Retrospective comparison of V-notes hysterectomy, total laparoscopic hysterectomy and vaginal hysterectomy operations

Aim: Hysterectomy is an operation of great importance in gynecological surgery. Today, hysterectomy can be performed by abdominal and minimally invasive techniques (laparoscopic, vaginal, v-NOTES, robotic). In determining the hysterectomy method, the patient's clinic, anatomy, indication for hysterectomy, experience of the surgeon, and the equipment of the center where hysterectomy will be performed are decisive. Although it is thought that the vaginal route should be chosen more frequently in terms of patient comfort in the studies conducted in the literature, hysterectomy techniques have advantages and disadvantages compared to each other. The aim of this study was to retrospectively compare a new method, v-NOTES hysterectomy with vaginal hysterectomy and laparoscopic hysterectomy. Patients and Methods: Between January 1 2021 and December 1 2022, 186 cases of hysterectomy with benign indications performed in our Ondokuz Mayıs University Faculty of Medicine Obstetrics and Gynecology clinic were included in the study. While all v-NOTES hysterectomy operations performed in this date range were included in the study, the last 62 vaginal hysterectomy and the last 62 laparoscopic hysterectomy operations were included in the study in order to avoid bias in patient selection. Our study is a retrospective and single-centered study. Operations are included in an equal number of studies. Indications of these three hysterectomy techniques, pain scores and parities, postoperative discharge times, operation periods, age of the patients, basal mass index, preoperative and postoperative hemoglobin differences, whether there are intraoperative or postoperative complications, whether the patients have a previous history of cesarean section and/or pelvic surgery, the rates of oophorectomy and salpingectomy in the operations, the need for additional surgery, whether additional surgical procedures are performed and by uterine weight the three surgical techniques were evaluated comparatively. Results: When the three surgical techniques were compared, the least hemoglobin decrease was found in the v-NOTES hysterectomy group and the mean hemoglobin difference in v-NOTES hysterectomy was significantly lower than vaginal hysterectomy (p:0.009<0.05). The mean longest duration of the operation was in the V-NOTES hysterectomy group and the operation time of the vaginal hysterectomy group was significantly shorter than the V-NOTES hysterectomy group (p:0.005<0.05). When the discharge times were compared, it was seen that the v NOTES hysterectomy group was discharged significantly shorter than the laparoscopic hysterectomy group (p: 0.022<0.05), while there was no significant difference between the vaginal hysterectomy group (p: 1.00>0.05). When the mean age of the patients who participated in our study was evaluated, it was observed that the mean age of the group that underwent vaginal hysterectomy was the highest and that there was a significant difference between v-NOTES hysterectomy and laparoscopic hysterectomy group (p: 0.01<0.05). When the basal mass indexes of the patients were compared, the highest mean of the basal mass index was found in V NOTES hysterectomy group and a significant difference was observed between laparoscopic hysterectomy group (p:0.005<0.05). When the indications were evaluated, the most common indication in the laparoscopic hysterectomy and v NOTES hysterectomy group was abnormal uterine bleeding, while the most common indication for the vaginal hysterectomy group was pelvic organ prolabsus. These three surgical techniques are used postoperatively 6th hour pain score was compared the lowest pain score was in the v-NOTES hysterectomy group to 1.53, and there was a significant difference between the three surgical techniques in terms of pain score (p:0.01<0.05). Pelvic surgery history and cesarean section history were higher in the v-NOTES hysterectomy group than in the vaginal hysterectomy group. At the same time, when the rates of oophorectomy and salpingectomy were examined, it was more common in the v-NOTES hysterectomy group than in the vaginal hysterectomy group. It is highest in the laparoscopic hysterectomy group. When the parities of the patients were evaluated, no significant difference was observed between the three groups (p: 1,139>0,05). When intraoperative complications were evaluated, bladder perforation was observed in 1 v-NOTES hysterectomy and 2 vaginal hysterectomy operations, and bleeding was observed in 1 vaginal hysterectomy operation. Postoperative complication did not occur for all three groups. Additional surgery was needed in 3 patients in the V-NOTES hysterectomy group and in 1 patient in the vaginal hysterectomy group. In the laparoscopic hysterectomy group, the need for additional surgery was not observed. When the additional surgical procedures used in these three surgical techniques are evaluated, the operation with the most additional surgical procedures is the vaginal hysterectomy group and the operation with the least additional surgical procedure is the laparoscopic hysterectomy group. When the three surgical techniques were evaluated comparatively, a significant difference was observed between the surgical techniques in terms of additional surgical procedure (p:0,01<0,05). When the costs are evaluated, the vaginal hysterectomy group is the least costly operation and it is significantly lower cost than v-NOTES hysterectomy and laparoscopic hysterectomy ( p: 0.003<0.05, p: 0.01<0.05).When the v-NOTES hysterectomy and laparoscopic hysterectomy group are compared in terms of cost, the v-NOTES hysterectomy group is significantly lower cost than the laparoscopic hysterectomy group (p: 0.01<0.05). Conclusion: When the three surgical techniques were compared, the v-NOTES hysterectomy group had the lowest preoperative and postoperative hemoglobin difference, the lowest discharge time and the lowest postoperative 6th hour pain score were found in this surgical technique. According to the results of our study, v-NOTES hysterectomy group was found to be more effective than vaginal hysterectomy in accessing the adnex. In patients who have had a previous intra-abdominal operation or whose uterus is large, v-NOTES hysterectomy facilitates the operation compared to vaginal hysterectomy. When the cost was calculated, the lowest cost group was found to be the vaginal hysterectomy group. In addition, the v-NOTES hysterectomy group was found to be significantly lower cost than laparoscopic hysterectomy. v-NOTES hysterectomy provides a wider field of view than vaginal hysterectomy and is lower cost than laparoscopic hysterectomy. In addition, aesthetic results can be given to patients by using the vaginal route. With all these results, we believe that v-NOTES hysterectomy is a safe surgery that can be used as an alternative to laparoscopic hysterectomy and vaginal hysterectomy. Keywords: v-NOTES hysterectomy, Vaginal Hysterectomy, Laparoscopic Hysterectomy