Re: Hysterectomy by transvaginal natural orifice transluminal endoscopic surgery versus laparoscopy as a day‐case procedure: a randomised controlled trial

Abstract

Sir, We wish to congratulate the authors of the recently published paper ‘Hysterectomy by transvaginal natural orifice transluminal endoscopic surgery versus laparoscopy as a day-case procedure: a randomised controlled trial’. This was the first published randomised controlled trial that compared hysterectomy by transvaginal natural orifice transluminal endoscopic surgery (vNOTES) versus total laparoscopic hysterectomy (TLH). Although vNOTES may not be currently performed in the UK, we wish to thank the authors for highlighting this technique. The main outcome measures of the study were whether participants were discharged home within 12 hours of the procedure being performed and whether surgery had to be converted to an alternative approach. We are impressed by the findings: participants who had the vNOTES procedure had a significantly shorter hospital stay compared with participants who had a TLH, and only one participant who underwent vNOTES had to be converted to TLH. Surgery was performed only for benign conditions, and we note the exclusion criteria included anyone with suspected rectal vaginal endometriosis. The study does not stipulate, however, whether all participants had an MRI before surgery. The surgery was performed in the same centre and by the same surgeon for all participants. The surgeon had performed a high volume of vNOTES before the study began, and we presume that this was also true for TLH (although this is not stipulated in the study). This therefore introduces some bias into the results, and the results of the study may not be generalised. We note the baseline characteristics of participants: as a cohort they were ideal candidates for either type of surgery, particularly with respect to average age, body mass index (BMI), number of previous caesarean sections, and uterine weight. If participants had had high-risk characteristics, we wonder whether the results would have been different. We note with interest that the uterine weight in both cohorts was similar: in fact, the uterine weight in the TLH group was 177 g compared with 206 g for the vNOTES group. TLH, however, is generally considered the most effective approach for excising large and bulky uteri and for people with high BMI. If participants had either of these characteristics, we wonder whether the results of the TLH cohort would have been superior. Finally, pain scores were significantly better in the vNOTES group compared with the TLH group. The vNOTES group, however, were given four superficial abdominal skin incisions. This is compared with the TLH group, whose abdominal incisions would have been deeper and to the level of the anterior abdominal wall.&