vNOTES High Uterosacral Ligament Suspensions and Bilateral Adnexectomy Under Real-Time Visualization of Ureters Using Indocyanine Green

Study objective: Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) combines the benefits of traditional vaginal surgery-such as the absence of abdominal incisions, reduced postoperative pain, and improved cosmetic outcomes-with enhanced endoscopic visualization and working space compared to conventional vaginal instrumentation [1-3]. This is particularly relevant in urogynecological surgery, where lower urinary tract injuries, especially bladder and ureteral damage, are among the most frequent complications [4,5]. We present the feasibility and safety of performing high uterosacral ligament suspension (HUS) and bilateral adnexectomy through a vNOTES approach, with intraoperative ureteral visualization achieved using indocyanine green. Design: Stepwise demonstration of the technique with narrated video footage. Setting: A 63-year-old woman presenting with symptomatic pelvic organ prolapse (POP-Q: II Stage). Given that the patient presented with persistent and bothersome symptoms and an associated apical support defect, conservative management and isolated anterior repair were considered insufficient; therefore, an apical support procedure was selected to ensure durable anatomical and functional outcomes, and the proposed surgical management consisted of HUS with bilateral adnexectomy (upon patient's request), performed through vNOTES. The aims of the surgical approach and potential postoperative complications were clearly explained to the patient prior to obtaining informed consent. Interventions: Firstly, a cystoscopy was performed, with bilateral ureteral injection of IGC at a concentration of 0.25 mg/mL, with a total volume of 3 mL per side. Then the GelPoint vPATH1 device (Applied Medicine, Rancho Santa Margarita, CA) was placed in the vagina, and a low-pressure pneumoperitoneum was established. The uterosacral ligaments were identified by direct pulling. The suspension stitches were then placed crossing the uterosacral ligaments in their cranial part. Finally, a bilateral salpingo-oophorectomy was performed. The total operative time was 24 minutes, with minimal blood loss. Conclusion: Determining the pelvic course of the ureters by transperitoneal ICG visualization was pivotal to avoid ureteral kinking during placement of the suspension sutures and to dynamically confirm ureteral patency following apical suspension. The vNOTES HUS with real-time ICG injection is technically feasible and allows clear and reliable identification of the uterosacral ligament. Our technique allows a good identification of mooring points for suspension, an improved vision of adjacent anatomical structures, and the avoidance of any blindfolded surgical maneuvers, limiting the risk of ureteral injuries, making it a safer and more reproducible procedure. VIDEO ABSTRACT.