Transvaginal natural orifice transluminal endoscopic removal of a retroperitoneal pedunculated myoma without peritoneal opening in a patient with prior abdominal surgery

Retroperitoneal pedunculated myomas located near the internal os are rare and can present challenges in surgical management, particularly in patients with prior abdominal surgery. This report demonstrates the feasibility of removing such a myoma using the vaginal natural orifice transluminal endoscopic surgery (vNOTES) approach without peritoneal opening. The patient had a history of open abdominal surgery with hypertrophic scar formation, which led to the decision to avoid transabdominal entry.

A 49-year-old woman with a history of open abdominal surgery for gastrointestinal stromal tumors (GIST) presented with dyspareunia and voiding difficulty. Magnetic resonance imaging (MRI) revealed a 10 cm retroperitoneal mass arising from the posterior uterine wall near the internal os. She had a prominent hypertrophic abdominal scar and strongly wished to preserve her uterus, expressing a preference to avoid transabdominal surgery. Under general anesthesia, a transvaginal approach using vNOTES was performed without peritoneal opening. A wound retractor was inserted, and the mass was identified retroperitoneally. Robotic myomectomy was performed using the single-port system and the stalk was coagulated and excised, and the myoma was completely removed. The base of the stalk was sutured to ensure hemostasis. Intracavitary pressure was monitored throughout to confirm that the peritoneum remained intact. The vaginal incision was then closed with absorbable sutures, and the procedure was completed without complications.

The mass was successfully removed without peritoneal opening. Estimated blood loss was about 100 mL, and postoperative hemoglobin decreased from 13.7 to 11.8 g/dL. Pain scores were low (numerical rating scale [NRS] 2 on the day of surgery, 1 on postoperative day 1). A soft diet was initiated on the evening of surgery in accordance with enhanced recovery after surgery (ERAS) principles. The patient was discharged on postoperative day 1 without complications. One-week postoperative ultrasound showed no fluid collection. Pathology confirmed a cellular leiomyoma.

This case demonstrates that transvaginal removal of a retroperitoneal pedunculated myoma using the vNOTES approach without peritoneal opening is feasible and safe, even in patients with prior abdominal surgery. Avoiding peritoneal entry may reduce postoperative pain, support early recovery, and minimize the risk of intra-abdominal adhesion, making this technique a valuable option for selected patients.