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Review
. 2025 May 15;17(5):e84191.
doi: 10.7759/cureus.84191. eCollection 2025 May.

Natural Orifice Specimen Extraction for Right-Sided Colon Cancer: A Systematic Review and Meta-Analysis of Propensity Score-Matched Studies

Bernardo F Pompeu  1 , Victória Mara Vieira Rocha  2 , Ana Flávia Machado Oliveira  2 , Patricia Marcolin  3 , Luís C Dos Lucio Generoso  2 , Sérgio Mazzola Poli De Figueiredo  4 , Fernanda B Formiga  5
Affiliations
Review

Natural Orifice Specimen Extraction for Right-Sided Colon Cancer: A Systematic Review and Meta-Analysis of Propensity Score-Matched Studies

Bernardo F Pompeu et al. Cureus. .

Abstract

Minimally invasive surgery is the standard approach for right-sided colon cancer, but conventional laparoscopic specimen extraction (CVT) requires additional abdominal incisions, increasing the risk of postoperative complications and delayed recovery. Natural orifice specimen extraction (NOSE) minimizes abdominal incisions, potentially improving patient outcomes. This meta-analysis compares NOSE and CVT in terms of postoperative complications, operative characteristics, and long-term outcomes. A comprehensive literature search was conducted in PubMed, Scopus, the Cochrane Central Register of Clinical Trials, and Web of Science for studies available up to December 2024. A random-effects model was applied to compute ORs and mean differences (MDs) with 95% CIs. Heterogeneity was evaluated using the I² statistic. All statistical analyses were performed using R software (version 4.4.1, R Foundation for Statistical Computing). Seven propensity score-matched studies with 566 patients were included, with 240 (42.4%) undergoing NOSE and 326 (57.6%) undergoing CVT. NOSE was associated with significantly reduced postoperative pain on the 3rd day (MD -1.1; 95% CI -1.7 to -0.5; p < 0.01), lower SSI rates (OR 0.23; 95% CI 0.08-0.73; p = 0.012), and a shorter time to pass flatus (MD -0.8; 95% CI -1.2 to -0.4; p < 0.01). However, NOSE was linked to longer operative times (MD 36.4 minutes; 95% CI 3.4-69.4; p = 0.03). No significant differences were found in hospital stay (MD -0.5 days; 95% CI -2.1 to 1.1; p = 0.57), blood loss (MD -2.1; 95% CI -9.6 to 5.4; p = 0.58), or local recurrence (OR 0.44; 95% CI 0.07-3.01; p = 0.405). In conclusion, NOSE offers advantages such as reduced postoperative pain, lower SSI rates, and faster bowel recovery, with prolonged operative time as its main limitation. These findings support NOSE as a viable alternative to CVT for right-sided colon cancer without compromising safety or long-term outcomes.

Keywords: laparoscopic surgery; natural orifice specimen extraction; postoperative outcomes; propensity score matching; right-sided colon cancer.

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Conflict of interest statement

Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Figures

Figure 1
Figure 1. PRISMA flow diagram of study screening and selection.
PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses.
Figure 2
Figure 2. Forest plots comparing NOSE versus conventional laparoscopic surgery in right-sided colon cancer: (A) Surgical site infection (SSI), (B) Visual analog scale (VAS) score on postoperative day 3, (C) VAS score on postoperative day 1, and (D) Clavien-Dindo grade ≥ III complications.
NOSE: Natural orifice specimen extraction; SSI: Surgical site infection; VAS: Visual analog scale.
Figure 3
Figure 3. Forest plots comparing NOSE versus conventional laparoscopic surgery in right-sided colon cancer: (A) Ileus, (B) Urinary retention, and (C) UTI.
NOSE: Natural orifice specimen extraction.
Figure 4
Figure 4. Forest plots comparing NOSE versus conventional laparoscopic surgery in right-sided colon cancer: (A) intra-abdominal abscess, (B) anastomotic bleeding, and (C) anastomotic leak.
NOSE: Natural orifice specimen extraction.
Figure 5
Figure 5. Forest plots comparing NOSE versus conventional laparoscopic surgery in right-sided colon cancer: (A) operative time, (B) time to first flatus, and (C) blood loss.
NOSE: Natural orifice specimen extraction.
Figure 6
Figure 6. Forest plots comparing NOSE versus conventional laparoscopic surgery in right-sided colon cancer: (A) hospital stay, (B) incisional hernia, and (C) local recurrence.
NOSE: Natural orifice specimen extraction.
Figure 7
Figure 7. Critical appraisal of studies according to the Cochrane Collaboration’s tool for assessing risk of bias (ROBINS-I).
ROBINS-I: Risk Of Bias In Non-randomized Studies of Interventions.
Figure 8
Figure 8. Sensitivity analyses: (A) Baujat plot for VAS score on postoperative day 3, (B) Leave-one-out plot for VAS score on postoperative day 3, (C) Baujat plot for VAS score on postoperative day 1, and (D) Leave-one-out plot for VAS score on postoperative day 1.
VAS: Visual analog scale.
Figure 9
Figure 9. Sensitivity analyses: (A) Baujat plot for blood loss, (B) leave-one-out plot for blood loss, (C) Baujat plot for operative time, and (D) leave-one-out plot for operative time.
Figure 10
Figure 10. Sensitivity analyses: (A) Baujat plot for time to first flatus, (B) leave-one-out plot for time to first flatus, (C) Baujat plot for hospital stay, and (D) leave-one-out plot for hospital stay.
See this image and copyright information in PMC

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