Clinical Scorecard: Comparative Analysis of Three Surgical Techniques for Retroperitoneal Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES)

At a Glance

Key Highlights

• Retroperitoneal vNOTES is a safe and feasible approach for various gynecological surgeries.
• Anterior fornix approach primarily used for lateral suspension in POP with low complication rates and no mesh exposure.
• Lateral fornix approach mainly applied for lymphadenectomy; posterior fornix approach used for sacrocolpopexy and sacrospinous ligament fixation.

Guideline-Based Recommendations

Diagnosis

• Patient selection based on indication for POP surgery or pelvic/para-aortic lymph node dissection.
• Preoperative evaluation including demographic and surgical history to assess suitability for retroperitoneal vNOTES.

Management

• Choose vaginal fornix approach based on surgical indication: anterior fornix for lateral suspension, lateral fornix for lymphadenectomy, posterior fornix for sacrocolpopexy and SSLF.
• Perform retroperitoneal vNOTES with careful dissection to maintain peritoneal integrity and minimize bleeding.
• Monitor for complications using Clavien–Dindo classification.

Monitoring & Follow-up

• Postoperative monitoring of pain using Visual Analog Scale at 12 and 24 hours.
• Observe for early postoperative complications during hospitalization.
• Long-term follow-up to assess for mesh exposure and surgical outcomes.

Risks

• Grade I to III complications can occur, varying by approach and procedure type.
• Potential risks include minor complications (Grade I), moderate complications (Grade II), and severe complications requiring intervention (Grade III).
• No mesh exposure reported in anterior fornix approach for lateral suspension.

Patient & Prescribing Data

Women undergoing retroperitoneal vNOTES for POP or lymphadenectomy between 2019 and 2025

All 89 patients completed surgery safely with varying complication rates by approach; anterior fornix approach had 23.08% Grade I complications, lateral fornix had 25.00% Grade I and 6.25% Grade II, posterior fornix had up to 30.77% Grade I and 7.69% Grade III complications depending on procedure.

Clinical Best Practices

• Select vaginal fornix incision tailored to surgical procedure to optimize exposure and minimize complications.
• Utilize retroperitoneal approach to avoid entering peritoneal cavity, reducing risk of adhesions and injury.
• Ensure surgeons have extensive experience in vNOTES techniques for safety and efficacy.
• Employ careful dissection in retroperitoneal space to maintain clear operative field with minimal bleeding.
• Monitor patients closely postoperatively for complications using standardized classification.

References

• Chengdu Women’s and Children’s Central Hospital IRB Approval
• vNOTES technique and clinical applications
• Retroperitoneal surgical advantages and applications