Transureteral Natural Orifice Translumenal Endoscopic Surgery Nephrectomy: A Feasibility Study in the Porcine Model

Abstract

Aim: Natural orifice approaches for nephrectomy have included access via the stomach, vagina, bladder, and rectum. The use of the ureter as a natural orifice for natural orifice translumenal endoscopic surgery (NOTES) nephrectomy has not previously been reported. The aim of this study was to test the feasibility of transureteral laparoscopic NOTES nephrectomy. Materials and Methods: Three female farm pigs (29.2–30.8 kg) were placed into the lithotomy position. A cystoscopically placed extra-stiff guide wire was used to place a prototype dilating sheath into the left ureter. After dilation of the ureter and urethra, the sheath was exchanged for a 12-mm bariatric laparoscopic trocar. A 10.5-inch-long, 10-mm offset operating laparoscope with an internal 5-mm working port was utilized for the nephrectomy. One 2-mm and one 2/3-mm port were placed transabdominally to facilitate in situ morcellation. The kidney was cut into slices using the bipolar device and extracted via the ureteral port using the housing of a 12-mm bariatric stapling device. Results: All three transureteral nephrectomies were completed. The total mean operative time was 220 minutes (range, 113–346 minutes). Component portions of the procedure were ureteral access (mean, 21 minutes), nephrectomy (mean, 70 minutes), and kidney morcellation (mean, 103 minutes). Mean estimated blood loss was 20 mL (range, 5–50 mL). There were no intraoperative complications. Conclusions: This nonsurvival porcine feasibility study demonstrates the successful performance of transureteral nephrectomy. This approach shows promise as a way to decrease the invasiveness of NOTES nephrectomy by using the ureteral orifice as an access site. No competing financial interests exist. Runtime of video: 5 mins