Impact of prior caesarean delivery on perioperative outcomes of vNOTES hysterectomy: a propensity-score-matched study.

STUDY

OBJECTIVE

Vaginal natural orifice transluminal endoscopic surgery (vNOTES) hysterectomy has emerged as a minimally invasive alternative to conventional laparoscopic and vaginal hysterectomy. However, a history of caesarean delivery is often considered a technical challenge due to adhesions and the potential risk of bladder injury. This study aimed to evaluate the impact of prior caesarean delivery on perioperative outcomes of vNOTES hysterectomy for non-malignant gynaecological indications.

STUDY

DESIGN

This single-centre retrospective study included patients who underwent vNOTES hysterectomy ± bilateral salpingo-oophorectomy at Etlik City Hospital, one of the largest tertiary referral hospitals in Turkey, between September 2023 and January 2026. All procedures were performed by two experienced surgeons, both of whom had performed more than 50 VNOTES procedures prior to the study period and were certified in vNOTES hysterectomy. Patients were grouped according to prior caesarean delivery status. Propensity score matching was performed in a 1:1 ratio, resulting in 49 patients per group. Perioperative outcome, complication and 30-day re-admission rates were compared, and subgroup analysis was conducted according to the number of prior caesarean deliveries.

RESULTS

After matching, baseline characteristics were well balanced. The operative time and reduction in haemoglobin were similar between the groups (p = 0.082 and p = 0.232, respectively). Intraoperative complication rates were 4.1% (2/49) and 10.2% (5/49) in the no prior caesarean and prior caesarean groups, respectively (p = 0.436), and postoperative complication rates were 8.2% (4/49) and 10.2% (5/49), respectively (p = 1.000), with no significant differences between the groups. Conversion to laparoscopy occurred only in women with a history of caesarean delivery (3/49 patients, 6.1%), but the difference was not significant. In subgroup analysis, women with a history of two or more caesarean deliveries had a longer operative time (p < 0.001), with no differences in the reduction in haemoglobin, complication rate, conversion rate or readmission rate.

CONCLUSION

While significant differences were not reached, the conversion rate and perioperative complication rate were higher in patients with a history of caesarean delivery, suggesting that a history of caesarean delivery may be associated with increased perioperative morbidity. Although operative time may be prolonged in patients with a history of multiple caesarean deliveries, major morbidity and re-admission rates remain comparable. Overall, a history of caesarean delivery may not compromise the feasibility of vNOTES hysterectomy, and these patients may still be considered as suitable candidates when the procedure is performed by surgeons experienced in vNOTES hysterectomy.