LAUSR

OBJECTIVE To demonstrate the feasibility of Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) meshless anterior repair for the treatment of pelvic organ prolapse (POP). DESIGN Stepwise demonstration of the technique with narrated video footage. SETTING The vNOTES approach is a recent and rapidly developing technique which allows safe endoscopic transvaginal treatment of benign uterine pathologies (1). Its use in the treatment of POP is still in its early stages however the first results are encouraging in terms of anatomy, functionality and safety (2). INTERVENTIONS We describe the vNOTES technique of meshless anterior POP repair using a vaginal plastron (3). The "vaginal plastron" technique uses an autologous vaginal strip which is left attached to the bladder and suspended from the arcus tendineus. After the delimitation of a 6 cm square vaginal strip, a lateral dissection is performed on each side between the bladder and the vaginal fascia, to enter the paravesical space. The vaginal strip is left attached to the bladder wall and will later be fixed laterally to the arcus tendineus with 6 non-absorbable monofilament sutures, caliber 0 (3 on each side of the plastron). The fixation points on the arcus tendineus concern the internal obturator fascia ventrally and the iliococcygeus fascia dorsally. The sutures are placed under endoscopic view using a transvaginal access platform (GelPOINT® V-Path, Applied Medical, Rancho Santa Margarita, CA). After deflation and removal of the platform, the sutures are attached to the vaginal strip. Once the vaginal plastron is secured, the anterior vaginal wall is closed. CONCLUSION The vNOTES approach offers an endoscopic anatomical view of the paravesical space, thus reducing any blind surgical procedure. It provides an alternative route in the performance of meshless anterior POP repair.