The impact of the uterocervical angle, cervical length, sliding sign, and pelvic organ prolapse stage on surgical difficulty in V-NOTES hysterectomy for benign conditions: a prospective cohort study.

OBJECTIVES The aim is to identify objective anatomical and clinical predictors of surgical difficulty in vaginal natural orifice transluminal endoscopic surgery (V-NOTES) hysterectomy. MATERIAL AND METHODS This prospective cohort study included 65 patients who underwent hysterectomy with V-NOTES for benign conditions. Parameters such as the uterocervical angle (UCA), cervical length (CL), the sliding sign, and the stage of pelvic organ prolapse (POP-Q) were measured before surgery. The independent effects of these factors on high surgical difficulty, as defined by a surgeon-assessed Likert score of at least 4, were analysed using multivariate logistic regression. RESULTS High surgical difficulty was reported in 27.7% of patients. Multivariate analysis identified three independent risk factors for increased surgical difficulty: a negative sliding sign (indicative of adhesions), significant cervical elongation and a narrow uterocervical angle. In contrast, advanced pelvic organ prolapse (POP-Q stage ≥ II) was identified as a protective factor, significantly reducing the likelihood of high surgical difficulty. The final predictive model incorporating these four markers demonstrated good discriminative performance [area under the curve (AUC) = 0.84, 95% confidence interval (CI): 0.73-0.95]. CONCLUSIONS Preoperative assessment of the sliding sign, cervical length, and uterocervical angle, combined with the POP-Q stage, can reliably predict surgical difficulty in V-NOTES hysterectomy. Our predictive model (AUC = 0.84) provides surgeons with a practical tool to help them select and counsel patients more effectively. However, these findings are based on a single-centre cohort and require external validation.