Functional Outcomes After Vaginal Natural Orifice Transluminal Endoscopic Surgery Hysterectomy: A Systematic Review of Sexual Function and Pelvic Floor Integrity

ABSTRACT Introduction Vaginal hysterectomy is guideline‐preferred for benign disease, yet uptake is declining. Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) offers enhanced visualisation while optimising recovery; however, impact on functional outcomes remains unclear. Aims To evaluate sexual function and pelvic floor outcomes following vNOTES hysterectomy compared with minimally invasive alternatives. Methods A systematic review was conducted per PRISMA 2020 and Cochrane guidelines (PROSPERO CRD420251247524). MEDLINE, Embase, Cochrane and Scopus were searched to February 2026. Comparative studies (≥ 25 vNOTES patients) reporting functional outcomes (Female Sexual Function Index [FSFI], Pelvic Floor Distress Inventory [PFDI], International Consultation on Incontinence Questionnaire [ICIQ], Pelvic Organ Prolapse Quantification [POP‐Q]) were included. Non‐comparative studies and those without validated measures were excluded. Risk of bias was assessed using RoB2 and Newcastle‐Ottawa Scale. Results were synthesised narratively (SWiM). Results Five studies ( n  = 526; one randomised trial, four cohort studies) were included. Sexual function was equivalent between vNOTES and laparoscopic approaches at 3–6 months. One study with variable follow‐up extending beyond 6 months reported higher FSFI scores ( p  = 0.003), whereas others showed no difference ( p  > 0.05). Dyspareunia rates were comparable (2 studies). Pelvic floor outcomes (1 study) were limited, suggesting improved anterior compartment support (POP‐Q Aa; p   Discussion vNOTES hysterectomy demonstrates comparable medium‐term sexual and pelvic floor outcomes to laparoscopic approaches, with no signal of harm. Small samples, observational design and heterogeneity limited evidence, restricting definitive conclusions. Standardised long‐term studies are required to define functional safety and guide counselling.