vNOTES myomectomy shows earlier first flatus but lacks clear differences in operative time or blood lossvNOTES Surgery Shows Potential for Faster Recovery After Myomectomy

BACKGROUND: Vaginal natural orifice transluminal endoscopic surgery (vNOTES) avoids abdominal incisions and is increasingly used for benign gynecologic surgery, but evidence for fertility-sparing myomectomy remains limited. METHODS: We searched PubMed, MEDLINE, EMBASE and Scopus (January 1, 2000 - July 31, 2025) for comparative studies (vNOTES vs. multi-port or laparoendoscopic single-site [LESS] myomectomy) and single-arm vNOTES cohorts. Two reviewers screened/extracted data. Risk of bias was assessed using Newcastle-Ottawa (comparative) and Joanna Briggs Institute (JBI; case series). Random-effects meta-analysis (inverse-variance) was performed when mean ± standard deviation (SD) were available; heterogeneity was assessed with I. RESULTS: Seven studies were included (three comparative; four single-arm), totaling 348 vNOTES and 272 laparoscopic cases. Three cohorts contributed to the meta-analysis of vNOTES versus LESS for operative time, blood loss, length of stay, time to first flatus, and conversion; two cohorts contributed to infection pooling. There was no clear difference in operative time (mean differences [MD] -2.2 min, 95% confidence interval [CI] -10.8 to 6.4) or blood loss (MD -1.9 mL, 95% CI -20.2 to 16.5). vNOTES was associated with earlier first flatus (MD -7.4 h, 95% CI -9.7 to -5.1). Length of stay was shorter but highly heterogeneous and imprecise (MD -0.95 days, 95% CI -2.28 to 0.38; I=96%). Postoperative infection estimates favored LESS in two cohorts (RR 6.00, 95% CI 1.10 to 32.63). Conversion was uncommon but occurred only in vNOTES arms (RR 5.01, 95% CI 0.89 to 28.15). Across all vNOTES cohorts, rectal injury occurred in 4/348 (1.15%). CONCLUSIONS: In highly selected patients treated in expert centres, vNOTES myomectomy appears feasible, with low-certainty evidence suggesting earlier bowel recovery versus LESS. However, the available comparative evidence is event-sparse and observational; reported rectal injuries and vaginal/cuff infections should be interpreted as hypothesis-generating safety signals rather than definitive comparative risks. Generalizability and long-term reproductive outcomes remain uncertain, as there is need for more robust evidence from comparative studies.