The hysterectomy is one of the most performed gynaecological surgeries worldwide.
In the Netherlands about 14.500 hysterectomies are performed yearly. The most common
benign indications to perform a hysterectomy are abnormal uterine bleeding, uterine
leiomyomas, endometriosis or adenomyosis, chronic pelvic pain, uterine prolapse, benign
ovarian neoplasm, hyperplasia or atypia of the endometrium or cervical dysplasia.
The four approaches to perform a hysterectomy for benign disease are abdominal
hysterectomy (AH), vaginal hysterectomy (VH), (total) laparoscopic hysterectomy ((T)LH)
and robotic-assisted hysterectomy (RH).
VH appears to be superior to the AH, resulting in a quicker recovery. The LH results in a
quicker recovery than the AH and VH, but increases the risks of damage to the bladder or
ureter. That is why a recent Cochrane review advises to perform a VH when feasible for
women undergoing a hysterectomy for a benign indication. When VH is technically not
feasible, a LH or AH is performed. LH resulted in more rapid recovery, fewer febrile
episodes and less wound complications compared to AH. The RH is not superior compared to
the LH and is associated with higher costs.
Since the introduction of laparoscopy, the VH and AH decreased and the rate of LH
significantly increased between 2002 and 2012. Performing a LH gives the opportunity to
inspect the abdominal cavity and to easily perform an opportunistic salpingectomy
compared to VH. An opportunistic salpingectomy during a hysterectomy for benign
indication might reduce the overall risk of ovarian cancer.
Additionally, patients experience less postoperative pain after a LH compared to a VH and
therefore need less post-operative pain medication. Advantages of the VH compared to the
LH are a shorter operation duration, no visible scars and a lower chance of dehiscence of
the vaginal cuff.
In 2004, a novel approach of endoscopic surgery was described, 'Natural Orifice
Transluminal Endoscopic Surgery (NOTES) by researchers at the John Hopkins University. It
is a surgical technique using natural orifices of the body (e.g. mouth, anus, urethra,
vagina) to perform scarless surgery. The vaginal approach is called the vNOTES technique.
NOTES is an emerging field within minimal access surgery, evolves and presents multiple
possibilities for innovation and development. The initial approach was trans gastric, but
subsequently, NOTES has been evolved, resulting in trans rectal, trans gastric,
transvaginal, and transurethral approaches nowadays.
In 2012, the first vNOTES hysterectomy, also called vaginal assisted NOTES hysterectomy
(VANH) was performed. vNOTES surgery can be used for different indications, for example
hysterectomy, adnexectomy or salpingectomy in case of an ectopic pregnancy.
In 2018, the first randomised controlled trial (RCT) comparing TLH with VANH in 70 women
was published. This HALON trial showed VANH was non-inferior to TLH. Compared to TLH,
surgery time was significantly shorter, patients experience less post-operative pain and
same day discharge (SDD) was possible in 77% of the women who underwent the VANH compared
to 43% after TLH. Besides, the VANH showed less post-operative complications.
Except for the HALON trial and two retrospective studies and case-control studies, there
is little literature about VANH.
No studies have been performed comparing the VH with the VANH. Because the VH is the
preferred method to perform a hysterectomy for a benign indication, there is a need to
compare VH with VANH and to explore the indications to perform a VANH.
The aim of this study is to compare the VANH with the VH for same day discharge (SDD),
complications, treatment related outcomes, post-operative recovery, quality of life and
cost-effectiveness.
We hypothesize that patients who underwent a VANH procedure are more often able to be
treated in SDD setting.
