Pelvic organ prolapse is a common condition affecting the women worldwide. The lifetime risk for prolapse surgery is reported to be as high as approximately %19 [1]. Uterovaginal prolapse is a challenging condition for the urogynecologist. Although various surgical techniques, including uterus sparing ones exist, vaginal hysterectomy with the suspension of the vaginal cuff is the most frequently used procedure to treat apical prolapse.
Uterosacral ligament (USL) suspension is one of the two most commonly reported transvaginal apical (uterus or vault) prolapse repair procedures, performed using native tissue [2] . High USL suspension (HUSLS) is a modification which has led to a more stable point of fixation however it is burdened by the risk for hypogastric nerve and ureteral injury, especially with the utilization of the vaginal approach [3]. Laparoscopic approach is therefore preferred by many as it allows to overcome these complications.
Natural orifice transluminal endoscopic surgery (NOTES) is a minimally invasive surgical technique which has been receiving increasing attention for the past years. Various gynecological procedures can now be performed via transvaginal NOTES.
There are many studies that demonstrate the feasibility and outcomes of HSULS via transvaginal approach or laparoscopic approach. However, to the best of our knowledge, there is no case/video presentation or study reporting the natural orifice translumenal endoscopic surgery (NOTES) implementation of HUSLS.
The objective of this presentation is to present our initial experience of HUSLS via NOTES and to present the short-term outcomes and feasibility of the procedure.

From December 2018 to January 2019, 5 patients with symptomatic pelvic organ prolapse, aged 42-59, underwent NOTES high uterosacral ligament suspension at the time of vaginal hysterectomy. All of the participants had apical prolapse defined as Pelvic Organ Prolapse Quantification (POP-Q) stage III. Vaginal hysterectomy was performed in a classic fashion. A NOTES port was constructed using a sterile surgical glove, a pessary, 3 5-mm trocars and 1 10-mm trocar. Following vaginal hysterectomy a self constructed NOTES port was placed just beyond the vaginal cuff and pneumoperitoneum was achieved. 5-mm 30 degree scope and conventional laparoscopic instruments were utilized for NOTES. Bilateral salpingectomy or salpingo-oopherectomy was performed via NOTES. As an optional step, bowels were suspended to the anterior abdominal wall (performed in 1 case). Uterosacral ligaments were then identified under direct visualisation and ureterolysis was carried out on both sides to allow safer placement of the sutures and to avoid kinking of the ureters after sutures were placed and tied to the vaginal cuff. One 0 braided non-absorbable suture was placed into the proximal uterosacral ligaments on both sides. NOTES port was removed and 2 additional sutures (0 late absorbable) were placed into the distal uterosacral ligaments. Additional repairs (anterior colporraphy, posterior colporraphy) were performed when indicated. Finally uterosacral suspension sutures were sutured and tied to suspend the vaginal cuff at the time of colpotomy closure. Standard outcome measures (operative time, blood loss, pain scores and complications) and 6-week and 3-month follow-up visit data (POP-Q exam, quality of life questionnaires) were evaluated.

Between December 2018 and January 2019, data from 5 patients were evaluated retrospectively. All five patients returned for 6 week and 3 month follow-up. All five patients underwent vaginal hysterectomy and high uterosacral ligament suspension. Three patients received bilateral salpingo-oophorectomy and anterior colporraphy, one of the patients received bilateral salpingectomy and one other patient received bilateral salpingo-oophorectomy and posterior colporrhaphy as well. Mean operation time was 115+-15 minutes. Pain scores were 0 at postoperative 48 hours for all participants. Postoperative hospital stays were uneventful and all patients were discharged on postoperative day 2. There were no complications observed. Pre-operative and post-operative POP-Q examination data of the study participants were shown in table 1. Both subjective cure rate and objective cure rate (defined as POP-Q stage less than 2) was found to be %100.

All of the patients underwent NOTES HUSLS without any complications. Since NOTES allows endoscopic visualization similar to laparoscopic approach it gives surgeon all the capabilities laparoscopy could offer. This aids in eliminating complications related to traditional vaginal approach. Since all the procedure is carried transvaginally we believe that it provides better post-operative pain scores and quicker return to daily activities. Use of a self constructed NOTES port and conventional laparoscopic instruments makes it accessible and cost effective while being one of the least minimally invasive options. Furthermore utilization of NOTES increases the rate of successfully performed planned salpingectomy or salpingo-oophorectomy which is 100% in our study. Follow-up examination at 6-week and 3-month showed excellent subjective and objective improvement.

To the best of our knowledge this retrospective preliminary study is the first to evaluate HUSLS via NOTES. Although its proven success, due to complications especially the ones concerning the ureters, some surgeons avoid classic transvaginal HUSLS and opt for laparoscopic surgery. Furthermore rates of successfully performed planned salpingo-oopherectomy is reported to be higher in laparoscopy which may make it a favorable option.
We believe that NOTES implementation of HUSLS may encourage surgeons to choose vaginal route for HUSLS as it combines traditional vaginal approach with endoscopic approach and thus helps eliminating risks related to the traditional vaginal approach.
According to our short-term results, NOTES high uterosacral ligament suspension at the time of vaginal hysterectomy appears to be a feasible, safe and successful option for the surgical correction of apical prolapse.

Løwenstein E, Ottesen B, Gimbel H. Incidence and lifetime risk of pelvic organ prolapse surgery in Denmark from 1977 to 2009. Int Urogynecol J. 2015 Jan;26(1):49-55.
Jeffery ST, Doumouchtsis SK, Franco AVM, Fynes MM. High uterosacral ligament vault suspension at vaginal hysterectomy: ob- jective and subjective outcomes of a modified technique. J Obstet Gynaecol Res. 2009;35(3):539–44.
Margulies RU, Rogers MAM, Morgan DM. Outcomes of transvaginal uterosacral ligament suspension: systematic review and metaanalysis. Am J Obstet Gynecol. 2010;202(2):124–34.