IntroductionSurgery is the cornerstone of ovarian cancer treatment. Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) is a novel, minimally invasive technique that is gaining interest in gynecological oncology. However, its use in ovarian cancer is still limited, with only a few cases reported. This study aimed to evaluate the feasibility of vNOTES for the surgical staging of borderline and early-stage ovarian cancer.MethodsWe retrospectively reviewed all cases of borderline ovarian tumors (BOTs) and early-stage ovarian cancer surgically staged by vNOTES at our institution between October 2021 and August 2024.ResultsEleven patients were included, seven with early-stage ovarian or tubal cancer and 4 with BOTs. The median age was 47 (27–81) years, and the median body mass index was 28.1 (22.4–39.2) kg/m2. Complete vNOTES staging was achieved in all cases, including peritoneal washing, unilateral/bilateral salpingo-oophorectomy, abdominal cavity inspection, peritoneal biopsies, infracolic omentectomy, and total hysterectomy when required. The median operating time was 70 (35–138) min, with a median blood loss of 50 (10–100) ml. No intraoperative complications occurred except for one case of minor ovarian spillage. No conversions to conventional laparoscopy or laparotomy were needed. Postoperative complications included one surgical site infection (9.1%) and 2 cases of postoperative cystitis (18.2%). No severe complications graded ≥3 on the Clavien-Dindo classification were observed.ConclusionvNOTES appears to be a feasible approach for the surgical staging of highly selected patients with early-stage adnexal malignancies. Further studies are needed to validate its long-term safety and oncological outcomes.

Surgical approaches for ovarian cancer have advanced significantly in recent years. Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) is an emerging technique in gyneco-logical oncology, with limited reports of its use in ovarian cancer management. This study aimed to evaluate the feasibility and safety of vNOTES for the surgical staging of early-stage adnexal malignancies. Methods: We retrospectively reviewed all cases of borderline ovarian tumors (BOTs) and early-stage ovarian cancer surgically staged using vNOTES at our institution between October 2021 and August 2024. Results: Eleven patients were included, 7 with ear-ly-stage ovarian or tubal cancer and 4 with BOTs. The median age was 47 (27 – 81) years, and the median body mass index was 28.1 (22.4 – 39.2) Kg/m². Complete vNOTES staging was achieved in all cases, including peritoneal washing, unilateral/bilateral salpingo-oophorectomy, ab-dominal cavity inspection, peritoneal biopsies, infracolic omentectomy, and total hysterectomy when required. The median operating time was 70 (35 – 138) minutes, with a median blood loss of 50 (10 – 100) mL. No intraoperative complications occurred except for one case of minor ovar-ian spillage. No conversions to laparoscopy or laparotomy were needed. Postoperative compli-cations included one surgical site infection (9.1%) and two cases of postoperative cystitis (18.2%). No severe complications graded ≥3 on the Clavien-Dindo classification were observed. Conclu-sion: vNOTES appears to be a feasible and safe approach for the surgical staging of selected pa-tients with early stage adnexal malignancies. Further studies are needed to validate its long-term safety and oncological outcomes.

IntroductionSentinel lymph node (SLN) mapping has become a standard approach for early-stage endometrial malignancies, offering reduced morbidity compared to complete lymphadenectomy. Recently, transvaginal natural orifice transluminal endoscopic surgery (vNOTES) has emerged as a novel minimally invasive technique for SLN biopsy, with potential benefits in early surgical outcomes. This systematic review evaluates current evidence on SLN biopsy performed via vNOTES.Material and methodsA systematic literature search was conducted in PubMed, Embase, and Web of Science for articles published between January 1, 2014 and January 31, 2025. Studies were included if they reported SLN biopsy by vNOTES in at least 10 patients with early-stage endometrial cancer and provided detailed data on SLN detection. Our primary outcomes focused on SLN detection and failure rates. Secondary objectives included the early operative outcomes. PROSPERO registration number was CRD42024612607.ResultsSeven studies comprising 231 patients were included. The overall bilateral SLN detection rate was 89.2%, with higher detection in the retroperitoneal subgroup (94.3%) compared to the transperitoneal subgroup (81.1%). The overall failure rate was 3.9%. Nodal metastases were reported in 5.6% (10/179) of patients. Intraoperative complications occurred in 4.8% of cases, with bladder injury being the most frequent. The conversion rate to laparoscopy was 6.5%, primarily due to unsuccessful SLN mapping. Postoperative complications occurred in 3% of patients and were mostly minor. Comparisons with conventional laparoscopy showed similar operative times and blood loss, while vNOTES appeared to offer potential advantages in reducing pain and shortening hospital stay.ConclusionvNOTES is a promising technique for SLN mapping in early-stage endometrial cancer, demonstrating high detection rates with low complication rates. However, evidence remains limited and heterogeneous, highlighting the need for larger, prospective, and randomized studies to validate long-term oncological safety and define its role in clinical practice.

Introduction: This study evaluates the feasibility and safety of Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) in patients aged >= 65, focusing on early surgical outcomes for benign and malignant gynecological conditions. Methods: A total of 119 patients aged 65 and older who underwent vNOTES procedures at Valais Hospital from May 2020 to November 2024 were included. Data collected encompassed demographic characteristics, intraoperative details (e.g., complications, operative time), and postoperative outcomes (e.g., pain scores, complications, length of hospital stay). Results: The mean age was 72.5 years; 59.7 % underwent total hysterectomies, and 30.3 % had adnexal procedures. Mean operative time was 81.6 min (range: 15-221), and mean blood loss was 66.5 ml (range: 0-500). Conversion to conventional laparoscopy occurred in four cases (3.4 %). Intraoperative complications occurred in 14 cases (11.8 %), with higher rates in patients with BMI > 30 (p = 0.01). ASA III and IV patients experienced higher complications rates both intraoperatively (17.1 % vs. 9.5 %, p = 0.24) and postoperatively (28.6 % vs. 11.9 %, p = 0.03) compared to ASA I and II patients. Complication rates increased with surgical complexity, reaching 33.3 % for three or more concomitant procedures. The mean hospital stay was 2.8 days. Patients 75 years of age or older did not have significantly higher complication rates, operating times, or longer hospital stays. Conclusion: Our study confirms the feasibility and safety of vNOTES in elderly patients. However, increased number of concomitant procedures seems to correlate with higher complication rates, especially in patients with a high ASA score and high BMI. These findings offer valuable data for preoperative discussions with elderly patients.

(1) Background: Sentinel lymph node (SLN) mapping represents an accurate and feasible technique for the surgical staging of endometrial and cervical cancer. This is commonly performed by conventional laparoscopy or robotic-assisted laparoscopy, but in recent years, a new retroperitoneal transvaginal natural orifice transluminal endoscopic surgery (vNOTES) approach has been described and developed by Jan Baekelandt. This technique provides easy visualization of lymphatic afferent vessels and pelvic lymph nodes, early SLN assessment, and a coherent mapping methodology following the lymphatic flow from caudal to cranial. However, only a few publications have reported it. Following the IDEAL (Idea Development Exploration Assessment Long-term follow-up) framework, research concerning this technique is in Stage 2a, with only small case series as evidence of its feasibility. Its standardized description appears necessary to provide the surgical homogeneity required to move further. (2) Methods: Description of a standardized approach for retroperitoneal pelvic SLN mapping by vNOTES. (3) Results: We describe a 10-step approach to successfully perform retroperitoneal vNOTES SLN mapping, including pre-, intra-, and postoperative management. (4) Conclusions: This IDEAL Stage 2a study could help other surgeons approach this new technique, and it proposes a common methodology necessary for evolving through future IDEAL Stage 2b (multi-center studies) and Stage 3 (randomized controlled trials) studies.

ObjectiveTo describe a case of utero-ovarian transposition (UOT) before pelvic radiation in a patient with rectal cancer and provide a systematic literature review on all reported cases of UOT.MethodsWe performed a prospective collection and revision of clinical, intraoperative, and postoperative data from a patient who underwent UOT. In addition, a systematic review of the literature available to date on all cases of UOT was realized, and 14 patients from 10 articles were included.ResultsWe reported the case of a 28-year-old nulligravida patient who was diagnosed with a low-grade rectal adenocarcinoma and underwent neoadjuvant chemoradiotherapy, followed by transanal total mesorectal excision (TaTME). Before starting neoadjuvant oncological therapies, the patient underwent laparoscopic UOT. The intervention was performed without complications, and the patient received neoadjuvant oncological treatments as planned. TaTME and uterus repositioning were completed six weeks after the end of radiotherapy. No complications were observed during the first 9 postoperative months. Adequate utero-ovarian perfusion was assessed by Doppler ultrasound, cervicovaginal anastomosis appeared to have healed correctly, and the patient experienced menstrual bleeding. Data from the literature review of all reported cases of UOT were presented and discussed.ConclusionsUOT represents a valuable option to preserve fertility in patients requiring pelvic radiotherapy. This study provides additional evidence on the feasibility and safety of performing UOT.

INTRODUCTION:Evidence about intra- and postoperative complication rates related to transvaginal natural orifice transluminal endoscopic surgery (vNOTES) for benign gynecological conditions is still limited. We report and analyze data from a large cohort of patients operated in a single institution during 3.5 years. MATERIAL AND METHODS:To evaluate the safety and feasibility of vNOTES for benign gynecological indications, we performed a single-center observational study reporting and analyzing perioperative outcomes of 550 consecutive patients operated between 2020 and 2024. RESULTS:Of the 550 included patients, 365 (66.4%) underwent a vNOTES hysterectomy, 167 (30.4%) a procedure limited to the adnexa, and 18 (3.3%) other interventions, including myomectomy, pelvic adhesiolysis, post-hysterectomy pelvic hematoma drainage, pelvic organ prolapse repair, and appendectomy. The mean age was 49.4 ± 12.2 years, and the mean BMI was 26.2 ± 5.8 kg/m2. The total complication rate was 6.5% (36 cases), of which 2.7% (15 cases) were intraoperative complications and 4.0% (22 cases) were postoperative complications. Patients presented postoperative complications classified as Clavien-Dindo (CD) grade I in 4 cases (0.7%), grade II in 10 cases (1.8%), and grade III in 8 cases (1.5%). We observed no CD grade IV and V complications. Three patients (0.5%) were rehospitalized for postoperative complications management. The conversion rate was 1.6%, with nine cases of conversion to conventional laparoscopy and none to laparotomy. CONCLUSIONS:The application of vNOTES appears safe and feasible for most benign gynecological surgeries. Our study focused on surgical complications and demonstrated a profile similar to those reported in previous studies.

In Switzerland, breast cancer is the leading cancer among women, with breast-conserving surgery (BCS) being the preferred treatment for small tumors. The margin status post-surgery is a critical predictor of local recurrence. Achieving negative margins remains a challenge, leading to re-excision in 20–30% of cases. Traditional methods like intraoperative examination palpation and radiography have limitations in assessing excised margins. This study introduces the Histolog® Scanner, a confocal microscopy tool, as a potential solution. It provides real-time images of tissue architecture, allowing for rapid and accurate assessment of excised margins. Our research compared the Histolog® Scanner with standard per-operative radiography in patients with non palpable breast cancer. Preliminary results indicate that the Histolog® Scanner offers a reliable and time-efficient method for margin assessment, suggesting its potential for clinical integration.

Objective: Sentinel lymph node (SLN) dissection is a highly accurate surgical procedure allowing detection of lymph node invasion in patients with clinically negative axilla in early breast cancer. Superparamagnetic iron oxide (SPIO) is a marker used during SLN procedure, allowing the same detection rate as isotopes (Tc-99). A drawback of SPIO is skin staining that can occur around the injection site. The goal of this retrospective study was to assess the frequency of skin staining after oncological breast surgery with SPIO, and the impact of two different injection protocols on the rate of skin staining. Materials and Methods: Data from breast cancer patients undergoing magnetic tracer SLN detection (SLND) procedure in a single department between 2020 and 2022 was reviewed. Injection protocol P1 consisted of retro-areolar injection of Magtrace 0.8 mL. Injection protocol P2, consisted of retro-tumoral injection with 1 mL. Presence of skin staining was assessed at day 10 after surgery. The evolution and satisfaction of the patients was assessed at six and 12 months. Results: In total 175 sentinel lymph node biopsy procedures were performed (P1: 141/P2: 34), consisting of breast conservative surgery (BCS) (P1: 70%/P2: 53%) or mastectomy (P1: 30%/P2: 47%) with SLN. SLN detection rate was 97.7%. Skin staining was reported in 23% and occurred more often after BCS (31.6%) compared to mastectomy (6.8%). When BCS was performed, peritumoral injection was associated with a decreased risk of skin staining compared with retro-areolar injection (22.2% vs. 33.3%, respectively). When present skin staining persisted for 12 months, but most of the patients described only a slight discomfort. The low rate of discoloration after mastectomy, as previously reported, can be explained by the removal of skin and glandular tissue in which the tracer accumulates. Less skin staining in P2 may be because of a shorter interval between injection and surgery and the removal of the excess of SPIO during the lumpectomy. Conclusion: SPIO injection is a safe surgical technique. After mastectomy, the rate of discoloration was low. Despite the persistent skin discoloration in 58.6% in our study, patient satisfaction was high. Deeper injection, reduced doses, massage of the injection site and peritumoral injection may reduce skin staining.

INTRODUCTION:The current standard treatment for endometrial cancer is a laparoscopic hysterectomy with adnexectomies and bilateral sentinel node resection. A retroperitoneal vNOTES sentinel node resection has several theoretical potential advantages. These include being less invasive, leaving no visible scars, operating without Trendelenburg, and therefore offering the anesthetic advantage of easier ventilation in obese patients and following the natural lymph node trajectory from caudally to cranially and therefore a lower risk of missing the sentinel node. The aim of this study is to determine the feasibility of a retroperitoneal vNOTES approach to sentinel lymph node dissection for staging of endometrial cancer. MATERIAL AND METHODS:A prospective multicenter case series was performed in four hospitals. A total of 64 women with early-stage endometrial carcinoma suitable for surgical staging with sentinel lymph node removal were operated via a transvaginal retroperitoneal vNOTES approach. The paravesical space was entered through a vaginal incision after injecting the cervix with indocyanine green. A vNOTES port was placed into this space and insufflation of the retroperitoneum was performed. Sentinel lymph nodes were identified bilaterally using near-infrared light followed by endoscopic removal of these nodes. RESULTS:A total of 64 women with early-stage endometrial cancer underwent sentinel lymph node removal by retroperitoneal vNOTES technique. All patients also underwent subsequent vNOTES hysterectomy and bilateral salpingo-oophorectomy. The median age was 69.5 years, median total operative time was 126 min and the median estimated blood loss was 80 mL. In 97% of the cases bilateral sentinel nodes could be identified. A total of 60 patients had negative sentinel nodes, three had isolated tumor cells and one had macroscopically positive sentinel nodes. No complications with sequel occurred. CONCLUSIONS:This prospective multicenter case series demonstrates the feasibility of the vNOTES approach for identifying and removing sentinel lymph nodes in women with endometrial carcinoma successfully and safely. vNOTES allows sole transvaginal access with exposure of the entire retroperitoneal space, following the natural lymph trajectory caudally to cranially, and without the need for a Trendelenburg position.

OBJECTIVE:To present the rates of intra- and postoperative complications and conversions in a large cohort of unselected vNOTES hysterectomies, performed by surgeons with different levels of expertise. DESIGN:International register-based cohort study. SETTING:Hysterectomies in the iNOTESs registry, 2015 to January 2024, performed by 201 surgeons from multiple countries. POPULATION:4565 patients undergoing vNOTES hysterectomy. METHODS:Descriptive data are presented in frequencies (n) and percent (%). MAIN OUTCOME MEASURE:Intra- and postoperative complications. Conversions. RESULTS:Intraoperative and postoperative complication rates were 3.2% (n = 144) and 2.5% (n = 115), respectively. Conversions occurred in 1.6% (n = 72), of which 10 (0.2%) to laparotomy, and 82% of the conversions occurred within the first 50 cases of the surgeon's learning curve. The most common intraoperative complication was cystotomy, occurring in 1.3%, and almost half were performed by inexperienced surgeons. Other intraoperative organ injuries occurred in 20 cases (0.44%). Postoperatively, the most common complications were haemorrhage (n = 28), vault complications (n = 26) including 11 infected vault hematomas, cystitis (n = 18) and non-specific infections (n = 14). The vNOTES hysterectomies were performed by 201 surgeons, of which 9.5% had performed more than 50 vNOTES cases, representing 70% of the registered cases in the registry. The remaining 30% of the hysterectomies mainly represent learning curve data from 90% of the included surgeons. The complication rate decreased with increasing surgical experience. CONCLUSIONS:The largest study population of vNOTES hysterectomies is presented, including both learning curve data and data from experienced surgeons, with acceptable rates of intra- and postoperative complications. No implication was found of vNOTES being inferior to other minimally invasive methods.

Objective: This study aimed to investigate the impact of vNOTES on postoperative sexual dysfunction in patients undergoing adnexal procedures. Methods: We analyzed data from patients who underwent vNOTES adnexal surgeries for benign conditions between May 2020 and May 2023. The primary outcome was the presence of new postoperative deep dyspareunia (DD) or other sexual dysfunctions, which were assessed through a phone survey conducted 6 to 24 months after surgery. Secondary outcomes included surgical feasibility, operative times, complications rate, and postoperative pain evaluation. Results: We included 103 patients for primary and secondary outcomes and 111 patients for secondary outcomes analysis only. Newly postoperative DD was reported by three patients (2.9%), remained present at 12 postoperative months in one case (1.0%), and spontaneously disappeared in two cases (1.9%) after four and 10 postoperative months, respectively. In the remaining 100 patients (97.1%), no new DD or other sexual function disorders were reported after surgery. vNOTES procedures were successfully performed in all cases, with a mean operative time of 38.2 +/- 19.6 min and a conversion rate to conventional laparoscopy of 0.9%. No significant complication was observed. Conclusion: This study suggests a very limited risk of developing postoperative sexual dysfunction after vNOTES benign adnexal procedures.

Study ObjectiveTo determine the anatomical distribution of sentinel lymph nodes (SLNs), the overall, unilateral, and bilateral detection rates, and the bilateral SLN concordance in patients with endometrial cancer (EC) mapped through a retroperitoneal transvaginal natural orifice transluminal endoscopic surgery (vNOTES) approach.DesignProspective single-center observational study.SettingSwiss teaching hospital.PatientsPatients with EC or endometrial complex atypical hyperplasia who had undergone surgical staging with SLN mapping by a retroperitoneal vNOTES approach between October 2021 and November 2023.InterventionsPatients were placed in a horizontal dorsal lithotomy position under general anesthesia, and indocyanine green (ICG) was injected into the cervix. Access to the retroperitoneal space was achieved through vaginal incisions. A 7 cm GelPoint V-Path Transvaginal Access Platform was used as a vNOTES port, and CO2 was insufflated to expand the retroperitoneal space. The pelvic retroperitoneal space was inspected for ICG uptake by lymph nodes. After identification, SLNs were removed and sent for definitive histological examination.Measurement and Main ResultsA total of 34 patients were included in this study; 33 (97.1%) had a successful procedure (unilateral or bilateral mapping), and 1 (2.9%) had failed mapping. A total of 124 SLNs were identified and removed. SLNs were observed in the obturator region (81.5%), the external iliac region (10.5%), the internal iliac region (4.8%), and the common iliac region (3.2 %). Similar proportions were observed on both pelvic sides. No SLNs were detected in other regions. The SLN locations were symmetrical in 22/31 (71.0%) patients. SLNs were negatives in 120 cases (96.8%), while 2 lymph nodes (1.6%) presented isolated tumor cells, and 2 others (1.6%) presented macrometastases.ConclusionWe report anatomical distributions and detection rates for SLNs mapped by retroperitoneal vNOTES. Our results suggest substantial differences in the localization of SLNs compared to those reported for laparoscopic mapping.

Abstract Background Colorectal cancer represents the third most common cancer and the second leading cause of cancer-related mortality worldwide. The incidence of rectal cancer is rising faster and is increasing among young adults. Due to advances in diagnosis and treatment, most young patients with rectal cancer present long-term survival. Treatment-related infertility represents a largely unaddressed problem. Fertility preservation is essential in managing young women requiring chemo- and radiotherapy for rectal cancer. Ovaries and oocytes are very sensitive to radiation and chemotherapeutic agents, and current fertility preservation strategies include oocytes, embryos, or ovarian tissue cryopreservation and ovarian transposition out of the radiation field. Nevertheless, patients have little probability of procreating due to irreversible uterine radiation damages. Utero-ovarian “out of filed” Transposition [UOT] represent an interesting perspective specially in countries were pregnancy surrogacy is not allowed. Aims Demonstrate feasibility of an innovative surgical procedure permitting uterine functional preservation after long course neoadjuvant therapy for low rectal cancer including total chemo and radio-chemotherapy. Methods First Clinical Swiss experience case presentation. In addition, of a systematic review of the literature available to date on all cases of UOT was realized, and 13 patients from 9 articles were included. Results A 28-year-old nulligravida patient was diagnosed with a low-grade rectal adenocarcinoma. Before neoadjuvant therapies, the patient underwent laparoscopic UOT. The intervention was performed without complications, and the patient received neoadjuvant treatments as planned. TaTME and uterus repositioning were completed six weeks after the radiotherapy's end. No complications were observed during the first 9 postoperative months. Adequate utero-ovarian perfusion was assessed by Doppler ultrasound, cervicovaginal anastomosis appeared healed correctly, and the patient experienced menstrual bleeding. Data from the literature review of reported cases of UOT were presented. Conclusion UOT represents a valuable option to preserve fertility in patients requiring pelvic radiotherapy. This study provides additional evidence on the feasibility and safety of UOT.

Study Objective: To compare the perioperative outcomes of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) hysterectomies for different uterine weights and shapes. Design: Observational study. Setting: Swiss teaching hospital. Patients: Women who underwent vNOTES hysterectomy for benign conditions between May 2020 and July 2023 (N = 238). Patients were divided into 4 subgroups depending on uterus weight and shape. Uteri weighting <280 g were classified as type 0. Uteri weighting >= 280 g were categorized as type 1 (no vascular pedicle displacement), type 2 (cranial displacement of adnexal vascular pedicles), and type 3 (displacement of uterine arteries). Interventions: All women underwent vNOTES hysterectomies. We compared perioperative outcomes for the 4 subgroups. Measurement and Main Results: We classified 168 patients (70.6%) as uterus type 0, 33 patients (13.9%) as type 1, 24 patients (10.1%) as type 2, and 13 patients (5.4%) as type 3. Mean uterine weight was 135.8 +/- 59.5 g in type 0, 398.0 +/- 167.3 g in type 1, 603.5 +/- 217.9 g in type 2, and 661.7 +/- 281.6 g in type 3. Operative time in type 0 (65.1 +/- 30.9 minutes) and type 1 (65.1 +/- 24.0 minutes) was shorter than in type 2 (102.3 +/- 60.0 minutes) and type 3 (115.2 +/- 40.3 minutes). Blood losses were more significant in type 2 (158.5 +/- 212.0 mL) and type 3 (158.5 +/- 110.7 mL) than in type 0 (85.6 +/- 113.5 mL). No difference in the rate of total complications among groups was observed (8.3%, 3.0%, 12.5%, and 15.4% in types 0, 1, 2, and 3, respectively). Conclusion: The displacement of the vascular pedicles seems associated with longer operative time and more blood loss and could represent a marker for technical difficulty in vNOTES hysterectomy. However, it does not influence the perioperative complication rate. Journal of Minimally Invasive Gynecology (2024) 31, 115-122. (c) 2023 AAGL. All rights reserved.

Objective:This study aimed to determine the feasibility of performing omentectomy by transvaginal natural orifice transluminal endoscopic surgery (vNOTES) for surgical staging of ovarian and high-risk endometrial malignancies. Methods:This descriptive study was realized in a non-university hospital in Switzerland. Eighteen patients with suspicious adnexal masses or high-risk endometrial cancer underwent surgical staging comprising infracolic omentectomy by vNOTES between May 2020 and April 2023. Results:Patients underwent oncological surgical staging for suspicious adnexal masses in 14 cases (77.8%) and high-risk endometrial cancer in 4 cases (22.2%). vNOTES omentectomies were performed in all patients without complications. Associated procedures included salpingo-oophorectomy (94.4%), hysterectomy (55.6%), peritoneal biopsies (33.3%), pelvic sentinel lymph node biopsies (22.2%), and appendectomy (5.6%). The median time to perform omentectomies was 9 (4-13) min. All oncological staging were completed by vNOTES. No significant intraoperative complications occurred. We observed 1 case (5.6%) of postoperative fever probably associated with vaginal cuff infection (Clavien-Dindo grade II). Conclusions:This study demonstrated the feasibility of performing vNOTES oncological staging requiring complex extrapelvic procedures such as infracolic omentectomy, supporting its potential role for managing gynecological malignancies such as ovarian and high-risk endometrial cancers. However, before expanding this approach outside study settings, strong evidence of its feasibility, practical benefits, and long-term oncological outcomes are needed.

INTRODUCTION:This study aimed to determine the feasibility and safety of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) to treat benign and malign gynecological conditions in obese patients. MATERIAL AND METHODS:We analyzed data from 79 obese patients with a body mass index (BMI) > 30 Kg/m2 operated by vNOTES for gynecological conditions between May 2020 and April 2023. The primary outcome was the feasibility of performing the surgery as initially planned. Data were presented for subgroups of patients with obesity class I (BMI 30.1 - 34.9 Kg/m2), class II (BMI 35.0 - 39.9 Kg/m2), and class III (BMI ≥ 40.0 Kg/m2). RESULTS:Patients presented obesity class I in 39 cases (49.4 %), class II in 27 cases (34.2 %), and class III in 13 cases (16.4 %). Fifty-two patients (65.8 %) underwent vNOTES hysterectomy, 26 patients (32.9 %) underwent procedures limited to the adnexa, and 1 patient (1.3 %) underwent myomectomy. The conversion rate was 0 %, 11.1 %, and 7.7 % in obesity class I, II, and III, respectively. Intraoperative bladder injury was observed in 1 case (1.3 %) and rectal serosal tear in 2 cases (2.5 %). Postoperatively, we observed 3 cases (3.8 %) of wound infection, 2 cases (2.5 %) of cystitis, and 1 case (1.3 %) of deep vein thrombosis. DISCUSSION:This study demonstrated the feasibility and safety of performing gynecological vNOTES procedures in obese patients. However, obesity could be associated with longer and more complex interventions, especially in obesity class II and III patients.

Objective:Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) is an emerging minimally invasive approach increasingly applied to perform many gynecological procedures. Despite a still limited level of evidence, compared to conventional laparoscopy, vNOTES seems to be associated with reduced blood loss, shorter operative time, less postoperative pain, shorter hospitalization time, better cosmetic results and decreased postoperative morbidity. Although growing evidence supports the effectiveness of vNOTES for elective adnexal surgeries, there is still limited knowledge regarding its feasibility and safety in emergency settings. In the present study, we report our experience performing vNOTES in gynecological emergency cases.Study design:We prospectively collected and analyzed data from patients who underwent vNOTES for gynecological emergencies between November 2021 and June 2023. Demographic and perioperative characteristics were collected and analyzed.Results:Seventeen patients were included. Interventions were realized for suspicion of ectopic pregnancy in 7 cases (41.2%), for suspicion of adnexal torsion in 7 cases (41.2%), for post-hysterectomy hemoperitoneum in 2 cases (11.8%), and for uncontrollable uterine bleeding in 1 case (5.9%). Emergency procedures included unilateral salpingectomy (35.3%), ovarian cystectomy (23.5%), ovarian cystotomy (17.6%), adnexal detorsion (11.8%), hemoperitoneum drainage (11.8%), hysterectomy (5.9%), and appendectomy (5.9%). The overall median operative time was 38 [18-72] minutes. The median estimated intraoperative blood loss was 30 [5-150] mL, and no intraoperative complications occurred. Conversion to conventional laparoscopy or laparotomy was never needed. Patients stayed hospitalized for a median time of 30 [4-144] hours after the intervention. The median visual analog scale value for postoperative pain evaluation was 2 [0-5] at 12, 24, and 48 postoperative hours. No complications associated with the procedure occurred.Conclusions:This study demonstrated the feasibility of performing vNOTES procedures for managing gynecological emergencies such as tubal ectopic pregnancy, adnexal torsion, painful ovarian lesions, post-hysterectomy hemoperitoneum, and uncontrollable uterine bleeding. Associated with data reported in the available literature, our results suggest potential benefits in treating gynecological emergencies by vNOTES over conventional laparoscopy. However, stronger evidence from larger studies is needed to confirm it.

To summarize the evidence on the current management and outcomes for metastatic and recurrent malignant phyllodes tumors (MPTs) of the breast. A systematic literature review of all cases of metastatic or recurrent MPTs of the breast published between 2010 and 2021 was performed. In total, 66 patients from 63 articles were included. Fifty-two (78.8%) had distant metastatic disease (DMD subgroup), and 21 (31.8%) showed locoregional recurrent/progressive disease (LRPR subgroup). Locoregional recurrences in patients with no distant metastases were treated with surgical excision in all cases. Radiotherapy was administered in 8/21 cases (38.1%) and was combined with chemotherapy in 2/21 cases (9.5%). Metastatic disease was managed through metastases surgical excision, chemotherapy, radiotherapy, or a combination of these three in 84.6% of cases, while the remaining patients received no oncological treatments. Chemotherapy was proposed in 75.0% of cases. Anthracycline and alkylating agent-based combination regimens were most frequently administered. The median survival time was 24 (2.0-152.0) months, and 72.0 (2.5-98.5) months in the DMD and LRPR subgroups, respectively. Management of recurrent or metastatic MPTs is challenging. Surgery is the fundamental approach, but the use of adjuvant radio- and chemo-therapy remains controversial due to the lack of scientific evidence. Further studies and international registers are needed to implement new and more efficient treatment strategies.