Comparison of prone with lithotomy position in removal of posterior myoma in transvaginal natural orifice endoscopic surgery: a prospective cohort study

Objective Vaginal natural orifice transluminal endoscopic surgery (vNOTES) is considered to have the advantages of completely scarless, less postoperative pain, earlier flatus, and faster postoperative recovery. However, posterior myoma are relatively difficult to operate through vNOTES in the conventional lithotomy position. Thus, we innovated the application of prone position in removal of posterior myoma in vNOTES. The aim of this study is the comparison of myomectomy outcomes of patient for single posterior myoma in prone and lithotomy position. Design A single-center, prospective study. Setting A university teaching hospital. Patients A total of 81 patients with posterior myoma who underwent myomectomy in vNOTES from January 2021 to December 2022. Interventions The patients underwent myomectomy in vNOTES in prone or lithotomy position. Measurements and Main Results Among the patients who underwent vNOTES myomectomy, 29 (35.8%) were in the lithotomy position group, and 52 (64.2%) in the prone position group. Of note, 4 (4.9%) patients underwent a conversion to LESS during the operation—3 in the lithotomy and 1 in the prone position group. And a patient in lithotomy position group underwent re-surgery for hemostasis due to postoperative pelvic bleeding. Compared with the lithotomy position, prone position significantly shortens the operation time (12.3, 95% CI: 6.811,17.761. p=0.009) without increasing the complications and postoperative discomfort of patients. Conclusion Compared to the lithotomy position, the prone position provides greater convenience for operation and exhibits a lower rate of surgical conversion during the removal of single posterior myomas via vNOTES. Further, for patients selecting vNOTES, surgeons need to conduct sufficient preoperative evaluation, timely hemostasis during surgery, and timely surgical conversion if necessary to ensure patient safety.