Effectiveness and comparison of vnotes assisted uterosacral ligament suspension and vaginal Mccall culdoplasty in apical prolapse.

OBJECTIVE

This study compared endoscopic high uterosacral ligament suspension (USLS) performed with a vNOTES platform and McCall culdoplasty for apical support in women undergoing hysterectomy for POP-Q stage II,III uterine prolapse. Primary outcomes were total vaginal length (TVL) and cuff prolapse at 12 months.

METHODS

In this prospective, single center cohort, 92 women were allocated equally to USLS (n = 46) or McCall culdoplasty (n = 46), with stratification by surgical route (vNOTES vs vaginal hysterectomy) and prolapse stage. USLS was performed under magnified endoscopic visualization, while McCall culdoplasty was performed using the traditional vaginal technique. Baseline characteristics were comparable between groups.

RESULTS

At 12 months, women in the USLS group had a significantly longer TVL compared with McCall (9.0 ± 0.8 vs 8.2 ± 0.9 cm; adjusted mean difference + 0.82 cm, 95 % CI 0.51-1.13; p < 0.001). Cuff prolapse was less frequent with USLS (2.2 % vs 13.0 %; adjusted risk ratio 0.19, 95 % CI 0.04-0.83; p = 0.02). No ureteral complications occurred with USLS, whereas one ureteral and one bladder injury were observed with McCall culdoplasty. Routine cystoscopy was not required during USLS because angled endoscopic optics allowed continuous ureteral visualization; selective cystoscopy confirmed normal findings when performed.

CONCLUSIONS

In this prospective stratified cohort, vNOTES assisted USLS appeared to provide better apical support and preservation of vaginal length at 12 months compared with McCall culdoplasty, with fewer cuff prolapses. The enhanced visualization offered by the vNOTES approach likely improves ureteral safety and may reduce the need for routine cystoscopy. These findings should be interpreted cautiously given the limited sample size and the fact that randomization was applied only at the apical suspension stage.