Robotic single port versus robotic multiple port transvaginal orifice transluminal endoscopic surgery hysterectomy: a comparison of surgical outcomes.

To evaluate the feasibility and safety of robotic single-port transvaginal natural orifice transluminal endoscopic surgery (RSP-vNOTES) compared to robotic multi-port vNOTES (RMP-vNOTES) for hysterectomy and associated procedures. 383 patients were retrospectively analyzed. Among the participants, 291 underwent RMP-vNOTES hysterectomy and 92 underwent RSP-vNOTES hysterectomy. The RSP-vNOTES group had a lower median BMI (26 vs. 29 kg/m2, p = 0.02), fewer patients with prior vaginal delivery (32% vs. 46%, p = 0.02), and lower median uterine weight (92 vs. 122 g, p = 0.02). Regarding additional surgical procedures performed, the RSP-vNOTES group had a higher proportion of endometriosis excision-related interventions (lysis of adhesions, endometriosis excision, ovarian cystectomy, appendectomy, bowel shaving, and bowel oversew, all p < 0.05). Multiple linear regression analysis was conducted to adjust for these variables. After adjustment, no significant differences were observed between the groups in total operative time, port placement time, hysterectomy time, estimated blood loss, or conversion rate. No significant differences existed in postoperative pain or complications. In total, three conversions to abdominal robotics occurred (0.8%), all due to complex endometriosis. Robotic vNOTES enhances the performance of vaginal surgeries by leveraging the established advantages of robotic technology with the minimally invasive advantage of vaginal surgery. Both RSP-vNOTES and RMP-vNOTES are effective and safe, but RSP-vNOTES offering logistical and ergonomic benefits while facilitating increased complexity of procedures, particularly endometriosis excision. Overall, RSP-vNOTES is an efficient approach for advanced gynecologic surgery.