To describe the national distribution of the different routes of minimally invasive hysterectomy.

To compare perioperative outcomes between patients undergoing Vaginal natural orifice surgery (V-NOTES) and those undergoing traditional laparoscopic surgery (TLH), vaginal surgery (VH) and laparoscopy assisted vaginal hysterectomy (LAVH).

Design:

Retrospective cohort study of targeted hysterectomy data prospectively collected from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP)

Setting:

NSQIP Database

Patients or Participants:

Women aged 18 years or older undergoing minimally invasive hysterectomy in 2022. Patients were further classified into four groups according to the route of surgery. We excluded patients who had cancer diagnosis or concurrent surgeries.

Interventions:

The variable including “operative approach” was utilized to stratify patients into groups. Patient demographics, medical history and perioperative outcomes were collected. Composite morbidity outcomes were compared.

Measurements and Main Results:

A total of 31,280 hysterectomies were analyzed, with TLH being the most common approach (73.6%), followed by (TAH) (14.7%), VH (5.2%), LAVH (5.1%), and V-NOTES (1.2%). Robotic assistance was utilized in a significant proportion of TLH (56%), V-NOTES (12%), and LAVH (24.9%) cases.

After adjusting for the significant demographics differences, including Age, Race, BMI, Diabetes, Hypertension and Operative time, the composite morbidity was found to be similar in LAVH (7.6%) and V-NOTES (7.3%) compared to TLH (6.5%), but significantly higher in VH (9.8%), (aOR = 1.51 (1.27-1.78), p<0.001 for VH vs TLH).

Conclusion: These findings suggest that V-NOTES, although uncommon, can be performed with relatively low morbidity rates similar to more established minimally invasive techniques. Vaginal hysterectomy, however, was associated with the highest composite morbidity, highlighting the importance of careful consideration of surgical approach. This study provides valuable insights into the contemporary landscape of minimally invasive hysterectomy procedures and underscores the need for further research to optimize patient outcomes and inform clinical decision-making.