Antimicrobial prophylactic strategies in vNOTES: No consensus, but what do we know?

Aim: Vaginal natural orifice transluminal endoscopic surgery (vNOTES) combines vaginal and laparoscopic techniques and is increasingly used in gynecologic surgery. Given the lack of standardized guidelines for antibiotic prophylaxis, this review aims to evaluate infection rates, current prophylactic practices, and recommendations.

Method: A literature search was conducted in PubMed/MEDLINE and the Cochrane Library using Medical Subject Headings (MeSH) and keywords such as "v-NOTES," "infection," "prophylaxis," and "antibiotics". Studies were grouped into vNOTES hysterectomy, adnexal surgery, and other vNOTES procedures (e.g., pelvic floor surgery, myomectomy). Extracted data included procedure types, indications, operative time, antimicrobial use, follow-up, and postoperative infections.

Results: A total of 83 studies involving 11,963 patients and 9,173 vNOTES cases were analyzed. Among 4,483 vNOTES hysterectomies, infection rates were low: pelvic abscess/infected hematoma (0.13 %), vaginal cuff infection (0.4 %), urinary tract infection (UTI) (1.6 %), postoperative fever (0.77 %), surgical site infection (0.27 %), and sepsis (0.02 %). In 2,152 non-vNOTES hysterectomies, higher rates were noted, including fever (3.2 %) and vaginal cuff infection (0.73 %). In adnexal surgeries (2,614 vNOTES vs. 519 laparoscopy), vNOTES had low infection rates (e.g., pelvic inflammatory disease (PID) 0.4 %, UTI 0.18 %), while laparoscopy reported only fever (1.77 %). Among 619 other vNOTES procedures, UTIs (2.3 %) and pelvic abscess (0.69 %) occurred. Regarding antimicrobial prophylaxis, 33 % of studies did not report any preoperative regimens, 30 % used first-generation cephalosporins, and 19 % used a cephalosporin plus metronidazole or clindamycin. Postoperative antibiotics were reported in 17 %.

Conclusion: No consensus exists for antibiotic prophylaxis in vNOTES. First-generation cephalosporins or a cephalosporin plus metronidazole or clindamycin were generally used. Although data from prospective studies are limited, current evidence suggests that vNOTES does not have an increased infection risk.