In the present study, vNOTES USLS showed marked improvement in both anatomic prolapse and quality of life without conversion or serious peri- or postoperative complications. These information suggest that vNOTES USLS may be a feasible technique for treating severe POP.
USLS is a classic surgical method for the treatment of middle compartment POP. Lavelle et al described uterosacral ligament suspension performed vaginally or traditionally via laparoscopy, resulting in a higher prolapse recurrence rate than sacrocolpopexy for stage III prolapse [6]. vNOTES provides direct visualization of the uterosacral ligaments and important organs, such as the ureter and rectum, which results in operative precision by the surgeon. Precise surgery often leads to satisfactory results. Additionally, this approach provides a chance to pull down the sutured uterosacral ligament to further confirm the tensile strength of the suspension. This may be the key step for this procedure to be suitable for patients with severe prolapse. vNOTES USLS in this study presents good short-term efficacy in both anatomic prolapse and quality of life, without serious complications.
vNOTES decreases the risk of abdominal wound infection because of the absence of incisions on the abdomen [10, 11]. However, infection remains the most concerning complication after transvaginal laparoscopic surgery [12]. In this study, we took the following measures to avoid infection. First, prophylactic antibiotics were administered: cefuroxime half an hour before the operation until the day of the operation. Second, the repeated demolition and construction of a vaginal single hole platform were reduced. Third, the pelvic cavity was washed with normal saline after the pelvic operation to reduce the bacterial load. In this study, there were no serious infections except a urinary tract infection, which was cured after anti-infection treatment. Our preventive measures could be effective. This is in accordance with the opinion of Linke, indicating a low risk of peritoneal contamination caused by transvaginal access [12].
Postoperative urinary retention is a common complication after POP surgery [13]. Houlihan et al reported that the rate was 31% in vaginal USLS and 15% in laparoscopic USLS [14]. In this study, the rate was 2.9%. Good visualization under vNOTES played a big role. The patient was cured after 3 days of acupuncture and moxibustion. De novo SUI is another common complication of prolapse surgery [15]. Occult SUI may be originally covered by prolapsed organs. De novo SUI appeared after the anatomic deconstruction was restored. Fortunately, there were no de novo SUIs in this study. Studies with a longer follow-up period should be conducted. Another patient had difficulty defecating, which may be related to the limited postoperative activity.
Sexual activity was suggested to be restored 3 months after surgery in this study. However, only nine of the 17 patients recovered their sexual life. The main reasons were as follows. 1) The patients were older with less of a need for sex. This is different from that in western countries. The sexual needs of Chinese women decrease rapidly with age, especially after the age of 50 [16]. 2) Patients fear that sex will cause prolapse recurrence. Compared with sacrocolpopexy in our hospital [17], with this approach, the postoperative hospital stay was shorter, and the hospitalization cost was lower, which significantly reduces the national medical insurance cost. The main reasons were as follows:1) fewer complications; and 2) no price for the mesh.
This study has several limitations. First, the follow-up time was relatively short, and the sample size was limited. Second, most of our patients were perimenopausal or postmenopausal women, and only 8 (< 45 y) of 35 participants (22%) were sexually active before surgery, limiting the ability to evaluate postoperative sexual function and dyspareunia. Moreover, it is difficult for Chinese people to talk about their sex lives, so the patients had poor cooperation in the investigation of sexual quality of life.