Systematic review and meta-analysis of vaginal natural orifice transluminal endoscopic surgery vs laparoscopic hysterectomy

Abstract

Objective: Because vaginal natural orifice transluminal endoscopic surgery and laparoscopic hysterectomy techniques both aim to decrease tissue injury and postoperative morbidity and mortality and to improve a patient's quality of life, we sought to evaluate the safety and effectiveness of a hysterectomy by vaginal natural orifice transluminal endoscopic surgery and compared that with conventional laparoscopic hysterectomy among women with benign gynecologic diseases.

Data sources: We used Scopus, Medline, ClinicalTrials.Gov, PubMed, and the Cochrane Library and searched from database inception to September 1, 2023.

Study eligibility criteria: We included all eligible articles that compared vaginal natural orifice transluminal endoscopic surgery hysterectomy with any conventional laparoscopic hysterectomy technique without robotic assistance for women with benign gynecologic pathology and that included at least 1 of our main outcomes. These outcomes included estimated blood loss (in mL), operation time (in minutes), length of hospital stay (in days), decrease in hemoglobin level (g/dL), visual analog scale pain score on postoperative day 1, opioid analgesic dose required, rate of conversion to another surgical technique, intraoperative complications, postoperative complications, and requirements for blood transfusion. We included randomized controlled trials and observational studies. Ultimately, 14 studies met our criteria.

Methods: The study quality of the randomized controlled trials was assessed using the Cochrane assessment tool, and the quality of the observational studies was assessed using the ROBINS-I tool. We analyzed data using RevMan 5.4.1. Continuous outcomes were analyzed using the mean difference and 95% confidence intervals under the inverse variance analysis method. Dichotomous outcomes were analyzed using OpenMeta[Analyst] and odds ratios and 95% confidence intervals were reported.

Results: The operative time and length of hospitalization were shorter in the vaginal natural orifice transluminal endoscopic surgery cohort. We also found lower visual analog scale pain scores, fewer postoperative complications, and fewer blood transfusions in the vaginal natural orifice transluminal endoscopic surgery group. We found no difference in the estimated blood loss, decrease in hemoglobin levels, analgesic usage, conversion rates, or intraoperative complications.

Conclusion: When evaluating the latest data, it seems that vaginal natural orifice transluminal endoscopic surgery techniques may have some advantages over conventional laparoscopic hysterectomy techniques.

Keywords: hysterectomy; laparoscopy; vNOTES.

Figure 1

PRISMA flow diagram PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Figure 2

Results of the Cochrane tool risk of bias assessment of the RCTs RCTs, randomized controlled trials.

Figure 3

Meta-analysis of the total operation time (in minutes) CI, confidence interval; IV, inverse variance; RCT, randomized controlled trial; SD, standard deviation; vNOTES, vaginal natural orifice transluminal endoscopic surgery.

Figure 4

Meta-analysis of estimated blood loss (in mL) CI, confidence interval; IV, inverse variance; RCT, randomized controlled trial; SD, standard deviation; vNOTES, vaginal natural orifice transluminal endoscopic surgery.

Figure 5

Meta-analysis of length of hospital stay (in days) CI, confidence interval; IV, inverse variance; RCT, randomized controlled trial; SD, standard deviation; vNOTES, vaginal natural orifice transluminal endoscopic surgery.

Figure 6

Meta-analysis of the decrease in hemoglobin levels (g/dL) CI, confidence interval; IV, inverse variance; RCT, randomized controlled trial; SD, standard deviation; vNOTES, vaginal natural orifice transluminal endoscopic surgery.

Figure 7

Meta-analysis of the VAS score on postoperative day 1 CI, confidence interval; IV, inverse variance; RCT, randomized controlled trial; SD, standard deviation; VAS, visual analog scale; vNOTES, vaginal natural orifice transluminal endoscopic surgery.

Figure 8

Meta-analysis of the required postoperative analgesia dose CI, confidence interval; IV, inverse variance; RCT, randomized controlled trial; SD, standard deviation; vNOTES, vaginal natural orifice transluminal endoscopic surgery.

Figure 9

Meta-analysis of the rate of conversion to another surgical technique CI, confidence interval; RCT, randomized controlled trial.

Figure 10

Meta-analysis of the rate of intraoperative complications CI, confidence interval; RCT, randomized controlled trial.

Figure 11

Meta-analysis of the rate of postoperative complications CI, confidence interval; RCT, randomized controlled trial.

Figure 12

Meta-analysis of the rate of required blood transfusions CI, confidence interval; RCT, randomized controlled trial.