Robotic single-port (SP) vaginal hysterectomy: the first cases in Europe and surgical steps

BACKGROUND: Vaginal hysterectomy is the preferred approach when feasible, but technical limitations may restrict its use in complex cases. Robotic assistance combined with vaginal natural orifice transluminal endoscopic surgery (vNOTES) aims to overcome these limitations. The da Vinci® Single-Port (SP) system, designed for narrow spaces, may further optimize robotic-assisted vaginal surgery. METHODS: We conducted a retrospective, single-center case series including all robotic-assisted vaginal hysterectomies performed using the da Vinci® SP system (RSP-vNOTES) between October 2024 and April 2026. Clinical, perioperative, and postoperative data were collected from medical records. Outcomes were analyzed using descriptive statistics. RESULTS: Seventeen RSP-vNOTES hysterectomies were performed by two experienced surgeons. Median total operative time was 74 min (60.8, 96.8). The main surgical indication was uterine fibroids with large uterine volume; median uterine weight was 370 g (61, 800). Estimated blood loss was minimal, with no conversions or intraoperative complications. Sixteen patients (94.1%) underwent same-day discharge; one patient required one night hospitalization due to anesthetic contraindications related to comorbidities. Postoperative pain was low, with a median VAS score of 0 at 4 h (0-1). No postoperative complications were observed within 30 days. CONCLUSION: Robotic-assisted vaginal hysterectomy using the da Vinci® Single-Port system is feasible and safe, with favorable short-term outcomes, including in cases with large uterine volume. Direct intravaginal insertion of the SP access port provides effective robotic assistance in a confined anatomical space. Larger prospective studies are needed to confirm these findings and further define the role of single-port robotic technology in vaginal gynecologic surgery.