Uterus-preserving transvaginal natural orifice endoscopic extraperitoneal pelvic reconstruction for multicompartment pelvic organ prolapse.

To evaluate the feasibility and safety of uterus-preserving pelvic reconstruction (PRC) performed via extraperitoneal vaginal natural orifice transluminal endoscopic surgery (vNOTES) for multicompartment pelvic organ prolapse (POP). We describe a novel retroperitoneal, uterus-preserving PRC technique for multicompartment POP, demonstrated step-by-step using operative images and video. A representative case involved a 42-year-old woman with POP-Q stage III/III/II. Extraperitoneal access was obtained through a posterior vaginal approach using a transvaginal single-port platform. Presacral dissection enabled fixation of a tailored Y-shaped mesh to the anterior longitudinal ligament (S1-S2). The anterior and posterior mesh arms were then secured to the pubic fascial surfaces and posterior vaginal wall, respectively, providing uterine suspension and anatomic restoration. Between June 2024 and November 2025, 23 patients (mean age 49.2 ± 9.3 years) underwent uterus-preserving extraperitoneal vNOTES-PRC. The mean operative time was 97.7 ± 24.1 min, mean estimated blood loss was 126.4 ± 87.7 mL, and mean postoperative hospital stay was 4.1 ± 0.8 days. During a median follow-up of 9.4 months (range 6.3-22.4 months), all patients demonstrated significant anatomic improvement without recurrence, mesh erosion, or the need for reoperation. Uterus-preserving extraperitoneal vNOTES-PRC is a safe and effective surgical option for multicompartment POP, offering favorable anatomic outcomes while minimizing pelvic organ injury and operative duration.