Uterine leiomyomas, or myomas, is a kind of benign tumor of female reproductive system with a high incidence rate. Previous investigations have documented an incidence rate ranging between 30% and 70%, primarily affecting women in their reproductive years [1,2]. While most patients are asymptomatic, larger myomas can lead to clinical symptoms such as anemia, dysmenorrhea, infertility, recurrent miscarriage, frequent urination, and difficulty defecating [3,4].

Surgical intervention is frequently recommended for patients presenting with evident clinical symptoms and myoma diameters exceeding 5 cm [5]. The preferred surgical approach for individuals necessitating the preservation of reproductive function is myoma removal [6]. Since the inaugural report on vNOTES myomectomy in 2018, this scarless surgical approach has witnessed rapid advancement [7]. Within our institution, vNOTES serves as the conventional surgical modality for patients with singular myomas. We have conducted nearly 5000 gynecological procedures utilizing vNOTES [8,9], including cases of early-stage gynecological cancers. Specifically, vNOTES offers benefits such as lack of abdominal scars, reduced postoperative pain, earlier return of bowel function and quicker postoperative recovery [10,11].

However, addressing posterior myomas via vNOTES in the conventional lithotomy position presents challenges. With the uterus positioned above the surgical field, fixation becomes difficult, and needle insertion and suturing follow non-standard directions, potentially resulting in inadequate suture depth and an increased risk of postoperative complications [10]. Consequently, we have devised the prone position for posterior myoma removal via vNOTES [12]. By adjusting the patient's body position, managing posterior myomas becomes a routine surgical procedure, enhancing ease of operation. Our previous investigation has demonstrated the feasibility of this surgical method, and our surgeons subjectively perceive managing posterior myomas in the prone position as more convenient [12]. However, there is currently insufficient objective evidence to substantiate the safety and advantages of this procedure.

Accordingly, this study investigates the perioperative variables related to the use of the prone position for posterior myoma removal via vNOTES, comparing it with the lithotomy position. The primary aim is to assess the myomectomy outcomes in patients with a single posterior myoma in both prone and lithotomy positions. Additionally, we have elucidated pivotal points for consideration by other surgeons embarking on this innovative surgical endeavor.