Robotic assisted vaginal natural orifice transluminal endoscopic surgery high uterosacral ligament suspension (NOTES-HUS) for uterine prolapse with and without uterine preservation

Study objective: To demonstrate stepwise techniques for the successful use of the robotic-assisted transvaginal natural orifice transluminal endoscopy surgery high uterosacral ligament suspension (RvNOTES-HUS) technique for pelvic organ prolapse with and without uterine preservation. Design: Stepwise demonstration with narrated video footage (Canadian Task Force classification III). Setting: An academic tertiary care hospital. Case 1: A 62-year-old G0P0 with a symptomatic stage Ⅱ anterior vaginal prolapse and Stage Ⅱ uterine prolapse. The preoperative vaginal length was measured at 9 ​cm. Case 2: A 42-year-old G3P2 with a symptomatic fibroid uterus with stage Ⅱ anterior vaginal prolapse and Stage Ⅱ uterine prolapse. The preoperative vaginal length was measured at 8 ​cm. Interventions: Since the approval of the robotic platforms in gynecologic surgery by the Food and Drug Administration in 2005,1 robotic assisted surgery has been proliferating in the treatment of benign gynecological diseases including sacrocolpopexy, hysterectomy, myomectomy and endometriosis resection.2–5 In recent years, publications have demonstrated the feasibility and safety of traditional laparoscopic assisted high uterosacral ligament suspension for pelvic organ prolapse with long term follow up.6–8 However, robotic assisted RvNOTES-HUS has yet to be investigated in a publication. Utilizing the RvNOTES-HUS technique with or without uterine preservation operations greatly reduces the difficulty of intraperitoneal suture for the surgeon and postoperative pain for the patient. Nevertheless, this approach may be technically challenging.For patients requesting uterine preservation, posterior colpotomy is required to place the port. Contrasting with hysterectomy, after the uterine removal the port was placed through the vaginal cuff; the remaining steps show great similarities. The succeeding techniques were adopted to perform RvNOTES-HUS: the bilateral uterosacral ligaments were tagged with sutures prior to the vNOTES port placement, highlighting the ureters, plucking the tagged uterosacral ligament to aid in identifying the high uterosacral ligament, elevating the uterosacral ligament while suturing, and pulling on the suture post-placement to determine the correct location.The results were as follows:Case 1: The procedure was successfully performed with a postoperative vaginal length of 8 ​cm. Her pain level was 4/10 in the first week, 2/10 in the second week, 0/10 in the third week, 0/10 in the fourth week. Postoperative pelvic organ prolapse quantification was stage 0.Case 2: The procedure was successfully performed with a postoperative vaginal length of 7 ​cm. She had one day of post-operative pain. Postoperative pelvic organ prolapse quantification was stage 0. Conclusion: RvNOTES-HUS is a practical technique in women with uterine prolapse while choosing whether to preserve the uterus. This technique allows for the better exposure of the ureter, while the articulating robotic joints allow for increased precision of dissection and suturing.