Supplementary Material for: Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) for Gynaecological Oncology Procedures: A Systematic Review

Introduction: Natural Orifice Transluminal Endoscopic Surgery (NOTES) is a minimally invasive technique that accesses the abdominal cavity through natural orifices, eliminating the need for abdominal incisions. While this approach holds significant promise, particularly with its adaptation as vaginal NOTES (vNOTES), long-term safety data remain limited, especially beyond benign indications and hysterectomy. This review aims to evaluate the feasibility and outcomes of vNOTES in gynaecological oncology procedures that do not involve concurrent hysterectomy.

Methods: This systematic review, registered with PROSPERO (CRD42022380581) and conducted per PRISMA guidelines, searched MEDLINE, EMBASE, CINAHL, SCOPUS, and CENTRAL up to March 31, 2023. Using MeSH, Emtree, and keywords including "vaginal natural orifice transluminal endoscopic surgery," "vNOTES," and "gynaecological surgery," studies were selected if they included women undergoing vNOTES for oncological indications without hysterectomy.

Results: Of 5,367 records screened, 58 underwent full-text review; four articles (n=6) were included for oncological procedures without hysterectomy. These involved staging of peritoneal (n=3), endometrial (n=2), and cervical cancers (n=1). Mean age was 54.3 years, BMI 30 kg/m², and operative time 93.5 minutes. Mean estimated blood loss was 17.2 mL. No conversions occurred. One patient developed a postoperative fever (12.5%), managed conservatively.

Conclusion: This review highlights the limited but promising evidence for vNOTES in gynaecological oncology beyond hysterectomy. It offers a potential minimally invasive alternative for complex pelvic procedures requiring retroperitoneal access, including obturator pathology, sentinel lymph node dissection, and mesh excision. Careful patient selection and use within a research setting, mirroring protocols for Transanal Total Mesorectal Excision, are recommended. Prospective case registration via the International NOTES Society is advised to support safe implementation.