Feasibility, safety, and short term outcomes of v-notes assisted sacrocolpopexy for vaginal cuff support following hysterectomy for uterine prolapse

Feasibility, safety, and short term outcomes of v-notes assisted sacrocolpopexy for vaginal cuff support following hysterectomy for uterine prolapse | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Feasibility, safety, and short term outcomes of v-notes assisted sacrocolpopexy for vaginal cuff support following hysterectomy for uterine prolapse Ali Deniz ERKMEN, Kevser ARKAN, Mesut Ali HALISCELIK, Kubra CAKAR YILMAZ, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7180719/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Effective apical support following hysterectomy is crucial for preventing subsequent vaginal vault prolapse. While abdominal sacrocolpopexy is the gold standard for durable apical repair, it necessitates abdominal incisions. Vaginal natural orifice transluminal endoscopic surgery (vNOTES) presents a promising scarless platform to perform this gold-standard procedure entirely transvaginally. Objective To evaluate the feasibility, safety, and short-term clinical outcomes of concomitant hysterectomy and vNOTES-assisted sacrocolpopexy in patients with uterine prolapse. Methods This retrospective cohort study included 30 consecutive patients with stage 2 uterine prolapse who underwent the combined procedure at a single tertiary center. Pre- and postoperative anatomical outcomes were assessed using the Pelvic Organ Prolapse Quantification (POP-Q) system at a 1-year follow-up. The primary outcome was objective anatomical success, defined as a postoperative C-point of ≤ − 1 cm. Secondary outcomes included operative time, estimated blood loss, hospital stay, postoperative pain (Visual Analog Scale), and complication rates, including mesh-related adverse events. Results The mean age of the cohort (n = 30) was 57.1 ± 10.8 years, and the mean operative time was 100.2 ± 11.7 minutes. The procedure resulted in a significant restoration of apical support, with the mean POP-Q C-point improving from + 0.2 ± 0.4 cm preoperatively to − 1.4 ± 1.1 cm postoperatively (p < 0.001). Objective anatomical success was achieved in 73.3% of patients (22/30). The clinical recurrence rate was 3.3% (1/30). Postoperative pain was minimal, with mean VAS scores decreasing to 0.80 ± 0.85 at 24 hours. The most common long-term complications were de novo dyspareunia (10.0%) and mesh exposure (6.7%). No major intraoperative complications were observed. Conclusion Concomitant hysterectomy and vNOTES-assisted sacrocolpopexy is a feasible, safe, and effective procedure for the management of uterine prolapse. This novel, scarless technique successfully combines the principles of a gold-standard apical repair with the benefits of a truly minimally invasive approach, offering a promising alternative to conventional laparoscopic and robotic surgery. Uterine Prolapse Sacrocolpopexy vNOTES Apical Support Minimally Invasive Surgery Vaginal Hysterectomy Figures Figure 1 Figure 2 Key Points 1. What is already known? Durable apical support is essential following hysterectomy for uterine prolapse, with laparoscopic sacrocolpopexy considered the gold-standard repair, though it requires abdominal incisions. 2. What are the new findings? This study demonstrates that performing sacrocolpopexy via a vNOTES approach at the time of hysterectomy is a feasible, safe, and effective technique, resulting in significant anatomical correction (mean C-point improvement of -1.6 cm) and a high clinical success rate (93.3%) with low short-term morbidity. 3. What are the implications for clinical practice? vNOTES sacrocolpopexy emerges as a scarless alternative to conventional laparoscopy, offering the benefits of a gold-standard apical suspension through a completely transvaginal route, which may enhance postoperative recovery and patient satisfaction. Introduction Pelvic organ prolapse (POP) is a prevalent condition that significantly impairs the quality of life for millions of women worldwide, representing a major public health concern ( 1 ). Uterine prolapse, characterized by the descent of the uterus due to the failure of apical pelvic support, is one of the most common indications for gynecologic surgery. While vaginal hysterectomy is a frequently performed procedure for this condition, hysterectomy alone, without a concomitant apical suspension procedure, is associated with a subsequent vaginal vault prolapse risk as high as 11%, often necessitating reoperation ( 2 ). Therefore, providing adequate and durable support to the vaginal apex at the time of hysterectomy is critical for long-term surgical success( 3 ). In the modern surgical armamentarium for apical prolapse, abdominal sacrocolpopexy (ASC) has long been revered as the gold-standard procedure. Whether performed laparoscopically or robotically, its reputation is built on a foundation of robust evidence demonstrating superior anatomical longevity and better functional results when benchmarked against conventional transvaginal approaches. ( 4 , 5 ). However, these abdominal approaches are not without drawbacks, including the need for abdominal incisions, longer operative times, higher costs, and the inherent risks of visceral or vascular injury during dissection of the presacral space( 6 ). The evolution of minimally invasive surgery has recently led to the emergence of vaginal natural orifice transluminal endoscopic surgery (vNOTES). This technique offers a truly scarless platform for gynecologic procedures by providing direct retroperitoneal access through a transvaginal incision ( 7 ). The true innovation of vNOTES lies in its ability to fundamentally solve a decades-old surgical dilemma: it grants the surgeon the high-definition, panoramic view of laparoscopy through a direct, transvaginal route. This approach effectively bypasses the notorious limitations of conventional vaginal surgery namely, operating in a deep, narrow field with restricted instrument mobility. While the surgical community has rapidly adopted vNOTES for hysterectomy and adnexal procedures, its application to the technically demanding field of pelvic reconstruction, particularly a complex procedure like sacrocolpopexy, represents the next frontier and remains largely unexplored. ( 8 ). This study aims to evaluate the feasibility, safety, and short-term anatomical and functional outcomes of performing vNOTES-assisted sacrocolpopexy for vaginal cuff support concurrently with hysterectomy in a cohort of patients with uterine prolapse. We hypothesized that this innovative, combined approach could provide the durability of a gold-standard apical fixation while completely avoiding abdominal incisions, thereby representing a significant advancement in pelvic reconstructive surgery. Materials and Methods Study Design and Patient Population This retrospective cohort study was designed and conducted in accordance with the STROBE guidelines (Strengthening the Reporting of observational studies in Epidemiology) ( 9 ). After receiving approval from the Institutional Ethics Committee of Diyarbakır Gazi Yaşargil Training and Research Hospital (No: 374; Date: February 28, 2025), we retrospectively reviewed the medical records of 30 consecutive patients treated with concomitant vaginal hysterectomy and vNOTES-assisted sacrocolpopexy for symptomatic stage ≥ 2 uterine prolapse between January 2023 and January 2024.All procedures were performed in line with the principles of the Declaration of Helsinki. Written informed consent for the surgery and the use of anonymized data for research was obtained from all participants. The study included adult women with symptomatic stage 2 uterine prolapse, as defined by the Pelvic Organ Prolapse Quantification (POP-Q) system. ( 10 ). Exclusion criteria included prior surgery for apical pelvic organ prolapse, suspicion of malignancy, active pelvic inflammatory disease, severe endometriosis obliterating the cul-de-sac, or inability to provide informed consent. All patients received comprehensive preoperative counseling regarding the surgical procedure, including a discussion of the potential risks and benefits associated with the use of permanent synthetic mesh for apical support. Surgical Procedure All procedures were performed by a single senior surgeon experienced in both vNOTES and pelvic reconstructive surgery. Patients received preoperative antibiotic prophylaxis in accordance with institutional guidelines ( 11 ). Under general anesthesia and in the dorsal lithotomy position, a hysterectomy was performed via either a conventional vaginal approach or a total vNOTES hysterectomy, based on surgeon preference and patient anatomy. Crucially, following the removal of the uterus, the vaginal cuff was intentionally left open. A 9 cm vNOTES access port (GelPOINT® V-Path, Applied Medical, Rancho Santa Margarita, CA, USA) was then placed within the open vaginal apex, providing an airtight seal for peritoneal insufflation. The procedure then followed a hybrid, dual-approach technique: Endoscopic Promontory Exposure : The vNOTES endoscope was introduced into the peritoneal cavity through the port. Standard endoscopic instruments were used to visualize the sacral promontory and dissect the overlying peritoneum to clearly expose the anterior longitudinal ligament. This step provided a clear, endoscopically confirmed target for sacral fixation. Retroperitoneal Tunneling and Mesh Passage : Simultaneously, from the vaginal side of the open cuff, a long dissecting instrument was introduced into the retroperitoneal space. This instrument was advanced extraperitoneally under the peritoneum in a tunneling fashion, guided by the endoscopic view from within the abdomen and careful anatomical knowledge to avoid the ureter and major vessels. The instrument was advanced until its tip emerged through the anterior longitudinal ligament at the previously exposed promontory. The proximal end of a Y-shaped, macroporous, lightweight polypropylene mesh was then grasped by the dissector ( 12 ). By withdrawing the instrument, the mesh was retrogradely pulled through the retroperitoneal tunnel, with one end emerging from the open vaginal cuff while the other remained at the promontory. Mesh Fixation and Cuff Closure : The proximal end of the mesh was anchored to the anterior longitudinal ligament over the S1 vertebral body. This fixation was achieved with 2–3 permanent titanium tacks (e.g., ProTack™) in 17 patients (56.7%). In 13 patients (43.3%) where tack fixation was deemed to have suboptimal purchase on the ligament, two non-absorbable 2 − 0 polypropylene sutures were used for a more secure fixation. The two arms of the mesh were then securely affixed to the anterior and posterior fibromuscular layers of the vaginal cuff using multiple, interrupted 2 − 0 non-absorbable polypropylene sutures, ensuring full-thickness bites were taken to prevent suture pull-through. The central portion of the vaginal cuff was closed. Finally, the lateral sutures for the cuff were placed, incorporating the mesh sutures. Critically, care was taken to ensure the mesh was laid with appropriate laxity before these final sutures were tied, avoiding any undue tension on the vaginal cuff. This step is crucial to prevent postoperative complications such as vaginal shortening, pain, or de novo dyspareunia. The sutures were then tied down to elevate the vaginal apex. As the mesh was placed in a retroperitoneal tunnel, extensive peritoneal opening was avoided, and therefore, no peritoneal closure (peritonealization) was required. Postoperatively, patients were mobilized on the first day, and the urinary catheter was typically removed within 24 hours after surgery, following a successful voiding trial. Outcome Measures and Data Collection Pre- and postoperative anatomical assessments were performed using the POP-Q system ( 13 ). The primary anatomical outcome was objective success at the 1-year follow-up, defined as a postoperative C-point at or below − 1 cm (C ≤ -1 cm). Secondary outcomes included operative time, estimated blood loss (EBL), length of hospital stay, and postoperative pain, assessed on a 10-point visual analog scale (VAS) at 6, 24, and 48 hours. Intra- and postoperative complications were recorded and graded according to the Clavien-Dindo classification system ( 14 ). Long-term adverse events, including mesh exposure/erosion, de novo dyspareunia, and voiding dysfunction, were also documented. Postoperative Follow-up and Assessment All patients were followed for a minimum of 12 months postoperatively. Scheduled follow-up visits were conducted at 6 weeks, 6 months, and 12 months after the surgical procedure. At each visit, a comprehensive evaluation was performed by a gynecologic oncologist, which included three key components: Objective Anatomical Assessment : A standardized pelvic examination was conducted, including a speculum and bimanual exam, to perform POP-Q measurements. This was used to objectively assess the anatomical position of the vaginal apex (C-point) and other compartments (Aa, Ba, Ap, Bp). Subjective Symptom Assessment : Patients were systematically queried regarding the resolution of their initial prolapse symptoms (such as the sensation of a vaginal bulge or pelvic pressure). Additionally, they were asked about the emergence of any new or worsening functional issues, including urinary symptoms (stress incontinence, urgency, voiding difficulty), bowel symptoms (constipation, incomplete emptying), or sexual symptoms (dyspareunia). Complication Screening : A thorough visual inspection and palpation of the vaginal epithelium overlying the mesh was performed at each visit to screen for any signs of mesh exposure, erosion, or granulation tissue. Patients were also specifically asked about any persistent or new-onset pelvic pain or other adverse events. The data collected at the 12-month visit served as the primary endpoint for the final outcome analysis of this study. Statistical Analysis All statistical analyses were conducted using Python (v3.11) with the aid of the following packages: `pandas` for data manipulation, `scipy.stats` for inferential statistics, `seaborn` and `matplotlib` for data visualization. Continuous variables were evaluated using descriptive statistics (mean ± standard deviation [SD], median, interquartile range [IQR]) depending on the distribution, which was assessed visually and supported by normality tests when appropriate. Categorical variables were reported as frequencies and percentages. Paired pre- and postoperative values for POP-Q measurements (Aa, Ba, C, Ap, Bp) were compared using the Wilcoxon signed-rank test due to the non-normal distribution of differences. The primary endpoint was objective anatomical success, defined as a postoperative C-point value of ≤ − 1 cm. Postoperative pain was assessed at three time points (6 hours, 24 hours, and discharge) using a visual analog scale (VAS). These scores were summarized over time and their distributions visualized. Secondary endpoints included recurrence rates and postoperative complication frequencies, including early complications (graded per Clavien-Dindo classification), urinary retention, mesh erosion, dyspareunia, and voiding difficulty. A two-tailed p-value < 0.05 was considered statistically significant across all tests. Results Baseline Patient Characteristics A total of 30 patients who underwent concomitant hysterectomy and vNOTES sacrocolpopexy were included. The mean age of the cohort was 57.1 ± 10.8 years, and the mean parity was 5.2 ± 1.9. All patients presented with stage 2 pelvic organ prolapse preoperatively. Eight patients (26.7%) had a history of previous pelvic surgery, with cesarean section being the most common. The mean operative time was 100.2 ± 11.7 minutes, with a mean estimated blood loss of 155.3 ± 74.8 mL. The average length of hospital stay was 1.5 ± 0.7 days. Detailed demographic, clinical, and intraoperative characteristics are summarized in Table 1 . Sacral fixation of the mesh was achieved with titanium tacks in 17 (56.7%) patients and with two permanent sutures in 13 (43.3%) patients in whom tack placement was considered suboptimal.While not formally analyzed as part of this study, it was noted that operative times progressively decreased after the initial 10–12 cases, suggesting a manageable learning curve associated with the vNOTES sacrocolpopexy technique. Table 1 Patient Demographics and Perioperative Characteristics This table summarizes the baseline characteristics of the study cohort (n = 30). Variable Mean ± SD / Median (IQR) n (%) Previous pelvic surgery 8 (26.7) Previous pelvic surgery, type Cesarean Appendectomy Cholecystectomy Laparoscopic Adhesiolysis Ovarian Cystectomy 3( 10 ) 2(6.67) 1 (3.33) 1 (3.33) 1 (3.33) Age 57.1 ± 10.8 / 55.5 (50.0–67.5) Parity 5.2 ± 1.9 / 5.0 (4.0–6.0) BMI 29.7 ± 2.06 / 30.0 (29.1–31.0) Preoperative POP Stage (II) 30 Postoperative POP Stage (0 vs I) 11 vs 19 (36.6 vs 63.4) Operative Time (min) 100.2 ± 11.7 / 100.0 (90.0–110.0) Blood loss 155.3 ± 74.8 / 150 (100–200) Hospital stay 1.5 ± 0.68 / 1.0 (1.0–2.0) Anatomical Outcomes and POP-Q Parameter Changes The procedure resulted in significant improvements in the anatomical positions of all vaginal compartments. All measured POP-Q points, with the exception of Ap, showed a statistically significant improvement at the 1-year follow-up. The most pronounced effect was observed in the apical compartment, with the C-point improving from a mean preoperative value of + 0.2 ± 0.4 cm to − 1.4 ± 1.1 cm postoperatively (mean change: − 1.58 cm; p < 0.001) (Fig. 1 ). Similarly, significant improvements were noted for points Aa (p < 0.001), Ba (p < 0.001), and Bp (p < 0.001). The change in point Ap was not statistically significant (p = 0.101). A detailed comparison of pre- and postoperative POP-Q parameters is provided in Table 2 . Table 2 Comparison of Pre- and Postoperative POP-Q Measurements Parameter N Preoperative (Mean ± SD) Postoperative (Mean ± SD) Mean Change p-value Aa_cm 30 –0.7 ± 0.5 –1.7 ± 0.5 –1.00 < 0.001 Ba_cm 30 0.2 ± 0.4 –0.6 ± 0.8 –0.73 < 0.001 C_cm 30 0.2 ± 0.4 –1.4 ± 1.1 –1.58 < 0.001 Ap_cm 30 –0.7 ± 0.5 –0.6 ± 0.8 0.17 0.101 Bp_cm 30 0.2 ± 0.4 –0.6 ± 0.8 –0.73 < 0.001 Clinical Success and Recurrence Based on the strict objective criterion of a postoperative C-point ≤ − 1 cm, anatomical success was achieved in 22 out of 30 patients (73.3%). However, when considering the overall clinical assessment by the physician, which includes the absence of prolapse symptoms and prolapse beyond the hymen, anatomical success was recorded in 28 out of 30 patients (93.3%). During the follow-up period, only one patient (3.3%) experienced a clinically evident recurrence requiring further management. Postoperative Pain and Complications Postoperative pain levels were low and decreased rapidly. The mean VAS pain score was 2.23 ± 0.86 at 6 hours post-surgery, which significantly reduced to 0.80 ± 0.85 at 24 hours and 0.57 ± 0.57 at discharge (Fig. 2 ). The overall complication rate was low. Early complications (Clavien-Dindo Grade I-II) occurred in three patients (10%), primarily consisting of urinary retention managed with temporary catheterization (n = 1) and minor wound care needs. At the 1-year follow-up, two patients (6.7%) were diagnosed with mesh exposure, which was managed conservatively with local estrogen therapy. Three patients (10%) reported de novo dyspareunia. A comprehensive list of postoperative complications is presented in Table 3 . Table 3 Postoperative Complications at 1-Year Follow-up Complication n/N Percentage Early Complications (Clavien-Dindo) 3/30 10.0% Urinary Retention (Catheterization) 1/30 3.3% Mesh Erosion/Exposure (1 Year) 2/30 6.7% Dyspareunia (1 Year) 3/30 10.0% Chronic Pelvic Pain (1 Year) 1/30 3.3% New-Onset Voiding Difficulty (1 Year) 2/30 6.7% Defecation dysfunction 1/30 3.3% Discussion In this study, we present the short-term outcomes of a novel, fully transvaginal approach combining hysterectomy with vNOTES-assisted sacrocolpopexy. Our findings demonstrate that this technique is not only feasible and safe but also highly effective in restoring apical pelvic support, positioning it as a promising scarless alternative to the current gold-standard laparoscopic and robotic approaches. The procedure was associated with a rapid recovery, minimal postoperative pain, and a short hospital stay, underscoring the benefits of avoiding abdominal incisions. For any surgical repair of apical prolapse, the overriding priority is to achieve a durable anatomical correction that restores the normal support of the vaginal apex. In our cohort, we observed a statistically significant improvement in apical support, with the mean C-point being corrected by nearly 1.6 cm (p < 0.001). Our objective anatomical success rate, based on the strict criterion of a postoperative C-point ≤ -1 cm, was 73.3%. While this is highly encouraging, it is slightly lower than the 80–95% success rates reported in some large series of laparoscopic or robotic sacrocolpopexy ( 4 , 12 ). However, it is crucial to interpret this alongside our clinical success rate of 93.3% and a low recurrence rate of 3.3%. This discrepancy between strict anatomical measurements and overall clinical success is a known phenomenon in pelvic floor surgery. It suggests that a single anatomical point may not fully capture the patient's symptomatic improvement and overall satisfaction. Future studies should incorporate validated Patient-Reported Outcome Measures (PROMs), such as the Pelvic Floor Distress Inventory (PFDI-20), to provide a more holistic view of success from the patient's perspective ( 15 ). An interesting and important finding of our study was the lack of statistically significant improvement in the anterior vaginal wall (Ap point), despite excellent apical and posterior correction. This should not be interpreted as a failure of the technique but rather as a critical insight into its specific mechanics. Sacrocolpopexy, by design, provides a strong posterosuperior vector of support. Our results therefore suggest that this procedure alone may not be sufficient to correct a pre-existing, significant cystocele, and for such patients, a concomitant anterior repair may still be necessary to achieve global pelvic reconstruction ( 16 , 17 ). Conversely, this targeted vector of support could be interpreted as a potential advantage. By avoiding aggressive anterior traction, the vNOTES sacrocolpopexy may reduce the risk of postoperative anterior compartment over-correction, a phenomenon that has been linked to de novo voiding dysfunction. This highlights the technique's elegant specificity: it robustly elevates the apex without unduly distorting the anterior anatomy, potentially preserving normal bladder function. The most compelling advantage of the vNOTES approach is its truly minimally invasive and scarless nature. The mean operative time of 100 minutes and minimal blood loss are comparable to, if not better than, many laparoscopic series. The rapid decline in postoperative pain scores and the short hospital stay (1.5 days) are significant benefits that directly impact the patient's experience and reduce healthcare costs. By providing access to the sacral promontory through a vaginal port, vNOTES successfully merges the anatomical correctness of the abdominal "gold standard" with the patient-centric benefits of transvaginal surgery, a combination previously thought to be unattainable. A key innovation of the technique described herein is its hybrid nature, which combines the precise visualization of endoscopy with the safety of a primarily extraperitoneal approach for mesh placement. Unlike conventional laparoscopic or robotic sacrocolpopexy that requires extensive peritoneal dissection and subsequent closure, our method creates a retroperitoneal tunnel to pass the mesh. This "peritoneum-sparing" approach is a significant advantage, as it completely obviates the need for peritonealization, thereby reducing operative time and theoretically lowering the risk of postoperative bowel adhesions or mesh-related visceral complications ( 18 ). This technique shares principles with other extraperitoneal pelvic reconstructions, which have been shown to minimize visceral risks ( 19 ). Furthermore, the adaptability of the sacral fixation method—using sutures in 43.3% of cases where tacking was insecure—highlights the procedure's versatility and the surgeon's ability to ensure robust apical anchoring in varying anatomical situations. This hybrid vNOTES approach thus represents a thoughtful evolution, aiming to merge the durability of sacral fixation with an enhanced safety profile. The safety profile of the procedure was favorable, with no major intraoperative complications. However, the 6.7% (n = 2) rate of mesh exposure at one year warrants careful consideration. While this rate is within the wide range of 2–11% reported for abdominal sacrocolpopexy ( 20 ), simply stating this is insufficient. Importantly, both cases in our cohort were small (< 1 cm), asymptomatic exposures found on routine examination. They were managed successfully with a conservative first-line approach consisting of local estrogen therapy, which led to complete re-epithelialization within 8 weeks without the need for any surgical intervention. This outcome aligns with current management guidelines suggesting that non-symptomatic, low-grade mesh exposures can often be resolved without surgical excision ( 21 ). The 10.0% (n = 3) rate of de novo dyspareunia also requires careful analysis. This complication is multifactorial and may be attributed to several mechanisms, including alterations in the vaginal axis, excessive tension on the vaginal cuff leading to tissue rigidity, or mesh-induced fibrotic changes in the vaginal wall ( 22 ). This highlights the critical importance of meticulous surgical technique, particularly ensuring a tension-free mesh placement, and underscores the need for comprehensive preoperative counseling regarding potential impacts on sexual function. It is particularly noteworthy that these favorable outcomes were achieved in a cohort with a mean BMI of 30.9 kg/m², which is classified as obese. The vNOTES approach may be especially advantageous in this patient population, as it avoids the large abdominal incision often required for laparoscopy in obese patients, thereby potentially reducing the risk of wound-related complications such as infections or hernias. Based on our initial experience, the ideal candidates for this procedure appear to be patients with a non-bulky uterus (e.g., < 12 weeks' size) and adequate vaginal access. Conversely, patients with severe adhesive disease from multiple prior abdominal surgeries or those with a very narrow vaginal canal might be better suited for a conventional laparoscopic approach. Careful patient selection is paramount to successful outcomes in vNOTES surgery. This study has several important limitations that must be acknowledged. Its retrospective design and small sample size (n = 30) inherently limit the generalizability of our findings and introduce potential for selection bias. The single-center, single-surgeon experience, while ensuring consistency, means the results may not be immediately replicable by others without navigating a significant learning curve. The primary surgeon noted a significant increase in procedural efficiency and confidence after approximately 10–12 cases, particularly in the dissection of the presacral space and intracorporeal suturing. This suggests that while vNOTES sacrocolpopexy requires a unique skill set, proficiency can be achieved in a structured setting with dedicated practice ( 23 ). Furthermore, the one-year follow-up period is adequate for assessing short-term safety and efficacy but is insufficient to draw definitive conclusions about long-term recurrence rates and the manifestation of delayed mesh-related complications. In conclusion, our study provides strong proof-of-concept evidence for the feasibility, safety, and short-term efficacy of vNOTES-assisted sacrocolpopexy performed concurrently with hysterectomy. This scarless technique effectively addresses apical prolapse while offering superior cosmetic and recovery outcomes. Our findings provide compelling early evidence to support its consideration as a primary surgical option for appropriately selected patients. This technique has the potential to redefine the standards of minimally invasive pelvic reconstructive surgery by prioritizing both anatomical restoration and patient-centered outcomes. While prospective, comparative trials are needed to validate these results in the long term, this approach represents a significant step forward in the surgical management of pelvic organ prolapse. Declarations Author Contributions Ali Deniz Erkmen conceptualized and designed the study, performed the surgical procedures, analyzed the data, wrote the original manuscript draft, and managed the project. Kevser Arkan contributed to the study's conceptualization, performed surgical procedures, and critically reviewed the manuscript. Mesut Ali Haliscelik was involved in performing the surgical procedures and reviewing the manuscript. Gul Cavusoglu Colak, Kubra Cakar Yılmaz and Seyhmus Tunc were responsible for data collection and curation. Behzat Can and Sedat Akgol provided senior supervision for the project, validated the findings, and critically reviewed the manuscript for intellectual content. All authors have read and approved the final version of the manuscript for submission. Disclosures Funding : The authors declare that they received no financial support for the research, authorship, and/or publication of this article. This research was conducted using the institutional resources of the participating hospitals. Conflict of Interest: All authors declare that they have no financial or personal relationships that could constitute a potential conflict of interest with respect to the research, authorship, or publication of this article. Ethics Approval: This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Institutional Ethics Committee of Diyarbakır Gazi Yaşargil Training and Research Hospital (Approval No: 374; Date: February 28, 2025). Informed Consent:Written informed consent was obtained from all individual participants included in the study for the surgical procedure and for the use of their anonymized data in this research. Data Availability Statement: The datasets generated and/or analyzed during the current study are not publicly available due to patient privacy and confidentiality concerns but are available from the corresponding author on reasonable request. Acknowledgments The authors wish to express their gratitude to MD. Halil TANBOGA for their valuable assistance with the statistical analysis of this study. The authors are also sincerely grateful to all the patients who consented to participate and to the clinical staff at Diyarbakır Gazi Yaşargil Training and Research Hospital for their invaluable support. References Barber MD, Maher C. Epidemiology and outcome assessment of pelvic organ prolapse. Int Urogynecol J. 2013;24(11):1783–90. Marchionni M, Bracco GL, Checcucci V, Carabaneanu A, Coccia EM, Mecacci F, Scarselli G. True incidence of vaginal vault prolapse. Thirteen years of experience. J Reprod Med. 1999;44(8):679–84. PMID: 10483537. 103, Madsen AM, Sung VW, Raker C. 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Hysterectomy by transvaginal natural orifice transluminal endoscopic surgery versus laparoscopy as a day-care procedure: a randomised controlled trial. BJOG. 2019;126(1):105–113. 10.1111/1471-0528.15504 . PMID: 30325565. Kim JC, Yim GW, Kim YT. Clinical relevance of vaginal natural orifice transluminal endoscopic surgery (vNOTES) in gynecology. Obstet Gynecol Sci. 2024;67(2):199–211. https://doi.org/10.5468/ogs.23205 . von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP, STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. 2007;370(9596):1453–7. Bump RC, Mattiasson A, Bø K, Brubaker LP, DeLancey JO, Klarskov P, Shull BL, Smith AR. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol. 1996;175(1):10 – 7. 10.1016/s0002-9378(96)70243-0 . PMID: 8694033. ACOG Practice Bulletin No. 195: Prevention of Infection After Gynecologic Procedures. Obstet Gynecol. 2018;131(6):e172-e189. 10.1097/AOG.0000000000002670 . PMID: 29794678. Amid PK. Classification of biomaterials and their related complications in abdominal wall hernia surgery. Hernia. 1997;1:15–21. https://doi.org/10.1007/BF02426382 . Bump RC, Mattiasson A, Bø K, Brubaker LP, DeLancey JO, Klarskov P, Shull BL, Smith AR. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol. 1996;175(1):10 – 7. 10.1016/s0002-9378(96)70243-0 . PMID: 8694033. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240(2):205–13. Barber MD, Walters MD, Cundiff GW. Pelvic Floor Disorders Network. Responsiveness of the Pelvic Floor Distress Inventory (PFDI) and Pelvic Floor Impact Questionnaire (PFIQ) in women undergoing vaginal surgery. Am J Obstet Gynecol. 2007;197(6):e6851–7. Nager CW, Grimes CL, Nolen TL, Wai CY, Brubaker L, Jeppson PC, Wilson TS, Visco AG, Barber MD, Sutkin G, Norton P, Rardin CR, Arya L, Wallace D, Meikle SF. Pelvic Floor Disorders Network. Concomitant Anterior Repair, Preoperative Prolapse Severity, and Anatomic Prolapse Outcomes After Vaginal Apical Procedures. Female Pelvic Med Reconstr Surg. 2019 Jan/Feb;25(1):22–8. 10.1097/SPV.0000000000000526 . PMID: 29232267; PMCID: PMC5995601. Palma PCR, Monteiro MVC, Ledesma MA, Altuna S, Sardi JJL, Riccetto CLZ. Treatment of Anterior Vaginal Wall Prolapse Using Transvaginal Anterior Mesh With Apical Fixation: A Prospective Multicenter Study With up to 2 Years of Follow-up. Int Neurourol J. 2018;22(3):177–84. Epub 2018 Sep 28. PMID: 30286580; PMCID: PMC6177730. Deng T, Wang S, Liang X, Chen L, Wen Y, Zhang X, Xu L. Medium- to long-term outcomes of vaginally assisted laparoscopic sacrocolpopexy in the treatment of stage III-IV pelvic organ prolapse. BMC Womens Health. 2022;22(1):503. 10.1186/s12905-022-02105-1 . PMID: 36476590; PMCID: PMC9727883. Artsen AM, Stork A, Zyczynski HM. (2020). 13: The art of peritoneal closure during sacrocolpopexy. Am J Obstet Gynecol, 222 . Matthews CA, Myers EM, Henley BR, Kenton K, Weaver E, Wu JM, Geller EJ. Long-term mesh exposure after minimally invasive total hysterectomy and sacrocolpopexy. Int Urogynecol J. 2023;34(1):291–6. 10.1007/s00192-022-05388-y . Epub 2022 Nov 2. PMID: 36322173; PMCID: PMC9628638. Illiano E, Giannitsas K, Li Marzi V, Natale F, Manicini V, Costantini E. No Treatment Required for Asymptomatic Vaginal Mesh Exposure. Urol Int. 2019;103:223–7. Pennycuff J, Iglesia CB. (2019). Editorial Comment Regarding Changes in Female Sexual Function After Vaginal Mesh Repair Versus Native Tissue Repair for Pelvic Organ Prolapse: A Meta-Analysis of Randomized Controlled Trials. The journal of sexual medicine, 16 6 , 942. Liu W, Sun N, Zhang Y, Li Y, Lai W, Zhou Y, Guan X, Liu J. Analyzing the learning curve of vnotes sacrocolpopexy by the cumulative summation test: a cohort study. Int J Surg. 2025 Jun 27. 10.1097/JS9.0000000000002808 . Epub ahead of print. PMID: 40576114. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7180719","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":508122023,"identity":"9cbfb9e9-a83e-4083-9ff9-68029be6d494","order_by":0,"name":"Ali Deniz ERKMEN","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1klEQVRIiWNgGAWjYFACNhDBzMDA3gCkDSxI0cJzAKRFghQtEgkgBhFa+KWPpW74uMM6T37m86sbfhRIMPC3dyfg1SLZl3bs5swz6cWMs3PKbvYAHSZx5uwGvFoMzrC33eZtO5zYLJ2TdoMHqMVAIhe/FnuQlr9ALW2SZ9Ju/iFGiwEP27HbjEAtPRLsx24TZYvEGba0m71t6YkzeHLYbssYSPAQ9At/D5vZjZ9t1onz248/u/nmj40cf3svfi1IgMcATBKrHATYH5CiehSMglEwCkYQAABudUc+6nbewgAAAABJRU5ErkJggg==","orcid":"","institution":"Diyarbakir Gazi Yasargil Research and Training Hospital","correspondingAuthor":true,"prefix":"","firstName":"Ali","middleName":"Deniz","lastName":"ERKMEN","suffix":""},{"id":508122024,"identity":"d7b34efc-7e69-498e-9237-5fca4956f79b","order_by":1,"name":"Kevser ARKAN","email":"","orcid":"","institution":"Diyarbakir Gazi Yasargil Research and Training Hospital","correspondingAuthor":false,"prefix":"","firstName":"Kevser","middleName":"","lastName":"ARKAN","suffix":""},{"id":508122025,"identity":"12542456-f9d1-4fbd-a62f-f5ac23fe9258","order_by":2,"name":"Mesut Ali HALISCELIK","email":"","orcid":"","institution":"Diyarbakir Gazi Yasargil Research and Training Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mesut","middleName":"Ali","lastName":"HALISCELIK","suffix":""},{"id":508122026,"identity":"ced1e7a0-9598-46cf-922d-51e987233b90","order_by":3,"name":"Kubra CAKAR YILMAZ","email":"","orcid":"","institution":"Diyarbakir Gazi Yasargil Research and Training Hospital","correspondingAuthor":false,"prefix":"","firstName":"Kubra","middleName":"CAKAR","lastName":"YILMAZ","suffix":""},{"id":508122027,"identity":"23b384f1-3dde-4d5e-bf15-6ce9e35b6517","order_by":4,"name":"Serhat EGE","email":"","orcid":"","institution":"Diyarbakir Gazi Yasargil Research and Training Hospital","correspondingAuthor":false,"prefix":"","firstName":"Serhat","middleName":"","lastName":"EGE","suffix":""},{"id":508122028,"identity":"534982fd-bc2e-49fd-98fd-63050db5903e","order_by":5,"name":"Gul CAVUSOGLU COLAK","email":"","orcid":"","institution":"Diyarbakir Gazi Yasargil Research and Training Hospital","correspondingAuthor":false,"prefix":"","firstName":"Gul","middleName":"CAVUSOGLU","lastName":"COLAK","suffix":""},{"id":508122029,"identity":"e5d1a294-2181-4903-8b85-8fd3779d2540","order_by":6,"name":"Seyhmus TUNC","email":"","orcid":"","institution":"Diyarbakir Gazi Yasargil Research and Training Hospital","correspondingAuthor":false,"prefix":"","firstName":"Seyhmus","middleName":"","lastName":"TUNC","suffix":""},{"id":508122030,"identity":"97e2706e-ff77-43af-b13a-f46e3487ea76","order_by":7,"name":"Behzat CAN","email":"","orcid":"","institution":"Diyarbakir Gazi Yasargil Research and Training Hospital","correspondingAuthor":false,"prefix":"","firstName":"Behzat","middleName":"","lastName":"CAN","suffix":""},{"id":508122031,"identity":"890caf44-4340-4dee-9dcc-6cd453e6c798","order_by":8,"name":"Sedat AKGOL","email":"","orcid":"","institution":"Diyarbakir Gazi Yasargil Research and Training Hospital","correspondingAuthor":false,"prefix":"","firstName":"Sedat","middleName":"","lastName":"AKGOL","suffix":""}],"badges":[],"createdAt":"2025-07-21 20:38:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7180719/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7180719/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":90470461,"identity":"df925522-a280-4f7d-b7fd-f2b9f4456cfa","added_by":"auto","created_at":"2025-09-03 06:14:47","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":272987,"visible":true,"origin":"","legend":"POP-Q pre- vs post-operative comparison using A: boxplots for Aa, Ba, C, Ap, Bp points. B: Trajectories of POP-Q parameters (Aa, Ba, C, Ap, Bp) for individual patients. Red lines indicate the mean trend","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7180719/v1/80ba6ad0fb8ad70fab02c13f.jpeg"},{"id":90470477,"identity":"1ecafe02-86cf-4e2a-b4a4-f9fdc236f355","added_by":"auto","created_at":"2025-09-03 06:14:47","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":128357,"visible":true,"origin":"","legend":"Postoperative pain assessment. (A) Line plot of mean VAS pain scores over time. (B) Boxplots showing distribution of pain scores at each time point.","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7180719/v1/5dbc0e117c9b2d7452e99fd7.jpeg"},{"id":91950040,"identity":"2c779c7c-53ea-4fcc-82e1-060c54f33701","added_by":"auto","created_at":"2025-09-23 06:23:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1113174,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7180719/v1/ad4a2cec-6a05-4339-ac0a-5d9b7a49edcc.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eFeasibility, safety, and short term outcomes of v-notes assisted sacrocolpopexy for vaginal cuff support following hysterectomy for uterine prolapse\u003c/p\u003e","fulltext":[{"header":"Key Points","content":"\u003cp\u003e1. What is already known?\u003c/p\u003e\u003cp\u003eDurable apical support is essential following hysterectomy for uterine prolapse, with laparoscopic sacrocolpopexy considered the gold-standard repair, though it requires abdominal incisions.\u003c/p\u003e\u003cp\u003e2. What are the new findings?\u003c/p\u003e\u003cp\u003eThis study demonstrates that performing sacrocolpopexy via a vNOTES approach at the time of hysterectomy is a feasible, safe, and effective technique, resulting in significant anatomical correction (mean C-point improvement of -1.6 cm) and a high clinical success rate (93.3%) with low short-term morbidity.\u003c/p\u003e\u003cp\u003e3. What are the implications for clinical practice?\u003c/p\u003e\u003cp\u003evNOTES sacrocolpopexy emerges as a scarless alternative to conventional laparoscopy, offering the benefits of a gold-standard apical suspension through a completely transvaginal route, which may enhance postoperative recovery and patient satisfaction.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003ePelvic organ prolapse (POP) is a prevalent condition that significantly impairs the quality of life for millions of women worldwide, representing a major public health concern (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Uterine prolapse, characterized by the descent of the uterus due to the failure of apical pelvic support, is one of the most common indications for gynecologic surgery. While vaginal hysterectomy is a frequently performed procedure for this condition, hysterectomy alone, without a concomitant apical suspension procedure, is associated with a subsequent vaginal vault prolapse risk as high as 11%, often necessitating reoperation (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Therefore, providing adequate and durable support to the vaginal apex at the time of hysterectomy is critical for long-term surgical success(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn the modern surgical armamentarium for apical prolapse, abdominal sacrocolpopexy (ASC) has long been revered as the gold-standard procedure. Whether performed laparoscopically or robotically, its reputation is built on a foundation of robust evidence demonstrating superior anatomical longevity and better functional results when benchmarked against conventional transvaginal approaches. (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). However, these abdominal approaches are not without drawbacks, including the need for abdominal incisions, longer operative times, higher costs, and the inherent risks of visceral or vascular injury during dissection of the presacral space(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe evolution of minimally invasive surgery has recently led to the emergence of vaginal natural orifice transluminal endoscopic surgery (vNOTES). This technique offers a truly scarless platform for gynecologic procedures by providing direct retroperitoneal access through a transvaginal incision (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). The true innovation of vNOTES lies in its ability to fundamentally solve a decades-old surgical dilemma: it grants the surgeon the high-definition, panoramic view of laparoscopy through a direct, transvaginal route. This approach effectively bypasses the notorious limitations of conventional vaginal surgery namely, operating in a deep, narrow field with restricted instrument mobility. While the surgical community has rapidly adopted vNOTES for hysterectomy and adnexal procedures, its application to the technically demanding field of pelvic reconstruction, particularly a complex procedure like sacrocolpopexy, represents the next frontier and remains largely unexplored. (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThis study aims to evaluate the feasibility, safety, and short-term anatomical and functional outcomes of performing vNOTES-assisted sacrocolpopexy for vaginal cuff support concurrently with hysterectomy in a cohort of patients with uterine prolapse. We hypothesized that this innovative, combined approach could provide the durability of a gold-standard apical fixation while completely avoiding abdominal incisions, thereby representing a significant advancement in pelvic reconstructive surgery.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eStudy Design and Patient Population\u003c/p\u003e\u003cp\u003eThis retrospective cohort study was designed and conducted in accordance with the STROBE guidelines (Strengthening the Reporting of observational studies in Epidemiology) (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). After receiving approval from the Institutional Ethics Committee of Diyarbakır Gazi Yaşargil Training and Research Hospital (No: 374; Date: February 28, 2025), we retrospectively reviewed the medical records of 30 consecutive patients treated with concomitant vaginal hysterectomy and vNOTES-assisted sacrocolpopexy for symptomatic stage\u0026thinsp;\u0026ge;\u0026thinsp;2 uterine prolapse between January 2023 and January 2024.All procedures were performed in line with the principles of the Declaration of Helsinki. Written informed consent for the surgery and the use of anonymized data for research was obtained from all participants.\u003c/p\u003e\u003cp\u003eThe study included adult women with symptomatic stage 2 uterine prolapse, as defined by the Pelvic Organ Prolapse Quantification (POP-Q) system. (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Exclusion criteria included prior surgery for apical pelvic organ prolapse, suspicion of malignancy, active pelvic inflammatory disease, severe endometriosis obliterating the cul-de-sac, or inability to provide informed consent. All patients received comprehensive preoperative counseling regarding the surgical procedure, including a discussion of the potential risks and benefits associated with the use of permanent synthetic mesh for apical support.\u003c/p\u003e\u003cp\u003eSurgical Procedure\u003c/p\u003e\u003cp\u003eAll procedures were performed by a single senior surgeon experienced in both vNOTES and pelvic reconstructive surgery. Patients received preoperative antibiotic prophylaxis in accordance with institutional guidelines (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eUnder general anesthesia and in the dorsal lithotomy position, a hysterectomy was performed via either a conventional vaginal approach or a total vNOTES hysterectomy, based on surgeon preference and patient anatomy. Crucially, following the removal of the uterus, the vaginal cuff was intentionally left open. A 9 cm vNOTES access port (GelPOINT\u0026reg; V-Path, Applied Medical, Rancho Santa Margarita, CA, USA) was then placed within the open vaginal apex, providing an airtight seal for peritoneal insufflation.\u003c/p\u003e\u003cp\u003eThe procedure then followed a hybrid, dual-approach technique:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cem\u003eEndoscopic Promontory Exposure\u003c/em\u003e: The vNOTES endoscope was introduced into the peritoneal cavity through the port. Standard endoscopic instruments were used to visualize the sacral promontory and dissect the overlying peritoneum to clearly expose the anterior longitudinal ligament. This step provided a clear, endoscopically confirmed target for sacral fixation.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cem\u003eRetroperitoneal Tunneling and Mesh Passage\u003c/em\u003e: Simultaneously, from the vaginal side of the open cuff, a long dissecting instrument was introduced into the retroperitoneal space. This instrument was advanced extraperitoneally under the peritoneum in a tunneling fashion, guided by the endoscopic view from within the abdomen and careful anatomical knowledge to avoid the ureter and major vessels. The instrument was advanced until its tip emerged through the anterior longitudinal ligament at the previously exposed promontory. The proximal end of a Y-shaped, macroporous, lightweight polypropylene mesh was then grasped by the dissector (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). By withdrawing the instrument, the mesh was retrogradely pulled through the retroperitoneal tunnel, with one end emerging from the open vaginal cuff while the other remained at the promontory.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cem\u003eMesh Fixation and Cuff Closure\u003c/em\u003e: The proximal end of the mesh was anchored to the anterior longitudinal ligament over the S1 vertebral body. This fixation was achieved with 2\u0026ndash;3 permanent titanium tacks (e.g., ProTack\u0026trade;) in 17 patients (56.7%). In 13 patients (43.3%) where tack fixation was deemed to have suboptimal purchase on the ligament, two non-absorbable 2\u0026thinsp;\u0026minus;\u0026thinsp;0 polypropylene sutures were used for a more secure fixation. The two arms of the mesh were then securely affixed to the anterior and posterior fibromuscular layers of the vaginal cuff using multiple, interrupted 2\u0026thinsp;\u0026minus;\u0026thinsp;0 non-absorbable polypropylene sutures, ensuring full-thickness bites were taken to prevent suture pull-through. The central portion of the vaginal cuff was closed. Finally, the lateral sutures for the cuff were placed, incorporating the mesh sutures. Critically, care was taken to ensure the mesh was laid with appropriate laxity before these final sutures were tied, avoiding any undue tension on the vaginal cuff. This step is crucial to prevent postoperative complications such as vaginal shortening, pain, or de novo dyspareunia. The sutures were then tied down to elevate the vaginal apex. As the mesh was placed in a retroperitoneal tunnel, extensive peritoneal opening was avoided, and therefore, no peritoneal closure (peritonealization) was required.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003ePostoperatively, patients were mobilized on the first day, and the urinary catheter was typically removed within 24 hours after surgery, following a successful voiding trial.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eOutcome Measures and Data Collection\u003c/p\u003e\u003cp\u003ePre- and postoperative anatomical assessments were performed using the POP-Q system (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The primary anatomical outcome was objective success at the 1-year follow-up, defined as a postoperative C-point at or below \u0026minus;\u0026thinsp;1 cm (C \u0026le; -1 cm). Secondary outcomes included operative time, estimated blood loss (EBL), length of hospital stay, and postoperative pain, assessed on a 10-point visual analog scale (VAS) at 6, 24, and 48 hours. Intra- and postoperative complications were recorded and graded according to the Clavien-Dindo classification system (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Long-term adverse events, including mesh exposure/erosion, de novo dyspareunia, and voiding dysfunction, were also documented.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePostoperative Follow-up and Assessment\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAll patients were followed for a minimum of 12 months postoperatively. Scheduled follow-up visits were conducted at 6 weeks, 6 months, and 12 months after the surgical procedure. At each visit, a comprehensive evaluation was performed by a gynecologic oncologist, which included three key components:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eObjective Anatomical Assessment\u003c/b\u003e: A standardized pelvic examination was conducted, including a speculum and bimanual exam, to perform POP-Q measurements. This was used to objectively assess the anatomical position of the vaginal apex (C-point) and other compartments (Aa, Ba, Ap, Bp).\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eSubjective Symptom Assessment\u003c/b\u003e: Patients were systematically queried regarding the resolution of their initial prolapse symptoms (such as the sensation of a vaginal bulge or pelvic pressure). Additionally, they were asked about the emergence of any new or worsening functional issues, including urinary symptoms (stress incontinence, urgency, voiding difficulty), bowel symptoms (constipation, incomplete emptying), or sexual symptoms (dyspareunia).\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eComplication Screening\u003c/b\u003e: A thorough visual inspection and palpation of the vaginal epithelium overlying the mesh was performed at each visit to screen for any signs of mesh exposure, erosion, or granulation tissue. Patients were also specifically asked about any persistent or new-onset pelvic pain or other adverse events.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eThe data collected at the 12-month visit served as the primary endpoint for the final outcome analysis of this study.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eAll statistical analyses were conducted using Python (v3.11) with the aid of the following packages: `pandas` for data manipulation, `scipy.stats` for inferential statistics, `seaborn` and `matplotlib` for data visualization. Continuous variables were evaluated using descriptive statistics (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation [SD], median, interquartile range [IQR]) depending on the distribution, which was assessed visually and supported by normality tests when appropriate. Categorical variables were reported as frequencies and percentages.\u003c/p\u003e\u003cp\u003ePaired pre- and postoperative values for POP-Q measurements (Aa, Ba, C, Ap, Bp) were compared using the Wilcoxon signed-rank test due to the non-normal distribution of differences. The primary endpoint was objective anatomical success, defined as a postoperative C-point value of \u0026le; \u0026minus;\u0026thinsp;1 cm. Postoperative pain was assessed at three time points (6 hours, 24 hours, and discharge) using a visual analog scale (VAS). These scores were summarized over time and their distributions visualized. Secondary endpoints included recurrence rates and postoperative complication frequencies, including early complications (graded per Clavien-Dindo classification), urinary retention, mesh erosion, dyspareunia, and voiding difficulty. A two-tailed p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant across all tests.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eBaseline Patient Characteristics\u003c/p\u003e\u003cp\u003eA total of 30 patients who underwent concomitant hysterectomy and vNOTES sacrocolpopexy were included. The mean age of the cohort was 57.1\u0026thinsp;\u0026plusmn;\u0026thinsp;10.8 years, and the mean parity was 5.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9. All patients presented with stage 2 pelvic organ prolapse preoperatively. Eight patients (26.7%) had a history of previous pelvic surgery, with cesarean section being the most common. The mean operative time was 100.2\u0026thinsp;\u0026plusmn;\u0026thinsp;11.7 minutes, with a mean estimated blood loss of 155.3\u0026thinsp;\u0026plusmn;\u0026thinsp;74.8 mL. The average length of hospital stay was 1.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7 days. Detailed demographic, clinical, and intraoperative characteristics are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Sacral fixation of the mesh was achieved with titanium tacks in 17 (56.7%) patients and with two permanent sutures in 13 (43.3%) patients in whom tack placement was considered suboptimal.While not formally analyzed as part of this study, it was noted that operative times progressively decreased after the initial 10\u0026ndash;12 cases, suggesting a manageable learning curve associated with the vNOTES sacrocolpopexy technique.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePatient Demographics and Perioperative Characteristics This table summarizes the baseline characteristics of the study cohort (n\u0026thinsp;=\u0026thinsp;30).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD / Median (IQR)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrevious pelvic surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (26.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrevious pelvic surgery, type\u003c/p\u003e\u003cp\u003eCesarean\u003c/p\u003e\u003cp\u003eAppendectomy\u003c/p\u003e\u003cp\u003eCholecystectomy\u003c/p\u003e\u003cp\u003eLaparoscopic Adhesiolysis\u003c/p\u003e\u003cp\u003eOvarian Cystectomy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e2(6.67)\u003c/p\u003e\u003cp\u003e1 (3.33)\u003c/p\u003e\u003cp\u003e1 (3.33)\u003c/p\u003e\u003cp\u003e1 (3.33)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e57.1\u0026thinsp;\u0026plusmn;\u0026thinsp;10.8 / 55.5 (50.0\u0026ndash;67.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e5.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9 / 5.0 (4.0\u0026ndash;6.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBMI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e29.7\u0026thinsp;\u0026plusmn;\u0026thinsp;2.06 / 30.0 (29.1\u0026ndash;31.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePreoperative POP Stage (II)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePostoperative POP Stage (0 vs I)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11 vs 19 (36.6 vs 63.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOperative Time (min)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e100.2\u0026thinsp;\u0026plusmn;\u0026thinsp;11.7 / 100.0 (90.0\u0026ndash;110.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlood loss\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e155.3\u0026thinsp;\u0026plusmn;\u0026thinsp;74.8 / 150 (100\u0026ndash;200)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHospital stay\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e1.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.68 / 1.0 (1.0\u0026ndash;2.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAnatomical Outcomes and POP-Q Parameter Changes\u003c/p\u003e\u003cp\u003eThe procedure resulted in significant improvements in the anatomical positions of all vaginal compartments. All measured POP-Q points, with the exception of Ap, showed a statistically significant improvement at the 1-year follow-up. The most pronounced effect was observed in the apical compartment, with the C-point improving from a mean preoperative value of +\u0026thinsp;0.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4 cm to \u0026minus;\u0026thinsp;1.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1 cm postoperatively (mean change: \u0026minus;\u0026thinsp;1.58 cm; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Similarly, significant improvements were noted for points Aa (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), Ba (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and Bp (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The change in point Ap was not statistically significant (p\u0026thinsp;=\u0026thinsp;0.101). A detailed comparison of pre- and postoperative POP-Q parameters is provided in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of Pre- and Postoperative POP-Q Measurements\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParameter\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePreoperative (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePostoperative (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMean Change\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAa_cm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e\u0026ndash;0.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e\u0026ndash;1.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026ndash;1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBa_cm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e0.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e\u0026ndash;0.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026ndash;0.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC_cm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e0.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e\u0026ndash;1.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026ndash;1.58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAp_cm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e\u0026ndash;0.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e\u0026ndash;0.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.101\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBp_cm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e0.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e\u0026ndash;0.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026ndash;0.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eClinical Success and Recurrence\u003c/p\u003e\u003cp\u003eBased on the strict objective criterion of a postoperative C-point \u0026le; \u0026minus;\u0026thinsp;1 cm, anatomical success was achieved in 22 out of 30 patients (73.3%). However, when considering the overall clinical assessment by the physician, which includes the absence of prolapse symptoms and prolapse beyond the hymen, anatomical success was recorded in 28 out of 30 patients (93.3%). During the follow-up period, only one patient (3.3%) experienced a clinically evident recurrence requiring further management.\u003c/p\u003e\u003cp\u003ePostoperative Pain and Complications\u003c/p\u003e\u003cp\u003ePostoperative pain levels were low and decreased rapidly. The mean VAS pain score was 2.23\u0026thinsp;\u0026plusmn;\u0026thinsp;0.86 at 6 hours post-surgery, which significantly reduced to 0.80\u0026thinsp;\u0026plusmn;\u0026thinsp;0.85 at 24 hours and 0.57\u0026thinsp;\u0026plusmn;\u0026thinsp;0.57 at discharge (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The overall complication rate was low. Early complications (Clavien-Dindo Grade I-II) occurred in three patients (10%), primarily consisting of urinary retention managed with temporary catheterization (n\u0026thinsp;=\u0026thinsp;1) and minor wound care needs. At the 1-year follow-up, two patients (6.7%) were diagnosed with mesh exposure, which was managed conservatively with local estrogen therapy. Three patients (10%) reported de novo dyspareunia. A comprehensive list of postoperative complications is presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePostoperative Complications at 1-Year Follow-up\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComplication\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003en/N\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePercentage\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEarly Complications (Clavien-Dindo)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3/30\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10.0%\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUrinary Retention (Catheterization)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1/30\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.3%\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMesh Erosion/Exposure (1 Year)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e2/30\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e6.7%\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDyspareunia (1 Year)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e3/30\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e10.0%\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eChronic Pelvic Pain (1 Year)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e1/30\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e3.3%\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNew-Onset Voiding Difficulty (1 Year)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e2/30\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e6.7%\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDefecation dysfunction\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e1/30\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e3.3%\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, we present the short-term outcomes of a novel, fully transvaginal approach combining hysterectomy with vNOTES-assisted sacrocolpopexy. Our findings demonstrate that this technique is not only feasible and safe but also highly effective in restoring apical pelvic support, positioning it as a promising scarless alternative to the current gold-standard laparoscopic and robotic approaches. The procedure was associated with a rapid recovery, minimal postoperative pain, and a short hospital stay, underscoring the benefits of avoiding abdominal incisions.\u003c/p\u003e\u003cp\u003eFor any surgical repair of apical prolapse, the overriding priority is to achieve a durable anatomical correction that restores the normal support of the vaginal apex. In our cohort, we observed a statistically significant improvement in apical support, with the mean C-point being corrected by nearly 1.6 cm (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Our objective anatomical success rate, based on the strict criterion of a postoperative C-point \u0026le; -1 cm, was 73.3%. While this is highly encouraging, it is slightly lower than the 80\u0026ndash;95% success rates reported in some large series of laparoscopic or robotic sacrocolpopexy (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). However, it is crucial to interpret this alongside our clinical success rate of 93.3% and a low recurrence rate of 3.3%. This discrepancy between strict anatomical measurements and overall clinical success is a known phenomenon in pelvic floor surgery. It suggests that a single anatomical point may not fully capture the patient's symptomatic improvement and overall satisfaction. Future studies should incorporate validated Patient-Reported Outcome Measures (PROMs), such as the Pelvic Floor Distress Inventory (PFDI-20), to provide a more holistic view of success from the patient's perspective (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAn interesting and important finding of our study was the lack of statistically significant improvement in the anterior vaginal wall (Ap point), despite excellent apical and posterior correction. This should not be interpreted as a failure of the technique but rather as a critical insight into its specific mechanics. Sacrocolpopexy, by design, provides a strong posterosuperior vector of support. Our results therefore suggest that this procedure alone may not be sufficient to correct a pre-existing, significant cystocele, and for such patients, a concomitant anterior repair may still be necessary to achieve global pelvic reconstruction (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Conversely, this targeted vector of support could be interpreted as a potential advantage. By avoiding aggressive anterior traction, the vNOTES sacrocolpopexy may reduce the risk of postoperative anterior compartment over-correction, a phenomenon that has been linked to de novo voiding dysfunction. This highlights the technique's elegant specificity: it robustly elevates the apex without unduly distorting the anterior anatomy, potentially preserving normal bladder function.\u003c/p\u003e\u003cp\u003eThe most compelling advantage of the vNOTES approach is its truly minimally invasive and scarless nature. The mean operative time of 100 minutes and minimal blood loss are comparable to, if not better than, many laparoscopic series. The rapid decline in postoperative pain scores and the short hospital stay (1.5 days) are significant benefits that directly impact the patient's experience and reduce healthcare costs. By providing access to the sacral promontory through a vaginal port, vNOTES successfully merges the anatomical correctness of the abdominal \"gold standard\" with the patient-centric benefits of transvaginal surgery, a combination previously thought to be unattainable.\u003c/p\u003e\u003cp\u003eA key innovation of the technique described herein is its hybrid nature, which combines the precise visualization of endoscopy with the safety of a primarily extraperitoneal approach for mesh placement. Unlike conventional laparoscopic or robotic sacrocolpopexy that requires extensive peritoneal dissection and subsequent closure, our method creates a retroperitoneal tunnel to pass the mesh. This \"peritoneum-sparing\" approach is a significant advantage, as it completely obviates the need for peritonealization, thereby reducing operative time and theoretically lowering the risk of postoperative bowel adhesions or mesh-related visceral complications (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). This technique shares principles with other extraperitoneal pelvic reconstructions, which have been shown to minimize visceral risks (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Furthermore, the adaptability of the sacral fixation method\u0026mdash;using sutures in 43.3% of cases where tacking was insecure\u0026mdash;highlights the procedure's versatility and the surgeon's ability to ensure robust apical anchoring in varying anatomical situations. This hybrid vNOTES approach thus represents a thoughtful evolution, aiming to merge the durability of sacral fixation with an enhanced safety profile.\u003c/p\u003e\u003cp\u003eThe safety profile of the procedure was favorable, with no major intraoperative complications. However, the 6.7% (n\u0026thinsp;=\u0026thinsp;2) rate of mesh exposure at one year warrants careful consideration. While this rate is within the wide range of 2\u0026ndash;11% reported for abdominal sacrocolpopexy (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), simply stating this is insufficient. Importantly, both cases in our cohort were small (\u0026lt;\u0026thinsp;1 cm), asymptomatic exposures found on routine examination. They were managed successfully with a conservative first-line approach consisting of local estrogen therapy, which led to complete re-epithelialization within 8 weeks without the need for any surgical intervention. This outcome aligns with current management guidelines suggesting that non-symptomatic, low-grade mesh exposures can often be resolved without surgical excision (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). The 10.0% (n\u0026thinsp;=\u0026thinsp;3) rate of de novo dyspareunia also requires careful analysis. This complication is multifactorial and may be attributed to several mechanisms, including alterations in the vaginal axis, excessive tension on the vaginal cuff leading to tissue rigidity, or mesh-induced fibrotic changes in the vaginal wall (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). This highlights the critical importance of meticulous surgical technique, particularly ensuring a tension-free mesh placement, and underscores the need for comprehensive preoperative counseling regarding potential impacts on sexual function.\u003c/p\u003e\u003cp\u003eIt is particularly noteworthy that these favorable outcomes were achieved in a cohort with a mean BMI of 30.9 kg/m\u0026sup2;, which is classified as obese. The vNOTES approach may be especially advantageous in this patient population, as it avoids the large abdominal incision often required for laparoscopy in obese patients, thereby potentially reducing the risk of wound-related complications such as infections or hernias.\u003c/p\u003e\u003cp\u003eBased on our initial experience, the ideal candidates for this procedure appear to be patients with a non-bulky uterus (e.g., \u0026lt;\u0026thinsp;12 weeks' size) and adequate vaginal access. Conversely, patients with severe adhesive disease from multiple prior abdominal surgeries or those with a very narrow vaginal canal might be better suited for a conventional laparoscopic approach. Careful patient selection is paramount to successful outcomes in vNOTES surgery.\u003c/p\u003e\u003cp\u003eThis study has several important limitations that must be acknowledged. Its retrospective design and small sample size (n\u0026thinsp;=\u0026thinsp;30) inherently limit the generalizability of our findings and introduce potential for selection bias. The single-center, single-surgeon experience, while ensuring consistency, means the results may not be immediately replicable by others without navigating a significant learning curve. The primary surgeon noted a significant increase in procedural efficiency and confidence after approximately 10\u0026ndash;12 cases, particularly in the dissection of the presacral space and intracorporeal suturing. This suggests that while vNOTES sacrocolpopexy requires a unique skill set, proficiency can be achieved in a structured setting with dedicated practice (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Furthermore, the one-year follow-up period is adequate for assessing short-term safety and efficacy but is insufficient to draw definitive conclusions about long-term recurrence rates and the manifestation of delayed mesh-related complications.\u003c/p\u003e\u003cp\u003eIn conclusion, our study provides strong proof-of-concept evidence for the feasibility, safety, and short-term efficacy of vNOTES-assisted sacrocolpopexy performed concurrently with hysterectomy. This scarless technique effectively addresses apical prolapse while offering superior cosmetic and recovery outcomes. Our findings provide compelling early evidence to support its consideration as a primary surgical option for appropriately selected patients. This technique has the potential to redefine the standards of minimally invasive pelvic reconstructive surgery by prioritizing both anatomical restoration and patient-centered outcomes. While prospective, comparative trials are needed to validate these results in the long term, this approach represents a significant step forward in the surgical management of pelvic organ prolapse.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eAuthor Contributions\u003c/p\u003e\n\u003cp\u003eAli Deniz Erkmen conceptualized and designed the study, performed the surgical procedures, analyzed the data, wrote the original manuscript draft, and managed the project. Kevser Arkan contributed to the study\u0026apos;s conceptualization, performed surgical procedures, and critically reviewed the manuscript. Mesut Ali Haliscelik was involved in performing the surgical procedures and reviewing the manuscript. Gul Cavusoglu Colak, Kubra Cakar Yılmaz and Seyhmus Tunc were responsible for data collection and curation. Behzat Can and Sedat Akgol provided senior supervision for the project, validated the findings, and critically reviewed the manuscript for intellectual content. All authors have read and approved the final version of the manuscript for submission.\u003c/p\u003e\n\u003cp\u003eDisclosures\u003c/p\u003e\n\u003cp\u003eFunding : The authors declare that they received no financial support for the research, authorship, and/or publication of this article. This research was conducted using the institutional resources of the participating hospitals.\u003c/p\u003e\n\u003cp\u003eConflict of Interest:\u0026nbsp;All authors declare that they have no financial or personal relationships that could constitute a potential conflict of interest with respect to the research, authorship, or publication of this article.\u003c/p\u003e\n\u003cp\u003eEthics Approval: This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Institutional Ethics Committee of Diyarbakır Gazi Yaşargil Training and Research Hospital (Approval No: 374; Date: February 28, 2025).\u003c/p\u003e\n\u003cp\u003eInformed Consent:Written informed consent was obtained from all individual participants included in the study for the surgical procedure and for the use of their anonymized data in this research.\u003c/p\u003e\n\u003cp\u003eData Availability Statement: The datasets generated and/or analyzed during the current study are not publicly available due to patient privacy and confidentiality concerns but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eAcknowledgments\u003c/p\u003e\n\u003cp\u003eThe authors wish to express their gratitude to MD. Halil TANBOGA for their valuable assistance with the statistical analysis of this study. The authors are also sincerely grateful to all the patients who consented to participate and to the clinical staff at Diyarbakır Gazi Yaşargil Training and Research Hospital for their invaluable support.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBarber MD, Maher C. Epidemiology and outcome assessment of pelvic organ prolapse. Int Urogynecol J. 2013;24(11):1783\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMarchionni M, Bracco GL, Checcucci V, Carabaneanu A, Coccia EM, Mecacci F, Scarselli G. True incidence of vaginal vault prolapse. Thirteen years of experience. J Reprod Med. 1999;44(8):679\u0026ndash;84. PMID: 10483537.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e103, Madsen AM, Sung VW, Raker C. Trends in Hysteropexy and Apical Support for Uterovaginal Prolapse in the United States from 2002 to 2012. 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PMID: 40576114.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Uterine Prolapse, Sacrocolpopexy, vNOTES, Apical Support, Minimally Invasive Surgery, Vaginal Hysterectomy","lastPublishedDoi":"10.21203/rs.3.rs-7180719/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7180719/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eEffective apical support following hysterectomy is crucial for preventing subsequent vaginal vault prolapse. While abdominal sacrocolpopexy is the gold standard for durable apical repair, it necessitates abdominal incisions. Vaginal natural orifice transluminal endoscopic surgery (vNOTES) presents a promising scarless platform to perform this gold-standard procedure entirely transvaginally.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e\u003cp\u003eTo evaluate the feasibility, safety, and short-term clinical outcomes of concomitant hysterectomy and vNOTES-assisted sacrocolpopexy in patients with uterine prolapse.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis retrospective cohort study included 30 consecutive patients with stage 2 uterine prolapse who underwent the combined procedure at a single tertiary center. Pre- and postoperative anatomical outcomes were assessed using the Pelvic Organ Prolapse Quantification (POP-Q) system at a 1-year follow-up. The primary outcome was objective anatomical success, defined as a postoperative C-point of \u0026le; \u0026minus;\u0026thinsp;1 cm. Secondary outcomes included operative time, estimated blood loss, hospital stay, postoperative pain (Visual Analog Scale), and complication rates, including mesh-related adverse events.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe mean age of the cohort (n\u0026thinsp;=\u0026thinsp;30) was 57.1\u0026thinsp;\u0026plusmn;\u0026thinsp;10.8 years, and the mean operative time was 100.2\u0026thinsp;\u0026plusmn;\u0026thinsp;11.7 minutes. The procedure resulted in a significant restoration of apical support, with the mean POP-Q C-point improving from +\u0026thinsp;0.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4 cm preoperatively to \u0026minus;\u0026thinsp;1.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1 cm postoperatively (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Objective anatomical success was achieved in 73.3% of patients (22/30). The clinical recurrence rate was 3.3% (1/30). Postoperative pain was minimal, with mean VAS scores decreasing to 0.80\u0026thinsp;\u0026plusmn;\u0026thinsp;0.85 at 24 hours. The most common long-term complications were de novo dyspareunia (10.0%) and mesh exposure (6.7%). No major intraoperative complications were observed.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eConcomitant hysterectomy and vNOTES-assisted sacrocolpopexy is a feasible, safe, and effective procedure for the management of uterine prolapse. This novel, scarless technique successfully combines the principles of a gold-standard apical repair with the benefits of a truly minimally invasive approach, offering a promising alternative to conventional laparoscopic and robotic surgery.\u003c/p\u003e","manuscriptTitle":"Feasibility, safety, and short term outcomes of v-notes assisted sacrocolpopexy for vaginal cuff support following hysterectomy for uterine prolapse","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-03 06:14:42","doi":"10.21203/rs.3.rs-7180719/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c1fbf0d0-43a9-4eca-be2f-c78475849c1c","owner":[],"postedDate":"September 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-23T06:23:40+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-03 06:14:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7180719","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7180719","identity":"rs-7180719","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}