To compare the surgical and postoperative outcomes of vaginal natural orifice transluminal endoscopic surgery (vNOTES) with conventional or single-site laparoscopy in the management of tubal ectopic pregnancy.

Studies were eligible if they directly compared vNOTES with conventional or single-site laparoscopy for the surgical treatment of tubal ectopic pregnancy. Two reviewers independently screened titles and abstracts, assessed full texts, and evaluated risk of bias using the Cochrane Risk-of-Bias tool for randomized trials or the ROBINS-I tool for nonrandomized studies. Discrepancies were resolved through discussion or third-party adjudication. After removing duplicates, 2661 records were screened, 14 underwent full-text review, and 5 studies met the inclusion criteria.

Five studies comprising 550 women (224 vNOTES; 326 laparoscopy) were included. Meta-analysis revealed a nonsignificant trend toward shorter operative time with vNOTES (MD, −10.08 min; 95 % CI, −22.03 to 1.86; p = .10) and no significant differences in estimated blood loss (MD, −2.79 mL; p = .51) or postoperative VAS pain scores (MD, −1.69; p = .23). vNOTES was associated with significantly reduced postoperative analgesic requirements (OR 0.27; 95 % CI 0.13–0.58; p < .001) and shorter hospital stay (MD, −0.32 days; 95 % CI, −0.59 to −0.05; p = .08). The conversion rate was higher with vNOTES (OR 6.72; 95 % CI 1.11–40.78; p = .04), occurring in 2.9 % of vNOTES cases, all converted to laparoscopy. Overall complication rates were comparable, with only Clavien–Dindo I–II events reported.

This systematic review with meta-analysis provides preliminary evidence that vNOTES is a feasible minimally invasive alternative to laparoscopy for tubal ectopic pregnancy when performed by experienced surgeons. The higher conversion rate reflects both patient-specific factors and the technical demands of the transvaginal approach, emphasizing that vNOTES requires appropriate surgical training and expertise. High-quality prospective studies are required to clarify patient selection, long-term reproductive outcomes, and training requirements before widespread clinical adoption.