A prospective study investigated a surgical algorithm that favors vaginal hysterectomy (VH) in patients without uterine descent. Pure vaginal hysterectomy was successful in 87.9% of cases (145 patients), while 7.3% of patients (12) required vNOTES technique support and 4.8% (8 patients) were converted to laparoscopy or laparotomy. In total, 95.2% of patients (157) achieved vaginal completion without abdominal incisions. The high success rate was also maintained in risk groups – the success rate was 93.1% for obese patients and 96.0% for those with previous caesarean sections. Analysis showed that with increasing surgeon experience, the rate of clean vaginal hysterectomies increased (from 81.7% to 93.9%) and the use of vNOTES decreased (from 11.0% to 3.6%). The study concluded that a "vaginal first" approach should be the standard in the management of patients without uterine descent, with vNOTES serving as an educational tool and a safety valve to prevent the abdominal approach.