The (R)evolution of vNOTES in gynecology

Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) has emerged as an innovative minimally invasive approach in gynecologic surgery, aiming to combine the benefits of vaginal surgery and conventional laparoscopy while avoiding abdominal incisions. Over the past two decades, its clinical applications have expanded considerably, encompassing an increasingly wide range of gynecologic procedures. The of this study was to provide a comprehensive narrative review of the evolution of vNOTES in gynecology, summarizing current evidence on surgical indications, perioperative outcomes, limitations, and future perspectives. A comprehensive literature search was performed in PubMed, Embase, Scopus, and the Cochrane Library from January 2004 to June 2026. Original studies, randomized trials, systematic reviews, and meta-analyses evaluating vNOTES in gynecologic surgery were included. vNOTES has evolved from an experimental access technique to an established minimally invasive approach for benign hysterectomy and adnexal surgery. Emerging applications include myomectomy, endometriosis surgery, urogynecologic procedures, gynecologic emergencies and selected oncologic indications. While high-quality evidence is available for hysterectomy and adnexal surgery, comparative data remain limited for most other gynecologic procedures, although preliminary results are highly promising. Learning curve, patient selection, and technical constraints remain key determinants of successful implementation. vNOTES represents a significant evolution in minimally invasive gynecologic surgery, with clear benefits in selected benign indications. However, its broader adoption is currently limited by heterogeneous evidence and technical challenges. Future studies should focus on standardization, training, and long-term oncologic and functional outcomes.