Natural Orifice Transluminal Endoscopic Surgery Nephrectomy Research Articles

Transvaginal natural orifice transluminal endoscopic surgery in female urologic diseases

Objective To describe our experience with the transvaginal natural orifice transluminal endoscopic surgery (NOTES) in female patients, and to evaluate its clinical value. Methods Between May 2010 and April 2017, a total of 289 female patients underwent transvaginal NOTES in our center, including 31cases of adrenal tumors, 46 cases of renal tumors, 188 cases of non-functional kidneys, 5 cases of renal cysts, 4 cases of duplex kidney, 7 cases of renal tuberculosis and 8 cases of renal pelvis tumors. Among them, 146 cases were on the left side, 142 cases on the right side, and 1 case on both sides (renal cysts). The median age was 39.4 (range 23 to 76) years, and the median body mass index was 21.8(range 15.4 to 32.6)kg/m2. After general anesthesia, the patients were positioned in lithotomy with ipsilateral lumbar at 30°-60° angle to the floor. Hybrid and pure transvaginal NOTES were performed. The specimen was removed through an extended incision at the posterior vaginal fornix. Results Transvaginal NOTES was successfully completed in 281 patients. Two patients required conversion to suprapubic-assisted laparoendoscopic single-site surgery because of the rectal injury in pure transvaginal NOTES nephrectomy. Six patients underwent open conversion. The various transvaginal hybrid NOTES procedures included adrenalectomy (31 cases), nephrectomy (206 cases; simple 174 cases, radical 32 cases), partial nephrectomy (13 cases), heminephroureterctomy for duplex kidney (4 cases) and hybrid endoscopy for nephroureterectomy (7 cases). The mean operative time was 105 min (45-310 min), the mean estimated blood loss was 87 ml (20-800 ml), the mean visual analogue score (VAS) of 48 hours after operation was 2.5 (1-4) points and the mean hospitalization was 7.3 d (4-13 d) for transvaginal hybrid NOTES. The various pure transvaginal NOTES procedures included nephrectomy (22 cases; simple 21, radical 1), renal cyst excision (5 cases). The mean operative time was 170 min (60-320 min), the mean estimated blood loss was 140 ml (20-500 ml), the mean VAS of 48 hours after operation was 1.7 (1-3) points and the mean hospitalization was 5.5 d (3-10 d) for transvaginal pure NOTES. Complications occurred in 56 cases (19.38%), including 20 cases (6.92%) of severe complications, and no death occurred. After a mean follow-up of 51 (range 3 to 86) months, umbilicus scar was hidden. The incision in the vagina healed well. No infection in the abdominal or pelvic cavity or celiocele occurred. The umbilicus scar is not obvious after surgery, and 3 months after surgery.The median Patient Scar Assessment Questionnaire (PSAQ) score was 38 (31-58) and the median Female Sexual Function Index (FSFI) score was 28.2 (22.5-32.2), and the quality of life index was significantly higher than that of preoperation. Conclusions Transvaginal NOTES could treat variousprimary diseases, and improve the postoperative quality of life. It does not increase the incidence of related complications, or cause negative effect on the female sexual function, pregnancy or fertility. It can lead to good cosmetic outcome and less pain, which is worth applying in clinical practice. Key words: Natural orifice transluminal endoscopic surgery (NOTES); Transvaginal approach; Female; Urologic diseases

Transvaginal Natural Orifice Transluminal Endoscopic Nephrectomy in a Series of 63 Cases: Stepwise Transition From Hybrid to Pure NOTES

BackgroundThe feasibility of hybrid transvaginal NOTES (natural orifice transluminal endoscopic surgery) nephrectomy (HTNN) has already been demonstrated. However, pure transvaginal NOTES nephrectomy (PTNN) has been limited to animal experiments with only one report of its use in humans. ObjectiveTo describe our initial experience with HTNN and a stepwise transition towards PTNN. Design, setting, and participantsBetween May 2010 and September 2011, 63 patients underwent nephrectomy (60 HTNNs and 3 PTNNs) in our institution, including 45 patients with benign renal disease and 18 patients with malignant renal disease. Surgical procedureOf the HTNNs, 33 were performed using two umbilical trocars and one transvaginal trocar, and 27 were performed using one umbilical trocar and a transvaginal multi-instrument access port; 3 PTNNs were performed using a self-developed, three-channel ZOU-port without any transumbilical assistance. Outcome measurements and statistical analysisAll data referring to patient demographics, surgery, pathology, and perioperative outcomes were recorded. Sexual function was assessed with the Female Sexual Function Index (FSFI) questionnaire before and after surgery. The cosmetic result was investigated by administering the Patient Scar Assessment Questionnaire and Scoring System (PSAQ). Results and limitationsA total of 59 HTNNs and 3 PTNNs were successfully performed. One patient was converted to open surgery because of injury to the inferior vena cava. The mean operative time was 130min (range: 100–260min) for HTNN and 193min (range: 180–210min) for PTNN. The mean estimated blood loss was 150ml. The mean postoperative hospital stay was 7.4 d. Forty-eight patients completed the FSFI questionnaire, and analysis did not show differences in FSFI scores before and after surgery. The better cosmetic results were confirmed by the PSAQ score. ConclusionsHTNN is feasible and safe in appropriate patients. Existing instruments are adequate for HTNN, but significant improvement is still needed. PTNN is technically challenging, but is feasible and may be performed safely. Further improvement of instruments is necessary for PTNN. Clinical investigation in comparison to the established techniques should take place to evaluate the outcome of technique. Patient summaryPure transvaginal natural orifice transluminal endoscopic nephrectomy (PTNN) is technically challenging but feasible and may be performed safely. Further improvements in instruments are necessary for PTNN.

Urological applications of natural orifice transluminal endoscopic surgery (NOTES).

Improvements in surgical techniques, and particularly the development and widespread clinical introduction of laparoscopy in the past two decades, have revolutionized the management of urological disease. Natural orifice transluminal endoscopic surgery (NOTES) holds promise in further advancing treatment outcomes in urology. This novel minimally invasive surgical approach can negate the requirement for skin incisions and, therefore, could potentially improve morbidity, convalescence, and cosmesis. After considerable preclinical development, the feasibility of 'hybrid' NOTES-involving concurrent laparoscopy-and 'pure' NOTES nephrectomy and prostatectomy procedures has now been successfully demonstrated in patients with urological conditions, whereas proof-of-concept studies of NOTES partial cystectomy have been performed in animal models. Whether such procedures offer therapeutic and safety benefits compared with traditional laparoscopic techniques remains unknown; indeed, concerns remain over the potential perioperative and postoperative adverse events associated with NOTES, such as incomplete closure of the entry-point incision, infection, and haemorrhage. In particular, however, the requirement for the development of specific rationally designed NOTES instrumentation as well as specially trained, highly skilled personnel to perform the surgery continues to restrict the utility of NOTES. Thus, considerable effort is now needed to shift the focus of research to refining NOTES methodologies to enable translation of these promising proof-of-principle studies into the clinic.

Hybrid transureteral nephrectomy in a survival porcine model.

Background and Objectives:Natural-orifice approaches for nephrectomy have included access via the stomach, vagina, bladder, and rectum. Recently, the feasibility of using the ureter as a natural orifice for natural-orifice transluminal endoscopic surgery nephrectomy has been demonstrated in a nonsurvival porcine model. The purpose of this study was to assess the outcomes of transureteral laparoscopic natural-orifice transluminal endoscopic surgery nephrectomy in a survival porcine model.Methods:Three pigs underwent hybrid transureteral natural-orifice transluminal endoscopic surgery nephrectomy. An experimental balloon/dilating sheath was inserted over a wire to dilate the urethra, ureteral orifice, and ureter. Through a bariatric 12-mm laparoscopic port, the ureter was opened medially and the hilar dissection was performed. Next, 2 needlescopic ports were placed transabdominally to facilitate hilar transection. The kidney was morcellated using a bipolar sealing device and extracted via the ureter using the housing of a bariatric stapling device. The ureteral orifice was closed with a laparoscopic suturing device. The bladder was drained by a catheter for 10 to 14 days postoperatively. Pigs were euthanized on postoperative day 21.Results:All surgical procedures were successfully completed, with no intraoperative complications. One pig had an episode of postoperative clot retention that resolved with catheter irrigation. Each pig was healthy and eating a normal diet prior to euthanasia.Conclusions:This study demonstrates the feasibility of a hybrid transureteral approach to nephrectomy in a survival porcine model. This technique avoids the intentional violation of a second organ system and the risk for peritoneal contamination. Improved instrumentation is needed prior to implementation in the human population.

Comparison of Transrectal and Transvaginal Hybrid Natural Orifice Transluminal Endoscopic Surgery Partial Nephrectomy in the Porcine Model

To compare the feasibility of porcine transrectal (TR) and transvaginal (TV) hybrid natural orifice transluminal endoscopic surgery (NOTES) partial nephrectomy (PN), as NOTES nephrectomy has recently been performed in the porcine model. A total of 10 female pigs (weight 45 kg) underwent TR (n= 5) or TV (n= 5) NOTES PN. The pneumoperitoneum was created by a periumbilical 12-mm trocar, through which a laparoscope was advanced for intra-abdominal visualization. For TV-NOTES PN, a gastroscope was used to obtain TV peritoneal access. For TR-NOTES PN, a horizontal incision was made 2 cm above the dentate line, and a submucosal tunnel was created in the posterior rectal wall. The gastroscope was advanced through the submucosal tunnel and retroperitoneum to the kidney, and a peritoneal window was created. For both TR- and TV-NOTES PN, the gastroscope was exchanged for the SPIDER Surgical System. Flexible dissecting instruments and hook cautery introduced through the SPIDER Surgical System were used to mobilize the kidney. A harmonic scalpel introduced periumbilically was used to excise a portion of the lower pole. LAPRA-TY-secured sutured renorrhaphy was performed, followed by TR or TV specimen extraction. TR- and TV-NOTES PN was successfully performed in all 10 pigs. A comparison of TR- and TV-NOTES PN revealed no significant differences in the mean access time (29.2 vs 29.6 minutes, P= .944), operative time (196.0 vs 183.0 minutes, P= .631), and estimated blood loss (59.0 vs 54.0 mL, P= .861). Necropsy did not demonstrate abdominal injuries. We have demonstrated proof-of-principle for TR and TV-NOTES PN in swine, with comparable perioperative parameters. Preclinical survival studies are requisite to assess the potential of TR-NOTES as an alternative to TV-NOTES.

Feasibility of Transrectal Hybrid Natural Orifice Transluminal Endoscopic Surgery (NOTES) Nephrectomy in the Cadaveric Model

To examine feasibility of transrectal hybrid natural orifice transluminal endoscopic surgery (NOTES) nephrectomy in human cadavers in the evolution of this technique, as transrectal hybrid NOTES nephrectomy has been demonstrated in the porcine model. Four hybrid transrectal NOTES nephrectomies were performed on 4 cadavers (3 female/1 male, 2 right/2 left). Pneumoperitoneum was created by periumbilical 12-mm trocar, through which a laparoscope was advanced to obtain intra-abdominal visualization. A 4-cm horizontal incision was made 2-cm above the dentate line and a submucosal tunnel was created in the posterior rectal wall/presacral space. A dual-channel gastroscope was advanced through the submucosal tunnel and retroperitoneum to the level of the kidney using air insufflation. A peritoneal window was created and renal mobilization was completed. A transumbilically applied laparoscopic 45-mm stapler was used to transect the ureter and renal hilum. A specimen entrapment bag was deployed transrectally for specimen extraction, followed by transrectal incision closure. Transrectal NOTES nephrectomy was successfully performed in all cases, with intact specimen extraction. Median weight was 77 kg (range 74-85 kg); median body mass index (BMI) was 30.1 kg/m(2) (range 25.6-31.2 kg/m(2)). Mean operative time was 175 minutes (range 150-210 minutes). Median transrectal access time was 36 minutes (range 24-47 minutes). Median dimensions of removed kidneys were length 11.2 cm (range 10-12 cm), width 5 cm (range 4.5-6 cm), and thickness 3.8 cm (range 3-4.5 cm). Transrectal hybrid NOTES nephrectomy in the cadaver model is feasible with intact specimen extraction and acceptable operative times. Preclinical survival studies are requisite to assess sterility and complications. This approach may be an alternative to transvaginal access.

Pure and hybrid natural orifice transluminal endoscopic surgery (NOTES): current clinical experience in urology

An exciting era of discovery in the field of scarless urological surgery has just begun. Hybrid natural orifice transluminal endoscopic surgery (NOTES) nephrectomy has been reported by a few groups in the last two years. Recently, our group at the Cleveland Clinic was able to demonstrate the feasibility of a transvaginal pure NOTES nephrectomy. During this pioneering period, a critical appraisal of results and a scrupulous determination of benefits are of utmost importance. Further studies are awaited to define the actual role of NOTES in the management of urological diseases.

Nefrectomía simple laparoscópica NOTES y LESS con el uso de instrumentos laparoscópicos estándar: Experiencia inicial en 3 casos

NOTES and LESS laparoscopic simple nephrectomy with the use of standard laparoscopic instruments: Initial experience in 3 cases Introduction: Natural orifi ce transluminal endoscopic surgery (NOTES) and Laparoendoscopic Single Site Surgery (LESS) are emerging technologies, which allows to performed surgical procedures avoiding any sur- gical scars. However there are some problems due to the lack of equipment available for these procedures. The aim of these study is to present our initial experience with the transvaginal nephrectomy NOTES and LESS using standard laparoscopic instruments. Material and Methods: Two female patients (23 and 26 years old) with diagnosis of recurrent urinary tract infection and renal atrophy. A laparoscopic simple nephrectomy with transvaginal NOTES assistance was performed, using one access port for the camera and two abdominal work ports of 10 and 3mm. In a third patient (15 years old) a transumbilical LESS nephrectomy was preformed with the use of standard laparoscopic instruments. Results: Average operative time was 110 min (40-200), with an estimated blood loss of 200 cc. There were no perioperative complications and all patients were discharged 36 hours after surgery. Conclusion: Laparoscopic simple nephrectomy with transvaginal NOTES assistance and LESS are technically feasible with the use of standard laparoscopic instruments. Special access trocars and instruments development for this procedure will allow to performed a pure technique without the use of abdominal incisions

Hybrid Natural Orifice Transluminal Endoscopic Surgery for Nephrectomy with Standard Laparoscopic Instruments: Experience in a Canine Model

The aim of this study was to demonstrate the feasibility of hybrid natural orifice transluminal endoscopic surgery (NOTES) nephrectomy with standard laparoscopic instruments through a modified vaginal trocar in a canine model. Ten cross-bred adult female dogs were used for right (n = 4) and left (n = 6) transvaginal nephrectomy. After transumbilical peritoneoscopy, a laparoscopic transvaginal trocar was introduced through the posterior vaginal fornix under direct vision. Using a 10-mm working laparoscope lens with a 3-mm working channel as endovision via the umbilical port and the transvaginal port, triangulation and dissection of the kidney and its hilum were performed. The renal artery and vein were closed with Hem-o-lok clips transvaginally. At the end of the procedure, after snaring the kidney in an endobag, the specimen was retrieved through a colpotomy incision by extending the vaginal port site. All procedures were completed without need for conversion. The mean operative time was 101 minutes (75-135 minutes). The mean preoperative/postoperative hemoglobin was 12.01/11.7 g/dL and intraoperative blood loss was minimal. The mean size of the removed kidneys was 9.1 x 5.1 cm and the mean weight was 98.5 g (90-115 g). Exploration of the abdomen and vagina after 1 month showed complete healing of the colpotomy incision with no visceral injury. There were no significant adhesions or fibrotic changes in the renal fossa. Hybrid NOTES nephrectomy is technically feasible in canine model with a standard laparoscopic setup and instruments. This study may remove barriers for further investigational work with NOTES technique, especially with a view to adapting it for use in low-resource centers, while offering a strategy to help surgeons train with this novel technology.

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

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.

Endoloop© Closure of the Urinary Bladder is Safe and Efficient in Female Piglets Undergoing Transurethral NOTES Nephrectomy

Recently, we showed that various procedures for rigid Natural Orifice Transluminal Endoscopic Surgery (NOTES) can be successfully performed in piglets. However, the safety and effectiveness of endoscopic closure of the urinary bladder remains to be determined before introducing transurethral NOTES in children. Our study was designed to investigate the safety and impermeability of the urinary bladder after endoscopic closure in transurethrally assisted nephrouretectomy in piglets. Five female piglets (mean weight 14.5 kg; range: 14-15) underwent right-sided transurethral nephroureterectomy using a hybrid technique with one 15 mm trocar placed umbilically and one 3 mm trocar placed transvesically. Hilar dissection was performed with a 5 mm Endoligasure vessel sealing device. After umbilical retrieval of the resected kidney, the urinary bladder was closed by an Endoloop via an umbilical "two in one system" with the assistance of a 2 mm transurethrally placed endoscopic clamp. Endpoints of the study were total operation time, duration of cystoscopy and transurethral trocar positioning, duration of nephrectomy, duration of bladder closure and determination of bladder impermeability. Intraoperatively, bladder filling was performed with normal saline (ml), while bursting pressure (mmHg) was measured by filling the harvested bladder with air. All nephroureterectomies were successfully performed with negligible blood loss. Mean total operation time was 46 min (range: 35-69). Cystoscopy and transurethral trocar positioning took 14 min (range: 9-23), and nephrectomy took 28 min (range: 18-48). Mean duration of bladder closure was 4 min (range: 2-6). Mean volume of intraoperative bladder filling was 94 ml (range: 80-100), indicating adequate capacity after closure with Endoloops. Post-mortem bladder impermeability was confirmed by a mean air filling bursting pressure of 88 mmHg (range: 70-140) indicating sufficient bladder closure. A safe urinary bladder closure is mandatory for transurethral rigid NOTES procedures and can be adequately achieved with Endoloops.

Pure ‘natural orifice transluminal endoscopic surgery’ for transvaginal nephrectomy in the porcine model

To determine the technical feasibility and reproducibility of pure natural orifice transluminal endoscopic surgery (NOTES) transvaginal nephrectomy using NOTES-specific instrumentation, with no transabdominal assistance. Five female farm pigs (mean weight 45 kg) had a right NOTES nephrectomy, using a single-channel gastroscope in the first three pigs and a dual-channel gastroscope in the remaining two. The peritoneal cavity was accessed through the posterior fornix of the vagina. Dissection was started at the lower pole of the kidney, and the ureter was retracted laterally and followed towards the hilum. An XL articulated 60 cm endo-GIA stapler (US Surgical, Norwalk, CO, USA), inserted transvaginally via a separate vaginal incision, was used for tissue retraction and renal hilar transection. The kidney was freed, entrapped in an impermeable sac, and extracted intact transvaginally. All five procedures were successful with no addition of a transabdominal laparoscopic port or open conversion. The total operative duration decreased from 200 min in the first pig to 60 min in the last (mean 113 min); the mean blood loss was <50 mL, the mean kidney length was 13.9 cm and the weight was 142 g. There were no intraoperative complications; at autopsy, there was no pelvic or bowel injury. Pure NOTES transvaginal nephrectomy is feasible in the porcine model. It has the potential of a less morbid approach, providing truly scar-less surgery. Further development of instrumentation is necessary.

Commentary on Complete transvaginal NOTES nephrectomy using magnetically anchored instrumentation

Evolution of minimally invasive techniques has prompted interest in natural orifice transluminal endoscopic surgery (NOTES). Challenges for NOTES include loss of instrument rigidity, reduction in working envelopes, and collision of instrumentation. Magnetic anchoring and guidance system (MAGS) is one surgical innovation developed at our institution whereby instruments that are deployed intra-abdominally are maneuvered by the use of an external magnet. We present our initial animal experience with complete transvaginal NOTES nephrectomy using MAGS technology. Transvaginal NOTES nephrectomy was performed in two female pigs through a vaginotomy, using a 40-cm dual-lumen rigid access port inserted into the peritoneal cavity. A MAGS camera and cauterizer were deployed through the port and manipulated across the peritoneal surface by way of magnetic coupling via an external magnet. A prototype 70-cm articulating laparoscopic grasper introduced through the vaginal access port facilitated dissection after deployment of the MAGS instruments. The renal artery and vein were stapled en-bloc using an extra-long articulating endovascular stapler. NOTES nephrectomies were successfully completed in both pigs without complications using MAGS instrumentation. The MAGS camera provided a conventional umbilical perspective of the kidney; the cauterizer, transvaginal grasper, and stapler preserved triangulation while avoiding instrument collisions. Operative duration for the 2 cases was 155 and 125 minutes, and blood loss was minimal. NOTES nephrectomy using MAGS instrumentation is feasible. We believe this approach improves shortcomings of previously reported NOTES nephrectomies in that triangulation, instrument fidelity, and visualization are preserved while hilar ligation is performed using a conventional stapler without need for additional transabdominal trocars.

Complete Transvaginal NOTES Nephrectomy Using Magnetically Anchored Instrumentation

Evolution of minimally invasive techniques has prompted interest in natural orifice transluminal endoscopic surgery (NOTES). Challenges for NOTES include loss of instrument rigidity, reduction in working envelopes, and collision of instrumentation. Magnetic anchoring and guidance system (MAGS) is one surgical innovation developed at our institution whereby instruments that are deployed intra-abdominally are maneuvered by the use of an external magnet. We present our initial animal experience with complete transvaginal NOTES nephrectomy using MAGS technology. Transvaginal NOTES nephrectomy was performed in two female pigs through a vaginotomy, using a 40-cm dual-lumen rigid access port inserted into the peritoneal cavity. A MAGS camera and cauterizer were deployed through the port and manipulated across the peritoneal surface by way of magnetic coupling via an external magnet. A prototype 70-cm articulating laparoscopic grasper introduced through the vaginal access port facilitated dissection after deployment of the MAGS instruments. The renal artery and vein were stapled en-bloc using an extra-long articulating endovascular stapler. NOTES nephrectomies were successfully completed in both pigs without complications using MAGS instrumentation. The MAGS camera provided a conventional umbilical perspective of the kidney; the cauterizer, transvaginal grasper, and stapler preserved triangulation while avoiding instrument collisions. Operative duration for the two cases was 155 and 125 minutes, and blood loss was minimal. NOTES nephrectomy using MAGS instrumentation is feasible. We believe this approach improves shortcomings of previously reported NOTES nephrectomies in that triangulation, instrument fidelity, and visualization are preserved while hilar ligation is performed using a conventional stapler without need for additional transabdominal trocars.

Pure Natural Orifice Transluminal Endoscopic Surgery (NOTES) Nephrectomy Using Standard Laparoscopic Instruments in the Porcine Model

Natural Orifice Transluminal Endoscopic Surgery (NOTES) is an emerging technology that uses endoscopic instruments passed into the peritoneal cavity through hollow viscera to perform surgical procedures without the use of abdominal incisions. There are, however, limitations regarding the equipment available to simulate traditional surgery. The aim of this study was to determine the feasibility of a pure NOTES nephrectomy by using standard laparoscopic instruments through a modified transvaginal trocar. One 40-kg female swine underwent transgastric peritoneoscopy. Transgastric endoscopic visualization guided the introduction of a second transvaginal endoscope through a novel laparoscopic trocar/endoscopic overtube device. The retroflexed transgastric endoscope provided triangulated visualization as standard endoscopic instruments provided retraction, which allowed dissection of the kidney with standard laparoscopic instruments through our modified transvaginal trocar device. Each renal hilum, artery, vein, and ureter was dissected and divided with a transvaginal laparoscopic stapler. Transgastric and transvaginal NOTES accesses were easily achieved, and bilateral nephrectomies were performed. Completion of peritoneoscopy revealed complete hemostasis and identification of ligated ureters and hilar vessels. Total operative time was 40 and 20 minutes for the right and left kidney, respectively. One kidney was captured with a laparoscopic retrieval sac and removed intact through the vaginal defect. Pure NOTES nephrectomies are technically feasible in the porcine model by using standard laparoscopic instruments. Survival studies are necessary to determine the long-term complications and physiologic implications of NOTES nephrectomy. The development of innovative NOTES access trocars may allow for an increased armamentarium of NOTES instruments.

Rapid Communication: Robot-Assisted NOTES Nephrectomy: Initial Report

Natural Orifice Transluminal Endoscopic Surgery (NOTES) using the daVinci robot (Intuitive Surgical, Sunnyvale, CA) has never been applied to urologic surgery. Here we present our initial experience with a combined transvaginal and transcolonic, single-port, robot-assisted NOTES nephrectomy. An acute experiment was performed in a female farm pig. A single 12-mm trocar was placed in the midline, and two 12-mm standard laparoscopic ports were placed into the abdomen via the vagina and the colon. The robotic ports were then telescoped into the 12-mm ports, and the daVinci S robot was docked. Dissection was performed using the Hot Shears and the ProGrasp instruments. The robotic camera was placed via the midline port and held by an assistant. Using the 12-mm transvaginal port, the renal artery and vein were divided separately with a vascular Endo GIA (US Surgical, Norwalk, CT) stapler. The kidney was placed into a 10-mm entrapment sack and removed intact via the vagina. Total operative time was 150 minutes. Estimated blood loss was less than 50 mL. No intraoperative complications occurred. A robot-assisted NOTES nephrectomy was accomplished in a porcine model using the daVinci S robot. Additional testing on survival animals is necessary to further explore this approach.