Feasibility of Right and Left Transvaginal Retroperitoneal Nephrectomy: From the Porcine to the Cadaver Model

Abstract

Minimally invasive nephrectomy performed through a natural orifice such as the vagina could enhance cosmesis and improve patient acceptance of the procedure and postoperative recovery. As the vagina has already been proposed as a site of specimen extraction in patients undergoing laparoscopic nephrectomy, the aim of this study was to explore the feasibility of transvaginal, retroperitoneal natural orifice transluminal endoscopic surgery (NOTES) nephrectomy for both left- and right-sided kidneys initially in a porcine model and thereafter in a human cadaver model. Ten female pigs underwent NOTES nephrectomy (five having a left nephrectomy and five having right nephrectomy). To do this, each pig was anesthetized and placed in a supine position. A retroperitoneal conduit was established by means of a posterior colpotomy and the retroperitoneal space then entered with a conventional double-channel endoscope (Storz). Thereafter, careful blunt dissection allowed a passage to be created up to the renal vessels and proximal ureter which were then dissected and divided separately after endoscopic clipping. We then attempted to reproduce the technique in two formaldehyde-preserved female cadavers. All the porcine procedures were accomplished by a totally NOTES approach with a mean operative time of 50 minutes (range 45-60). No bleeding or injury to any of the retroperitoneal structures occurred. In the two cadavers, the retroperitoneal access was reproduced, but a complete dissection of the kidney was not possible because of the rigor of the surrounding tissues. Transvaginal retroperitoneal NOTES right and left nephrectomy is certainly accomplishable in the porcine model, and the feasibility of the access was confirmed in two cadavers. As a retroperitoneal transvaginal dissection preserves the peritoneum and obviates bowel handling, this work should encourage further development of NOTES accesses for renal surgery.