vNOTES hysterectomy: strategic repositioning of the vaginal route through technological evolution and emerging surgical variants

Vaginal hysterectomy remains the least invasive approach for benign gynecologic diseases, but has steadily declined due to limited surgical exposure during residency. Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) has emerged as an innovative technique that combines endoscopic advantages with those of the vaginal route. This review systematically evaluates the clinical outcomes, emerging technological advancements, and global feasibility of vNOTES hysterectomy with a particular focus on its potential to strategically reposition the vaginal route as the primary minimally invasive option in gynecologic surgery. A comprehensive literature review was performed to assess comparative studies, surgical variants, perioperative outcomes, and learning curves of vNOTES, including advanced forms of total NOTES hysterectomy (TNH), isobaric vNOTES (iNH), and robotic vNOTES (RvNH). vNOTES hysterectomy consistently demonstrates favorable perioperative outcomes, such as reduced operative time, lower blood loss, decreased postoperative pain, and shorter hospital stay, compared with laparoscopic hysterectomy. vNOTES provides particular advantages in complex cases, including large uteri, obesity, nulliparity, and pelvic adhesions. Emerging variants such as TNH, iNH, and RvNH show promising feasibility but require further validation. The relatively short learning curve of vNOTES supports its broad clinical adoption. vNOTES hysterectomy is a transformative advancement that complements existing minimally invasive techniques and offers a strategic opportunity to revive the declining vaginal route. The versatility, evolving technical adaptations, and potential for global scalability of vNOTES make it a key modality in gynecologic surgery. Successful dissemination relies on structured training, standardized guidelines, device development, and long-term safety data.