Vaginal Natural Orifice Endoscopic Surgery for Primary Uterovaginal Prolapse: Evidence, Evolution, and Standardized Surgical Technique for Uterosacral Ligament Suspension.

INTRODUCTION AND HYPOTHESIS: Vaginal natural orifice transluminal endoscopic surgery (vNOTES) has emerged as a minimally invasive approach for primary uterovaginal prolapse with increasing application in urogynecology. A systematic review published in 2025 supports vNOTES uterosacral ligament suspension (USLS) as an alternative mode of access with favorable perioperative anatomic and patient-centered outcomes compared to conventional transvaginal repair. METHODS: In April 2026, a consensus conference on controversies in the surgical management of primary uterovaginal prolapse (U-POP) was conducted with the overarching goal of developing an evidence-based algorithm for surgical decision-making and standardizing best-practice surgical techniques for U-POP. For vNOTES USLS, a 2025 systematic review served as the primary evidence base for generation of consensus statements that were submitted for delphi voting. A recommendation for preferred surgical technique of vNOTES USLS was developed on the basis of expert opinion. RESULTS: Current evidence suggests improved operative efficiency, low complication rates, and improved visualization of the ureters and pelvic sidewall anatomy compared to conventional vaginal uterosacral ligament suspension. This review describes the integration of vNOTES in urogynecology, reviews the current evidence regarding safety and outcomes, and provides stepwise surgical technique and best-practice considerations for vNOTES USLS for the surgical treatment of primary U-POP with accompanying videos. CONCLUSIONS: vNOTES provides improved visualization of the uterosacral ligaments and using a standardized technique, may offer advantages over laparoscopic and conventional transvaginal uterosacral ligament suspension for primary uterovaginal prolapse repair.