Redefining hysterectomy: Robotic versus conventional approaches in transvaginal natural orifice transluminal endoscopic surgery and laparoscopically-assisted vaginal hysterectomy

Background: This study compares surgical outcomes of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) and laparoscopic-assisted vaginal hysterectomy (LAVH), using conventional and robotic-assisted laparoscopy, and examines factors influencing the choice of approach. Methods: A retrospective cohort study was conducted at a tertiary-care center involving 773 patients undergoing minimally invasive hysterectomy for benign gynecologic conditions between February 2015 and July 2024. Of these, 211 underwent vNOTES (153 conventional, 58 robotic-assisted) and 562 underwent LAVH (408 conventional, 154 robotic-assisted). Results: Patients in the vNOTES group had shorter operating times (90 vs. 135 min, p < 0.001), lower estimated blood loss (100 vs. 200 mL, p < 0.001), smaller uteri (340 vs. 388 g, p = 0.001), and higher rates of intraoperative hematuria (3.8 % vs. 0.5 %, p < 0.001) compared to LAVH. Robotic assistance was linked to longer operating times but similar blood loss compared to conventional laparoscopy. No cases required conversion to laparotomy, and overall complication rates were similar across groups. Regression analysis identified BMI, uterine weight, prior vaginal delivery, and history of abdominal surgery as significant predictors of operating time. Conclusion: Both vNOTES and LAVH are safe with either conventional or robotic assistance. Robotic assistance prolongs operating time, while surgical approach selection may depend on patient factors such as BMI, uterine size, obstetric history, and prior surgeries.