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vNOTES Radical Hysterectomy: A New Approach To Cervical Cancer.

OBJECTIVE: To demonstrate how a radical hysterectomy with sentinel node resection for cervical cancer can be performed via vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES).

DESIGN: Demonstration of the technique in 10 steps making use of narrated original video footage SETTING: The surgical treatment of cervical cancer is traditionally performed via one of the following techniques: Wertheim radical hysterectomy via laparotomy, Schauta radical hysterectomy vaginally, laparoscopic radical hysterectomy or robotic radical hysterectomy. The results of the LACC trial showed that minimally invasive radical hysterectomy was associated with lower rates in disease free survival and overall survival than open radical hysterectomy among women with early-stage cervical Cancer (1). For endometrial cancer a vNOTES retroperitoneal approach to sentinel node resection was first published in 2019 (2). Based on the experience with this approach and with Schauta-Stoeckel radical hysterectomy for cervical cancer (3), a new approach was developed to perform a radical hysterectomy via vNOTES whereby most of the procedure is performed retroperitoneally (4). This video article demonstrates in 10 steps how a radical hysterectomy via vNOTES is performed.

INTERVENTIONS: Radical hysterectomy via vNOTES demonstrated making use of original video footage of a 57 year old woman operated for cervical adenocarcinoma 7 weeks after a LEEP cone. The steps of the procedure are: 1. Vaginal cuff creation, 2. Development of lateral retroperitoneal space and sentinel node resection, 3. Uterine artery and vein transection, 4. Hypogastric nerve dissection, 5. Development of central retroperitoneal space and rectum dissection, 6. Posterior colpotomy, 7. Parametrium dissection, 8. Bladder pillar dissection, 9. Anterior colpotomy, 10. Salpingo-oophorectomy or salpingectomy. 3 Patients were so far treated by this new technique that allowed for good hemostatic control.

CONCLUSION: vNOTES enables a potentially less invasive approach to radical hysterectomy performed largely retroperitoneally and completely transvaginally leaving no visible scars. The endoscopic approach offers excellent visualization of the retroperitoneal and parametrial anatomy. This is a new approach that requires further validation and should only be performed in a research setting taking into account the current reservations about endoscopic surgery for cervical cancer resulting from the LACC trial.

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