Design: Retrospective review of multiple surgeons’ experience with vNOTES Sentinel lymph node removal.

Setting: Transvaginal laparoscopic entry into the paravesical space for lymph node evaluation and removal.

Patients or Participants: Women with gynecologic malignancies who were candidates for sentinel lymph node removal.

Interventions: The paravesical space was entered through a single midline infravesical or bilateral lateral incisions in the vaginal fornices after injecting the cervix with Indocyanine Green (ICG). A VPath retractor was placed into this space and insufflation of the retroperitoneal was performed. Sentinel lymph nodes were identified bilaterally using near-infrared light followed by laparoscopic removal of these nodes.

Measurements and Main Results: A total of 58 women with gynecologic cancer (cervix cancer – 4, endometrial hyperplasia or uterine cancer – 54) underwent bilateral sentinel lymph node removal by this technique. In 33 patients the midline approach was used; 25 had the lateral approach used. All patients also underwent vNOTES hysterectomy and bilateral salpingo-oophorectomy except for the cervical cancer patients. The mean age was 67.3 years (35-89) and mean BMI was 27.2 kg/m²(16-48). The average total operative time was 126 minutes (64-270), and the mean estimated blood loss was 98 mL (20-400). 55 patients had negative bilateral sentinel lymph nodes; 2 patients had isolated tumor cells in the Sentinel nodes; and 1 patient had macroscopically positive Sentinel nodes. There were two complications directly attributable to the sentinel lymph node dissection: 1 patient had a transient adductor paresis that resolved within three days, 1 patient had transection of an obturator nerve without sequelae.

Conclusion: This study demonstrates the feasibility of the vNOTES approach to identify and remove sentinel lymph nodes in gynecologic malignancies. This technique allows complete evaluation of the obturator space and the entire pelvic lymph node region.