To describe our experience with the transvaginal natural orifice transluminal endoscopic surgery (NOTES) in female patients, and to evaluate its clinical value.

Between May 2010 and April 2017, a total of 289 female patients underwent transvaginal NOTES in our center, including 31cases of adrenal tumors, 46 cases of renal tumors, 188 cases of non-functional kidneys, 5 cases of renal cysts, 4 cases of duplex kidney, 7 cases of renal tuberculosis and 8 cases of renal pelvis tumors. Among them, 146 cases were on the left side, 142 cases on the right side, and 1 case on both sides (renal cysts). The median age was 39.4 (range 23 to 76) years, and the median body mass index was 21.8(range 15.4 to 32.6)kg/m². After general anesthesia, the patients were positioned in lithotomy with ipsilateral lumbar at 30°-60° angle to the floor. Hybrid and pure transvaginal NOTES were performed. The specimen was removed through an extended incision at the posterior vaginal fornix.

Transvaginal NOTES was successfully completed in 281 patients. Two patients required conversion to suprapubic-assisted laparoendoscopic single-site surgery because of the rectal injury in pure transvaginal NOTES nephrectomy. Six patients underwent open conversion. The various transvaginal hybrid NOTES procedures included adrenalectomy (31 cases), nephrectomy (206 cases; simple 174 cases, radical 32 cases), partial nephrectomy (13 cases), heminephroureterctomy for duplex kidney (4 cases) and hybrid endoscopy for nephroureterectomy (7 cases). The mean operative time was 105 min (45-310 min), the mean estimated blood loss was 87 ml (20-800 ml), the mean visual analogue score (VAS) of 48 hours after operation was 2.5 (1-4) points and the mean hospitalization was 7.3 d (4-13 d) for transvaginal hybrid NOTES. The various pure transvaginal NOTES procedures included nephrectomy (22 cases; simple 21, radical 1), renal cyst excision (5 cases). The mean operative time was 170 min (60-320 min), the mean estimated blood loss was 140 ml (20-500 ml), the mean VAS of 48 hours after operation was 1.7 (1-3) points and the mean hospitalization was 5.5 d (3-10 d) for transvaginal pure NOTES. Complications occurred in 56 cases (19.38%), including 20 cases (6.92%) of severe complications, and no death occurred. After a mean follow-up of 51 (range 3 to 86) months, umbilicus scar was hidden. The incision in the vagina healed well. No infection in the abdominal or pelvic cavity or celiocele occurred. The umbilicus scar is not obvious after surgery, and 3 months after surgery.The median Patient Scar Assessment Questionnaire (PSAQ) score was 38 (31-58) and the median Female Sexual Function Index (FSFI) score was 28.2 (22.5-32.2), and the quality of life index was significantly higher than that of preoperation.

Transvaginal NOTES could treat variousprimary diseases, and improve the postoperative quality of life. It does not increase the incidence of related complications, or cause negative effect on the female sexual function, pregnancy or fertility. It can lead to good cosmetic outcome and less pain, which is worth applying in clinical practice.

Natural orifice transluminal endoscopic surgery (NOTES); Transvaginal approach; Female; Urologic diseases