vNOTES and Robotic vNOTES
Vaginal natural orifice transluminal endoscopic surgery (vNOTES) provides endoscopic access through a vaginal incision. Robotic vNOTES adds a robotic platform, but its instruments, camera route and approved procedures depend on that system. Conventional vaginal surgery, nonrobotic vNOTES, robotic vNOTES and transabdominal robotic surgery are distinct approaches.
For the urologic reconstructive application, see Transvaginal Ureteral Reimplantation.
Access and Platforms
| Approach / platform | What it adds | Important limit |
|---|---|---|
| Conventional vNOTES | Endoscopic visualization through vaginal access, with compatible laparoscopic instruments | Instrument configurations vary. |
| da Vinci SP vNOTES | An articulating camera and three jointed instruments through a vaginal access system in published reports | Published feasibility does not establish coverage under the local SP label for every gynecologic procedure; check the model and indication. |
| Hominis, renamed Anovo by Momentis in 2022 | Purpose-designed articulated robotic arms for transvaginal work | US authorizations cover specified adult benign, laparoscopic-assisted transvaginal procedures; later 6N/6Ne clearances also include transabdominal ventral-hernia repair. This system uses an abdominal laparoscopic camera in the described configuration.[1][2] |
Some vNOTES techniques avoid abdominal incisions; others use laparoscopic assistance or require an additional incision for access, extraction or conversion. The vaginal incision still needs to heal. The da Vinci SP and Anovo camera and access arrangements are different.
Patient and Procedure Selection
Access planning must account for vaginal exposure, the proposed colpotomy, prior surgery, adhesions, suspected endometriosis, uterine and adnexal pathology and safe specimen extraction. Severe disease or altered pelvic planes may require a different route or additional assistance.
Benign hysterectomy is the best-studied application. Reports of myomectomy, adnexal surgery, deep-endometriosis resection and prolapse procedures include technical reports and small series. Suspected malignancy requires an oncology-specific plan.
The changing orientation requires deliberate identification of the bladder, ureters, uterine vessels and rectum. Use the relevant operative technique and current device instructions for those decisions.
Comparative Evidence
The 2023 Cochrane review of hysterectomy for benign disease included two vNOTES-versus-laparoscopy trials with 96 women and found the evidence too limited to establish a patient benefit reliably. Its broader conclusions favor a vaginal approach over abdominal hysterectomy when feasible, while recognizing tradeoffs between vaginal, laparoscopic and other approaches.[3]
The 2026 VANH trial provides a direct comparison with conventional vaginal hysterectomy: 113 patients at two Dutch centers, with same-day discharge in 87.3% after vaginal-assisted NOTES versus 71.4% after VH (OR 2.76; 95% CI 1.04–7.25).[11]
A 2026 randomized trial of 90 women found better immediate pain and recovery outcomes with conventional vNOTES than total laparoscopic hysterectomy under its study pathway.[4] It studied low-risk elective patients (ASA I–II) at one center.[4]
| Robotic or mixed-route study | Findings with their actual scope |
|---|---|
| Lowenstein 2021: prospective 30-patient Hominis hysterectomy series | No conversion or intraoperative complication reported; median procedure time 57 minutes, blood loss 50 mL and hospital stay three days. This was a short-follow-up feasibility study.[5] |
| Kanno 2025: retrospective matched SP-versus-conventional vNOTES | 65 patients per group after matching. Reported outcomes did not differ significantly; hospital stay was four days in both groups.[6] |
| Guan 2024: 28 SP-vNOTES hysterectomies, most with endometriosis excision | Mean total operative time 188.7 minutes versus console time 97.3 minutes. One patient needed a mini-laparotomy for specimen extraction; cuff cellulitis and UTI were reported. Combining console/hysterectomy time with total time gives a misleading speed comparison.[7] |
| Lim 2025: retrospective 773-patient mixed-technique cohort | Included 211 vNOTES procedures (58 robotic) and 562 laparoscopic-assisted vaginal hysterectomies (154 robotic). vNOTES was associated with shorter operating time (90 versus 135 minutes) and more intraoperative hematuria (3.8% versus 0.5%), with similar overall complication rates; robotic assistance was associated with longer operating time and similar blood loss.[8] |
The 2026 urinary-injury network review contained only 48 vNOTES participants, with very wide estimates for uncommon injuries.[12]
Keep total operating time, console time, extraction time, discharge timing and follow-up definitions separate when comparing techniques.
Oncology and Prolapse Evidence Boundaries
The 2025 sentinel-node study compared 24 conventional vNOTES cases with 52 robotic cases; it did not study robotic vNOTES.[9]
In a two-center randomized trial of 60 women, vNOTES hysterectomy with uterosacral ligament suspension had shorter total surgical time (77 versus 93 minutes), lower mean estimated blood loss (60 versus 143 mL) and fewer adverse events than conventional vaginal hysterectomy with uterosacral suspension, with no difference in postoperative pain, analgesic use, objective surgical outcomes or patient-reported outcomes.[16] In a single-center randomized trial of 90 women undergoing vaginal hysterectomy for apical prolapse, mesh-based vNOTES lateral suspension produced small but statistically significant improvements in Aa, Ba, C, total vaginal length and PISQ-12 scores at 12 months compared with sacrospinous ligament fixation; operative time, blood loss and hospital stay were comparable.[17] Refer to the prolapse treatment atlas for the specific operation, mesh route and outcome evidence.
An early single-center retrospective pilot of transvaginal (nonrobotic) vNOTES sacrocolpopexy included 26 women: the technique was standardized after case 4, and 23 of the 26 procedures were completed successfully. Median operative time was 184 minutes for cases 5–26 after standardization; among the 23 completed vNOTES sacrocolpopexy cases, mean estimated blood loss was about 30 mL.[13] Short-term prolapse and quality-of-life measures improved among the completed cases. This early pilot had no comparator and reported only 1-month follow-up.[13] A separate retrospective cohort analyzed 55 of 57 women at a mean follow-up of 35.5 months; mesh exposure and prolapse recurrence each occurred in 3/55 (5.5%).[14] In a retrospective 2022 NSQIP cohort of 7,374 apical suspensions for benign indications (4.9% vNOTES, 21.3% vaginal, 36.7% laparoscopic, 37.1% robotic), adjusted odds of perioperative composite complications did not differ between vNOTES and the other routes (rates 4.28–6.21%); median operative time was 134 minutes for vNOTES, 125 for vaginal, 146 for laparoscopic and 172 for robotic surgery.[15]
Training, Costs and Counseling
Training requires vaginal and endoscopic anatomy, platform-specific access and docking skills, proctoring and assessment of competence. ACOG's 2020 guidance emphasizes appropriate training, quality assurance and choosing technology according to patient benefit; it calls for better evidence identifying who benefits from robotic assistance over other minimally invasive approaches.[10]
Compare costs using the local procedure, equipment, service, consumables, reprocessing and operating-room pathway. Discuss expected access and extraction, possible additional ports or conversion, urinary or bowel injury, bleeding, infection and vaginal healing using the evidence for the actual procedure.
See Also
- Vaginal Hysterectomy
- Single-Port Robotics
- Robotic Platforms & Manufacturers
- Reconstructive Applications
- Transvaginal Ureteral Reimplantation
References
1. US FDA. Hominis Surgical System, De Novo DEN190022, February 26, 2021. Classification and indications. FDA. Anovo 6Ne K251761, July 2025. Momentis. Hominis-to-Anovo name change, July 2022.
2. SAGES Technology and Value Assessment. Anovo Surgical System, October 31, 2025: device configuration and abdominal camera access. Assessment.
3. Pickett CM, Seeratan DD, Mol BWJ, et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev. 2023;CD003677. doi:10.1002/14651858.CD003677.pub6. Full Cochrane review.
4. Acil F, Dedeoğlu A, Andıç O, et al. vNOTES vs total laparoscopic hysterectomy: a randomized controlled trial of pain, opioid use, and quality of recovery. J Minim Invasive Gynecol. 2026. doi:10.1016/j.jmig.2026.06.032.
5. Lowenstein L, Mor O, Matanes E, et al. Robotic vaginal natural orifice transluminal endoscopic hysterectomy for benign indications. J Minim Invasive Gynecol. 2021;28:1101–1106. doi:10.1016/j.jmig.2020.10.021.
6. Kanno K, Taniguchi R, Higuchi N, et al. Single-port robotic versus conventional laparoscopic vNOTES hysterectomy: a propensity score-matched comparison of surgical outcomes and literature review. Eur J Obstet Gynecol Reprod Biol. 2025;315:114757. doi:10.1016/j.ejogrb.2025.114757.
7. Guan X, Yang Q, Lovell DY. Assessing feasibility and outcomes of robotic single port transvaginal NOTES hysterectomy: a case series. J Minim Invasive Gynecol. 2024;31:1041–1049. doi:10.1016/j.jmig.2024.08.018.
8. Lim JC, Yang LY, Lin WL, et al. Redefining hysterectomy: robotic versus conventional approaches in transvaginal natural orifice transluminal endoscopic surgery and laparoscopically-assisted vaginal hysterectomy. J Formos Med Assoc. 2025. doi:10.1016/j.jfma.2025.07.005.
9. Şimşek E, Karakaş S, Karaaslan O, et al. Comparison of robotic and natural orifice transluminal endoscopic surgical technique procedures in patients undergoing sentinel lymph node biopsy during endometrial cancer surgery. Surg Oncol. 2025;63:102282. doi:10.1016/j.suronc.2025.102282.
10. ACOG. Robot-Assisted Surgery for Noncancerous Gynecologic Conditions: Committee Opinion No. 810. Obstet Gynecol. 2020;136:e22–e30. doi:10.1097/AOG.0000000000004048.
11. Bekkers IPW, Wintraecken FRM, Smeets NAC, et al. Vaginal hysterectomy versus vaginal assisted natural orifice transluminal endoscopic surgery hysterectomy; results of a randomised controlled trial. BJOG. 2026. doi:10.1111/1471-0528.70260.
12. Cassani C, Spinillo A, Dominoni M, Gardella B. Revisiting urological injury risks in minimally invasive hysterectomy for benign indications: a rare-events network meta-analysis with sensitivity analyses. Int Urogynecol J. 2026. doi:10.1007/s00192-026-06566-y.
13. Liu J, Kohn J, Fu H, Guan Z, Guan X. Transvaginal Natural Orifice Transluminal Endoscopic Surgery for Sacrocolpopexy: A Pilot Study of 26 Cases. J Minim Invasive Gynecol. 2019;26(4):748-753. doi:10.1016/j.jmig.2018.08.009
14. Lu Z, Chen Y, Wang X, et al. "Mesh Exposure and Prolapse Recurrence Following Transvaginal Natural Orifice Transluminal Endoscopic Surgery for Sacrocolpopexy: Over 24 Months of Follow-up Data." J Minim Invasive Gynecol. 2022;29(12):1317-1322. doi:10.1016/j.jmig.2022.08.001
15. Abiodun O, Siddiqui G, Chen HY, Jalloul R. "vNOTES vs Minimally Invasive Colpopexy: National Study and Literature Review." Int Urogynecol J. 2026. doi:10.1007/s00192-026-06524-8
16. Lowenstein L, Mor O, Matanes E, Justman N, Stuart A, Baekelandt J. "Conventional vaginal approach vs. transvaginal natural orifice transluminal endoscopic surgery for treating apical prolapse, a randomized controlled study." Eur J Obstet Gynecol Reprod Biol. 2024;303:180-185. doi:10.1016/j.ejogrb.2024.10.032
17. Bacak HB, Salman S, Coskun ES, et al. "Anatomic and Functional Outcomes After Vaginal Hysterectomy With Mesh-Based V-NOTES Lateral Suspension Versus Sacrospinous Ligament Fixation: A Randomized Controlled Trial." J Minim Invasive Gynecol. 2026;33(4):440-449. doi:10.1016/j.jmig.2025.12.034