Stage-Specific outcomes of robotic transvaginal NOTES hysterectomy in endometriosis: A comparative study

The objective was to assess outcomes of robotic-assisted transvaginal natural orifice transluminal endoscopic surgery (RA-vNOTES) performed for hysterectomy and endometriosis excision. We conducted a retrospective case series across two hospitals belonging to the same academic tertiary institution in Houston, Texas, USA. From August 2019 to April 2025, RA-vNOTES hysterectomy with endometriosis resection was performed in 274 patients with stage I-IV disease, classified according to the revised American Society for Reproductive Medicine (rASRM) system. Of the 274 patients, 131 were classified as stage I, 56 as stage II, 46 as stage III, and 41 as stage IV endometriosis. Hysterectomy time, total operative time, and estimated intraoperative blood loss were associated with stage of endometriosis (all p < 0.05). Median total operative time was 132 min for stage I, 147 min for stage II, 166 min for stage III, and 222 min for stage IV disease. Through a RA-VNOTES approach, we could address an obliterated posterior cul-de-sac and complete all necessary procedures for excision of endometriosis, including lysis of adhesions, retrograde ureterolysis, complete peritonectomy, cystectomy of endometriomas, appendectomy, bowel shaving, and bowel discoid excision. Three cases were converted to abdominal robotic surgery for bowel resection and reanastomosis, ureteral reimplantation, and excision of diaphragmatic endometriosis. All patients had a significant improvement in VAS pain score pre- to post-surgery. Overall complication rates were low. RA-vNOTES offers a safe and practical method for endometriosis excision while providing the patient with the profits of the most minimally invasive approach – with complications being rare. Similar content being viewed by others Data availability The data that support the findings of this study are available on reasonable request to the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

Giudice LC, Kao LC (2004) Endometriosis. Lancet 364(9447):1789–1799. https://doi.org/10.1016/S0140-6736(04)17403-5 Zondervan KT, Becker CM, Missmer SA (2020) Endometriosis. N Engl J Med 382(13):1244–1256. https://doi.org/10.1056/NEJMra1810764 Koninckx PR, Ussia A, Adamyan L, Wattiez A, Gomel V, Martin DC (2019) Pathogenesis of endometriosis: the genetic/epigenetic theory. Fertil Steril 111(2):327–340. https://doi.org/10.1016/j.fertnstert.2018.10.013 Falcone T, Flyckt R (2018) Clinical management of endometriosis. Obstet Gynecol 131(3):557–571. https://doi.org/10.1097/AOG.0000000000002469 Santulli P, Bourdon M, Desportes C (2024) Assessment of the pelvic pain experienced by infertile women is of prime importance for diagnosing endometriosis. J Minim Invasive Gynecol 31(11):943-950e1. https://doi.org/10.1016/j.jmig.2024.07.010 Practice Committee of the American Society for Reproductive Medicine (2006) Treatment of pelvic pain associated with endometriosis. Fertil Steril 86(5 Suppl 1):S18–S27. https://doi.org/10.1016/j.fertnstert.2006.08.072 Brown J, Farquhar C (2014) Endometriosis: an overview of Cochrane reviews. Cochrane Database Syst Rev 2014:CD009590. https://doi.org/10.1002/14651858.CD009590.pub2 Kalra R, McDonnell R, Stewart F, Hart RJ, Hickey M, Farquhar C (2024) Excisional surgery versus ablative surgery for ovarian endometrioma. Cochrane Database Syst Rev 11(11):CD004992. https://doi.org/10.1002/14651858.CD004992.pub4 Lewin J, Vashisht A, Hirsch M, Al-Wattar BH, Saridogan E (2024) Comparing the treatment of endometriosis-related pain by excision of endometriosis or hysterectomy: a multicentre prospective cohort study. BJOG 131(13):1793–1804. https://doi.org/10.1111/1471-0528.17910 Atwal G, du Plessis D, Armstrong G, Slade R, Quinn M (2005) Uterine innervation after hysterectomy for chronic pelvic pain with, and without, endometriosis. Am J Obstet Gynecol 193(5):1650–1655. https://doi.org/10.1016/j.ajog.2005.05.035 Practice (2010) bulletin no. 114: management of endometriosis. Obstet Gynecol 116(1):223–236. https://doi.org/10.1097/AOG.0b013e3181e8b073 Committee Opinion 701 (2017) Choosing the route of hysterectomy for benign disease. Obstet Gynecol 129(6):e155–e159. https://doi.org/10.1097/AOG.0000000000002112 Thigpen B, Connell P, Erfani H, Koythong T, Sunkara S, Guan X (2023) Robotic-assisted vaginal natural orifice transluminal endoscopic surgery versus robotic-assisted single-site port for benign hysterectomy: a comparison of surgical outcomes. J Robot Surg 17(5):2487–2494. https://doi.org/10.1007/s11701-023-01680-1 Chaccour C, Giannini A, Golia D’Augè T et al (2023) Hysterectomy using vaginal natural orifice transluminal endoscopic surgery compared with classic laparoscopic hysterectomy: A new advantageous approach? A systematic review on surgical outcomes. Gynecol Obstet Invest 88(4):187–196. https://doi.org/10.1159/000530797 Lee CL, Wu KY, Su H, Wu PJ, Han CM, Yen CF (2014) Hysterectomy by transvaginal natural orifice transluminal endoscopic surgery (NOTES): a series of 137 patients. J Minim Invasive Gynecol 21(5):818–824. https://doi.org/10.1016/j.jmig.2014.03.011 Lee CL, Wu KY, Su H, Han CM, Huang CY, Yen CF (2015) Robot-assisted natural orifice transluminal endoscopic surgery for hysterectomy. Taiwan J Obstet Gynecol 54(6):761–765. https://doi.org/10.1016/j.tjog.2015.08.023 Kapurubandara S, Lowenstein L, Salvay H, Herijgers A, King J, Baekelandt J (2021) Consensus on safe implementation of vaginal natural orifice transluminal endoscopic surgery (vNOTES). Eur J Obstet Gynecol Reprod Biol 263:216–222. https://doi.org/10.1016/j.ejogrb.2021.06.019 Mangeshikar A, Youssef Y, Sheth H, Mangeshikar P, Moawad G (2024) Transvaginal natural orifice specimen extraction: a 10-step approach for laparoscopic excision of deep endometriosis infiltrating the rectosigmoid. Gynecol Minim Invasive Ther 13(1):62–63. https://doi.org/10.4103/gmit.gmit_52_23 Xu G, Lovell DY, Guan X (2024) Robot-assisted vaginal natural orifice transluminal endoscopic surgery (RvNOTES) with total hysterectomy for management of stage IV endometriosis with/without complete cul-de-sac obliteration: 23-case pilot feasibility study. J Minim Invasive Gynecol 31(6):496–503. https://doi.org/10.1016/j.jmig.2024.03.006 Guan X, Welch JR, Wu G (2022) Robotic transvaginal natural orifice transluminal endoscopic surgery for resection of parametrial and bowel deeply infiltrated endometriosis. J Minim Invasive Gynecol 29(3):341–342. https://doi.org/10.1016/j.jmig.2021.11.020 Lovell DY, Sendukas E, Yang Q, Guan X (2025) Surgical enhancement with the placement of temporary bilateral ureteral stents with indocyanine green injection for all stages of endometriosis in vNOTES: retrospective cross-sectional study. J Minim Invasive Gynecol 32(2):166–170. https://doi.org/10.1016/j.jmig.2024.09.365 Guan X, Guan Z, Sunkara S, Thigpen B (2023) Indocyanine green-assisted retrograde ureterolysis in robotic transvaginal NOTES for the management of stage IV endometriosis with obliterated cul-de-sac. J Minim Invasive Gynecol 30(4):266–267. https://doi.org/10.1016/j.jmig.2023.02.005 Zhang Y, Delgado S, Liu J, Guan Z, Guan X (2021) Robot-assisted transvaginal natural orifice transluminal endoscopic surgery for management of endometriosis: a pilot study of 33 cases. J Minim Invasive Gynecol 28(12):2060–2066. https://doi.org/10.1016/j.jmig.2021.06.004 Santillan-Gomez A (2024) Single-port robotic-assisted transvaginal hysterectomy (vNOTES) in a hostile abdomen. Int J Gynecol Cancer 34(7):1107–1108. https://doi.org/10.1136/ijgc-2023-004650 Guan X, Yang Q, Lovell DY (2024) Assessing feasibility and outcomes of robotic single port transvaginal NOTES(RSP-vNOTES) hysterectomy: a case series. J Minim Invasive Gynecol. https://doi.org/10.1016/j.jmig.2024.08.018 Loubeyre P, Petignat P, Jacob S, Egger JF, Dubuisson JB, Wenger JM (2009) Anatomic distribution of posterior deeply infiltrating endometriosis on MRI after vaginal and rectal gel opacification. AJR Am J Roentgenol 192(6):1625–1631. https://doi.org/10.2214/AJR.08.1856 Guan X, Yang Q, Lovell DY, Zhang C (2025) Application of 4-P port anchoring in transvaginal natural orifice transluminal endoscopic surgery (vNOTES): technique and initial feasibility. J Robot Surg 19(1):473. https://doi.org/10.1007/s11701-025-02653-2 Liu J, Tan L, Thigpen B et al (2022) Evaluation of the learning curve and safety outcomes in robotic assisted vaginal natural orifice transluminal endoscopic hysterectomy: a case series of 84 patients. Int J Med Robot 18(3):e2385. https://doi.org/10.1002/rcs.2385 Huang Y, Duan K, Koythong T et al (2022) Application of robotic single-site surgery with optional additional port for endometriosis: a single institution’s experience. J Robot Surg 16(1):127–135. https://doi.org/10.1007/s11701-021-01217-4 Carrubba AR, Whitmore GT, Radhakrishnan SJ, Sheeder J, Muffly TM (2019) Postoperative infections in women undergoing hysterectomy for benign indications: a cohort study. Minerva Ginecol 71(4):263–271. https://doi.org/10.23736/S0026-4784.19.04365-X Lowenstein L, Mor O, Matanes E et al (2021) Robotic vaginal natural orifice transluminal endoscopic hysterectomy for benign indications. J Minim Invasive Gynecol 28(5):1101–1106. https://doi.org/10.1016/j.jmig.2020.10.021 Radilla LAA, Yang Q, Lovell DY et al (2025) Fluorescence-guided ureteral identification in robotic surgery for advanced endometriosis: a comparison of junior versus senior surgeons. Sci Rep 15(1):19933. https://doi.org/10.1038/s41598-025-05082-1 Kanno K, Yanai S, Masuda S et al (2024) Comparison of surgical outcomes between robot-assisted and conventional laparoscopic nerve-sparing modified radical hysterectomy for deep endometriosis. Arch Gynecol Obstet 310(3):1677–1685. https://doi.org/10.1007/s00404-024-07674-0 Kaveh M, Malakouti H, Chaichian S, Kashi AM, Afshari M, Sadegi K (2025) Evaluation of laparoscopic surgery effects on pain severity and quality of life in different subtypes of endometriosis: a follow-up study. International Journal of Reproductive BioMedicine (IJRM) 23(2):199–206. https://doi.org/10.18502/ijrm.v23i2.18494 Rock JA (1995) The revised American fertility society classification of endometriosis: reproducibility of scoring. ZOLADEX endometriosis study group. Fertil Steril 63(5):1108–1110. https://doi.org/10.1016/s0015-0282(16)57556-6 Vercellini P, Trespidi L, De Giorgi O, Cortesi I, Parazzini F, Crosignani PG (1996) Endometriosis and pelvic pain: relation to disease stage and localization. Fertil Steril 65(2):299–304 Yang Q, Kohn J, Guan X (2025) Robotic single port versus robotic multiple port transvaginal orifice transluminal endoscopic surgery hysterectomy: a comparison of surgical outcomes. J Robot Surg 19(1):410. https://doi.org/10.1007/s11701-025-02593-x Funding This research received no external funding. Author information Authors and Affiliations Contributions Q.Y.: Data curation, Formal analysis, Visualization, Writing – original draft, Writing - review & editing, Validation; J.K.: Writing – original draft, Writing – review & ed-iting; C.Z.: Conceptualization, Supervision, Writing - review & editing, Validation; X.G.: Data curation, Conceptualization, Methodology, Supervision, Project administration, Resources, Writing - review & editing, Validation. All authors have read and agreed to the published version of the manuscript. Corresponding authors Ethics declarations Ethics approval and consent to participate The need for consent to participate was waived due to retrospective nature of the study by an Institutional Review Board (IRB). This study was IRB-approved from Baylor College of Medicine on March 8, 2022, under the approval number H-51429. Competing interests The authors declare no competing interests. Additional information Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Supplementary Information Below is the link to the electronic supplementary material. Rights and permissions Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law. About this article Cite this article Yang, Q., Kohn, J., Zhang, C. et al. Stage-Specific outcomes of robotic transvaginal NOTES hysterectomy in endometriosis: A comparative study. J Robotic Surg 19, 715 (2025). https://doi.org/10.1007/s11701-025-02903-3 Received: Accepted: Published: Version of record: DOI: https://doi.org/10.1007/s11701-025-02903-3