure quality assurance and long-term patient safety [ 51 – 54 ]. This review is limited by the relatively small number of high-quality comparative studies currently available on vNOTES hysterectomy [ 6 , 10 , 11 , 13 , 15 – 18 , 20 – 22 , 24 , 25 , 32 ]. Many of the included studies were observational or retrospective in design with small sample sizes and potential selection biases, limiting the generalizability of the findings [ 6 , 10 , 11 , 13 , 15 – 18 , 20 – 22 , 24 , 25 , 32 ]. In particular, evidence supporting emerging techniques such as TNH, iNH, and RvNH remains preliminary and requires further validation through large-scale RCTs to confirm their efficacy, safety, and long-term outcomes [ 7 – 9 , 23 , 29 , 31 , 43 ]. Additionally, the surgical indications, learning curves, and complication rates reported in the literature may not fully capture variability across different clinical settings and surgeon experience levels [ 6 , 10 , 11 , 13 , 15 – 18 , 20 – 22 , 24 , 25 , 32 ]. The global applicability of vNOTES is also influenced by the availability of specialized instruments, surgical platforms, and local training opportunities, which may vary significantly across healthcare systems [ 51 – 54 ]. As a narrative review, this study was subject to potential selection bias and did not include a quantitative meta-analysis, and heterogeneity in study design, patient populations, and outcome measures across the included literature further limited the ability to draw definitive conclusions [ 6 , 10 , 11 , 13 , 15 – 18 , 20 – 22 , 24 , 25 , 32 ]. Despite these limitations, this review provides a comprehensive synthesis of current evidence, providing valuable insights into comparative outcomes, evolving surgical technologies, and the strategic potential of vNOTES hysterectomy [ 6 – 12 , 14 , 16 – 25 , 29 , 32 , 33 , 43 ]. By systematically integrating conventional vNOTES, TNH, iNH, and RvNH within a unified clinical and strategic framework, this review highlights the potential of vNOTES to transform minimally invasive gynecologic surgery and address the persistent decline in VH proficiency [ 6 – 11 , 13 , 15 – 18 , 20 – 25 , 29 , 31 , 32 , 43 , 49 ]. Furthermore, this review serves as a foundational reference to guide future surgical innovations, inform training paradigms, and support the global dissemination of vNOTES through evidence-based clinical adoption [ 51 – 54 ].

A structured narrative review was conducted to compare vNOTES hysterectomy and LH and to evaluate emerging vNOTES variants. We systematically searched PubMed (n=413), MEDLINE (n=224), ClinicalTrials.gov (n=17), and EMBASE (n=66) for articles published from January 10, 2000 to July 31, 2025, using the following Boolean search terms: ("vNOTES" OR "vaginal NOTES" OR "NOTES" OR "natural orifice transluminal endoscopic surgery") AND ("hysterectomy"). Only studies published in English were included in this meta-analysis. In addition, 10 relevant records were identified through manual reference screening. After duplicates were removed, 480 articles remained. Sixty articles were selected for a full-text review based on title and abstract screening. Ultimately, 60 studies were included in this review, comprising 18 comparative studies and 42 related articles used for contextual and clinical analyses. The literature selection was independently verified by multiple reviewers to ensure accuracy. Comparative studies reporting perioperative outcomes-OT, estimated blood loss (EBL), complication rates, and conversion rates were included. Studies that did not meet the inclusion criteria, including cadaveric studies, conference abstracts without full texts, and unrelated articles, were excluded. The included studies were categorized according to the hysterectomy type: vNOTES (vaginal NOTES hysterectomy [vNH], NOTES-assisted vaginal hysterectomy [NAVH], iNH, TNH, and RvNH) and LH, which included total laparoscopic hysterectomy (TLH), laparoscopic-assisted vaginal hysterectomy (LAVH), single-port laparoscopic hysterectomy, and robotic-assisted single-site port (RSSP). The subtypes were further classified based on the uterine artery ligation sequence (pre-port vs. post-port ligation), pneumoperitoneum use (gasless vs. CO 2 insufflation), and robotic assistance. The included studies focused on benign gynecologic diseases and primarily evaluated perioperative outcomes. Additional non-comparative studies have confirmed the feasibility of vNOTES in complex conditions, such as deep infiltrating endometriosis (DIE), large uteri, and obesity. Procedural metrics, including recovery, learning curve, and cost, have been evaluated in relevant studies. Although a formal risk-of-bias assessment was not conducted, comparative studies with clearly reported outcomes were included to ensure reliability.