(Poster 104) vNOTES vs Traditional Hysterectomy for POP: Outcomes from a National Database

Objectives: Vaginal natural orifice transluminal endoscopic surgery (vNOTES) has emerged as a hysterectomy approach that combines the benefits of vaginal surgery, such as the absence of abdominal incisions and reduced pain, with the enhanced visualization of laparoscopy. Thus far, outcomes of vNOTES for pelvic organ prolapse (POP) surgery have primarily been reported in small, single-institution studies. To address this gap, our objective was to compare the risk of overall complications across various hysterectomy approaches, including vNOTES, using a national surgical quality database.

Methods: We performed a retrospective cohort study using 2022-2023 data from the National Surgical Quality Improvement Program (NSQIP) database. Hysterectomies performed for POP, as defined by ICD-10 codes, were included; cases involving cancer or endometriosis were excluded. Surgical approach was determined by CPT code and classified as abdominal (AH), laparoscopic (LH), vaginal (VH), and laparoscopic-assisted vaginal hysterectomy (LAVH). In addition, hysterectomies performed using vNOTES were identified based on abstraction of operative report text, as no specific CPT code for vNOTES currently exists. Concomitant procedures–including midurethral sling, sacrocolpopexy, uterosacral ligament suspension (USLS), sacrospinous ligament suspension (SSLS), and vaginal colporrhaphy–were also identified by CPT codes. Multivariable binomial regression modeling was performed to assess the relative risk of composite 30-day adverse events among surgical approaches. Covariates were selected based on biologic plausibility, and the final was built using stepwise reduction, retaining variables with a p-value < 0.1. Adverse events included readmission, reoperation wound infection, thromboembolism, stroke, cardiac arrest, sepsis, and shock.

Results: Among the 7,086 patients meeting study criteria, 51.1% underwent VH, 33.9% LH, 8.6% LAVH, 3.1% AH, and 3.3% vNOTES. Among hysterectomies performed via vNOTES, 75.4% were coded as VH, 8.5% as LH, and 16.1% as LAVH. Demographic characteristics of the cohort are presented in Table 1. The overall adverse event rate was 10.1%. In a final multivariable regression model, which adjusted for age, diabetes, hypertension, uterine weight, and concomitant midurethral sling, the risk of composite adverse events was similar between VH and vNOTES (adjusted relative risk [aRR] 1.03, 95% confidence interval [CI] 0.60-1.76), as well as VH and LAVH (aRR 0.99, 95% CI 0.70-1.40). LH was associated with a lower relative risk (aRR 0.78, 95% CI 0.62-0.97), while AH was associated with a higher relative risk (aRR 1.72, 1.15-2.58).

Conclusions: Compared to vaginal hysterectomy, vNOTES was associated with a similar risk of composite 30-day adverse events, while laparoscopic hysterectomy was associated with lower and abdominal hysterectomy with higher risk. Surgical coding variability for vNOTES underscores the need for standardized classification. Further research is needed to assess outcomes and cost-effectiveness of vNOTES for surgical POP treatment.