Transvaginal Procedures Research Articles

Sexual function in women following transvaginal mesh procedures for the treatment of pelvic organ prolapse

Synthetic mesh kits recently adopted in pelvic reconstructive surgeries have achieved great surgical efficacy, but the effects of transvaginal synthetic mesh procedures on women's sexual function are still controversial. This study was conducted to demonstrate sexual function in women before and after surgery with transvaginal mesh (TVM) repair for pelvic organ prolapse (POP). A total of 93 sexually active women scheduled for correcting POP with synthetic mesh kits were recruited. In addition to urogynecological history, pelvic examination by the Pelvic Organ Prolapse Quantification system, and urodynamic testing, consenting participants were asked to complete the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) to evaluate sexual function before and after surgery. At the 3-month urodynamic studies, among the 25 patients with coexistent urodynamic stress incontinence (USI) who had undergone a concomitant transobturator suburethral tape procedure (TOT), 1 (4 %) had persistent USI; 8 of 68 (11.8 %) patients with a negative pessary test developed postoperative USI. Six-month prolapse recurrence rates following TVM alone and TVM with concomitant TOT were 9 and 12 %, respectively. The total PISQ-12 score after surgery showed worse results in the TVM alone group but not in the TVM with concomitant TOT group. The individual scores of PISQ-12 after surgery demonstrated prolapse-related items improved in both TVM groups; sexual function worsened in dyspareunia and behavior domains. Our data revealed that transvaginal synthetic mesh procedures for the treatment of POP generated favorable clinical outcomes, but situations might worsen in dyspareunia and behavior domains, thereby invoking a negative emotional reaction during intercourse after surgery.

Natural orifice translumenal endoscopic surgery applications in clinical practice

To review natural orifice translumenal endoscopic surgery (NOTES) applications in clinical practice and assess the evidence base for each application as reported in the literature. An electronic literature search was performed. Inclusion criteria were publications relating to NOTES applications in humans. For each type of operation the highest level of evidence available for clinical NOTES publications was evaluated. Morbidity and short-term operative outcomes were compared with gold standard published evidence where available. Finally, registered trials recruiting patients for NOTES applications were identified. Human NOTES publications with the highest level of evidence in each application are identified. There were no RCTs in the literature to date. The strongest evidence came in the form of large, multi-centre trials with 300-500 patients. The results are encouraging, comparable with gold standard techniques on morbidity and mortality. While short-term operative outcomes were also similar when compared to the gold standard techniques, other than improved cosmesis little else can definitely be concluded as a clear benefit of a NOTES procedure. The most common procedures are cholecystectomy, appendicectomy and peritoneoscopy mainly performed via transvaginal access. It is evident that morbidity appears to be higher when the transgastric route is used. The safety profile of hybrid NOTES transvaginal procedures is beginning to be confirmed as is evident from the large number of procedures presented in this review. A number of authors have presented work on pure NOTES procedures but the results are inconsistent and thus the vast majority of NOTES procedures worldwide are performed in a hybrid fashion with a variable amount of laparoscopy. This review of the clinical applications of NOTES summarises the growing evidence behind this surgical discipline and highlights NOTES procedures with an acceptable safety profile.

Qualitative and quantitative analysis of women’s perceptions of transvaginal surgery

Prior surveys evaluating women's perceptions of transvaginal surgery both support and refute the acceptability of transvaginal access. Most surveys employed mainly quantitative analysis, limiting the insight into the women's perspective. In this mixed-methods study, we include qualitative and quantitative methodology to assess women's perceptions of transvaginal procedures. Women seen at the outpatient clinics of a tertiary-care center were asked to complete a survey. Demographics and preferences for appendectomy, cholecystectomy, and tubal ligation were elicited, along with open-ended questions about concerns or benefits of transvaginal access. Multivariate logistic regression models were constructed to examine the impact of age, education, parity, and prior transvaginal procedures on preferences. For the qualitative evaluation, content analysis by independent investigators identified themes, issues, and concerns raised in the comments. The completed survey tool was returned by 409 women (grouped mean age 53 years, mean number of 2 children, 82% ≥ some college education, and 56% with previous transvaginal procedure). The transvaginal approach was acceptable for tubal ligation to 59%, for appendectomy to 43%, and for cholecystectomy to 41% of the women. The most frequently mentioned factors that would make women prefer a vaginal approach were decreased invasiveness (14.4%), recovery time (13.9%), scarring (13.7%), pain (6%), and surgical entry location relative to organ removed (4.4%). The most frequently mentioned concerns about the vaginal approach were the possibility of complications/safety (14.7%), pain (9%), infection (5.6%), and recovery time (4.9%). A number of women voiced technical concerns about the vaginal approach. As in prior studies, scarring and pain were important issues to be considered, but recovery time and increased invasiveness were also in the "top five" list. The surveyed women appeared to actively participate in evaluating the technical components of the procedures.

Disinfection of the Access Orifice in NOTES: Evaluation of the Evidence Base

Introduction. Appropriate prevention of infection is a key area of research in natural orifice translumenal endoscopic surgery (NOTES), as identified by the Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR). Methods. A review of the literature was conducted evaluating the evidence base for access orifice preparation/treatment in NOTES procedures in the context of infectious complications. Recommendations based on the Oxford Centre for Evidence-Based Medicine guidelines were made. Results. The most robust evidence includes several experimental randomised controlled trials assessing infectious complications in the transgastric approach to NOTES. Transvaginal procedures are long established for accessing the peritoneal cavity following disinfection with antiseptic. Only experimental case series for transcolonic and transvesical approaches are described. Conclusion. Grade C recommendation requiring no preoperative preparation can be made for the transgastric approach. Antiseptic irrigation is recommended for transvaginal (grade C) NOTES access, as is current practice. Further human trials need to be conducted to corroborate the current evidence base for transgastric closure. It is important that future trials are conducted in a methodologically robust fashion, with emphasis on clinical outcomes and standardisation of enterotomy closure and postoperative therapy.

Comparison of quality-of-life changes in patients with stress urinary incontinence after midurethral sling placement

Objective To compare changes in quality of life for women undergoing either suprapubic or transvaginal midurethral sling placement for stress urinary incontinence (SUI). Methods A retrospective cohort study was conducted involving 113 patients who underwent transvaginal or suprapubic midurethral sling placement for SUI over 2 years at a US institution. All patients completed a short form of the urogenital distress inventory (UDI-6) questionnaire preoperatively and postoperatively. Preoperative and postoperative UDI-6 scores were compared between the 2 groups. Data were analyzed using the Mann-Whitney U test and the Fisher exact test. Results A midurethral sling was placed using the suprapubic approach in 70 patients, and 43 patients underwent the procedure using the transvaginal approach. Preoperatively, there was no statistical difference between mean UDI-6 scores for the suprapubic versus the transvaginal group (48.5 versus 51.0 P = 0.9). Postoperatively, patients who underwent a suprapubic procedure had significantly lower mean UDI-6 scores than those who underwent a transvaginal procedure (10.6 versus 17.0; P < 0.005). Conclusion Suprapubic midurethral sling placement was associated with a significantly greater quality of life postoperatively compared with the transvaginal procedure.

NOTES transanal rectal cancer resection using transanal endoscopic microsurgery

BACKGROUND: With a rapidly expanding international registry of cases, Natural Orifice Translumenal Endoscopic Surgery (NOTES) continues to be held as the next phase in minimally invasive surgery. While pure and hybrid transvaginal procedures predominate clinically, there is growing interest in transanal NOTES as it may potentially minimize the morbidity of colorectal resections. METHODS: Extensive experimental and clinical evidence support the fact that septic complications from intentional colotomy during colorectal procedures are minimized with adequate closure. Other advantages of transanal NOTES include the favorable ergonomics of transanal endoscopy and availability of Transanal Endoscopic Microsurgery (TEM) as a particularly well-suited endoscopic platform. RESULTS: Since the description of transanal endoscopic rectosigmoid resection using TEM in 2007, extensive evaluation in swine acute and survival studies has demonstrated that this technique is feasible, safe, and easily reproducible using conventional instrumentation. Validation of this approach in human cadavers has confirmed the feasibility of transanal total mesorectal excision using a standardized technique. In the first clinical report published to date, transanal endoscopic rectosigmoid resection with TME was performed using laparoscopic assistance in a female patient with a stage III mid-rectal cancer treated with neoadjuvant therapy. CONCLUSIONS: Although preliminary, these results highlight the potential impact of this approach in minimizing the morbidity associated with rectal cancer resection, and warrant further investigation with respect to safety and long-term oncologic outcomes. Improvements in the design of currently available endoscopic platforms and instrumentation will be important for widespread clinical application in the future, and if pure NOTES transanal resection remains the ultimate goal.

Endoscopic surgery through single-port incision: time for a trial?

It has been at least 30 years now that it was declared that one of the goals of surgery is the reduction of treatment invasiveness [1]. This pushed research in technology to define new techniques that proved safe and effective and are today considered gold standard treatments. Good examples are laparoscopic cholecystectomy for symptomatic gallstones and transanal endoscopic microsurgery for adenomas of the upper and middle rectum. More recently, natural orifice transluminal endoscopic surgery (NOTES) has been brought to the attention of the lay media and literature after the first clinical reports. The concept was introduced in 2004 [2] and feasibility was tested extensively in animal experiments in the following years. New scientific societies and dedicated committees within existing scientific organs were born with the declared aim of regulating research activity through sponsorships and registers, but the goal was never reached completely. After less than 3 years, the race for the first cholecystectomy under NOTES conditions in a human being had run its course. Since then, many authors have reported various personal case series, while many others presented consistent research activity in vitro or in vivo, but it seems evident that two different branches of research were being defined [3]. The first is what we would call endoscopic access natural orifice surgery (EA-NOS), which includes all procedures truly performed through natural orifices. It had the goal of designing new platforms for surgery to be brought within the human body to recreate safe surgical conditions. The evident difficulties in obtaining such an environment with guaranteed ease of use, safety, and efficacy reduced the interest in this field to a mere research activity. A few clinical applications were described consisting of hybrid procedures, i.e., procedures that were performed basically under laparoscopic conditions with the help of flexible instruments inserted through natural orifices. In fact, a recent large meta-analysis of the NOTES literature [4] focusing on various surgical intraabdominal procedures, all ascribable to EA-NOS, concluded that no human studies were found satisfactory for the inclusion criteria, for scarce disposable evidence, minor safety, and efficacy compared to laparotomy and laparoscopy. The recommendation that human procedures should first pass through hybrid NOTES surgery, under strict guidelines, and in apposite controlled registers was later supported, as known, by the revision of NOSCAR ‘‘white paper’’ [5]. In fact, a need for a worldwide register, a standardization of the nomenclature, safety data to be used by ethical committees in order to authorize human trials, and implementation of the interface between medical societies, industry, and regulatory offices is no longer discussed. In this field, on behalf of the EURONOTES Foundation, we have promoted a European registry of NOTES procedures (www.euronotes.world.it) for which preliminary results are now awaited. The cooling of enthusiasm related to EA-NOS procedures has naturally forced surgeons to concentrate on techniques that could be reproduced more easily in clinical activity. This brought the interest toward the second branch of research, what we call surgical access natural orifice surgery (SA-NOS) [3], which achieves a laparoscopy-like environment by approaching the abdominal cavity with surgical devices. A wider vision of this concept allows inclusion into SA-NOS of not only transvaginal procedures but also what is increasingly mentioned in international meetings and scientific journals: single-port access (SPA) A. Arezzo M. Morino (&) Digestive, Colorectal and Minimal Invasive Surgery, University of Turin, c.so Dogliotti 14, 10126 Torino, Italy e-mail: mario.morino@unito.it

Additional effects of the cervical length measurement in women with preterm contractions: a systematic review

PurposeTransvaginal cervical length measurement in women with symptoms of preterm labor has been used to decide if treatment is necessary. Cervical length measurement may also have additional effects on patients, such as providing reassurance, although the evidence to support this is unclear. We explored and summarized to what extent additional effects of cervical length measurement in women with threatened preterm labor have been reported in the clinical literature and what the magnitude of these effects was.MethodsWe performed a systematic review of the literature to identify articles reporting on cervical length measurements in women with symptoms of preterm labor. We assessed whether these articles reported patient outcomes other than preterm delivery.ResultsThe electronic and hand search resulted in 764 articles, of which 172 met initial criteria for further eligibility assessment. We found 12 articles that reported additional effects of cervical length measurement in symptomatic women, such as the reassurance or the sensory consequences related to the transvaginal procedure. None of the articles quantified such additional effects.ConclusionsThere appears to be a gap between the presumed effects of cervical length measurement on patient outcomes, such as patients’ reassurance, and the actual assessment of these effects during test evaluations. We suggest that future evaluations of prognostic preterm labor tests include a comprehensive assessment of patient outcomes.

Clinical experience with a multifunctional, flexible surgery system for endolumenal, single-port, and NOTES procedures

BackgroundSingle-port and incisionless surgical approaches hold the promise of fewer complications, reduced pain, faster recovery, and improved cosmesis compared with traditional open or laparoscopic approaches. The ability to select an access approach (i.e., endolumenal, single-port, transvaginal, or transgastric) with one platform may be important to optimization of individual patient results. The authors report their results using these four separate surgical approaches tailored to three different therapeutic procedures, all with the use of a single flexible platform, the Incisionless Operating Platform (IOP).MethodsAfter institutional review board approval, the IOP was used to perform nine cholecystectomies via transvaginal (TV) (n = 4), transgastric (TG) (n = 4), and single-port transumbilical (TU) (n = 1) access. Two appendectomies were performed via TG access. Endolumenal access was used for 18 gastric pouch and stoma reductions after Roux-en-Y gastric bypass. The TG and TV procedures involved the use of one to three trocars. The recorded data included safety, procedural success, operative time, patient pain assessment (on a 0–10 scale) at discharge, and length of hospital stay. ResultsProcedural success was achieved for 16 of 18 endolumenal procedures, 1 of 1 single-port procedure, and 10 of 10 NOTES procedures. For 5 of 10 NOTES procedures, only one small trocar was required. The mean operative times were 79 min for pouch with stoma reduction, 171 min for cholecystectomy, and 274 min for appendectomy. Of 29 patients, 27 were discharged in 24 h or less. The average pain scores were 0.44 for pouch with stoma reduction, 1.3 for cholecystectomy, and 2.5 for appendectomy. No significant complications occurred. The ergonomics of IOP allowed the surgeon to interface with the system using an endoscopic or laparoscopic orientation.ConclusionAvailability of a multifunctional, flexible surgery platform provides a choice of a single-port or incisionless surgical approach with the potential to reduce complications, pain, and recovery time while improving cosmesis.

Fertility Outcome Following Transvaginal Cervicoisthmic Cerclage Using a Polypropylene Sling

Transabdominal cervicoisthmic cerclage is beneficial in most women with cervical incompetence, for whom a conventional transvaginal procedure is inadequate or would be impossible. A large number of studies have reported that the fetal survival rate after the procedure increases from 70% to 95%. The high morbidity, however, associated with transabdominal cervicoisthmic cerclage limits its use. Recent studies have shown that a new procedure for transvaginal cervicoisthmic cerclage, using a macroporous monofilament polypropylene sling, may be an effective minimally-invasive alternative to transabdominal cervicoisthmic cerclage in women who present with a previous cerclage failure. This study evaluated the effect of the new procedure on the fertility and subsequent pregnancy outcomes among 57 women who underwent prophylactic transvaginal cervicoisthmic cerclage in a previous (reference) pregnancy, because of a high risk for preterm delivery. At 12 months or more after the reference pregnancy, telephone interviews were conducted to assess each patient's subsequent fertility. Of the 57 women interviewed, 8 had an inadequate follow-up of less than 12 months, 13 were lost to follow-up, 2 women required removal of the sling after cesarean delivery, and 1 needed a hemostatic peripartum hysterectomy. Among the other 33 women interviewed, 14 desired a subsequent pregnancy and 19 did not. One of the 14 women wanting a subsequent pregnancy had previously known tubal infertility and did not undergo in vitro fertilization. A total of 7 (54%) of the 13 subsequently became pregnant with the following outcomes: 1 had a spontaneous abortion at 11 weeks of pregnancy; 1 delivered at 22 weeks after spontaneous premature membrane rupture; 1 had a cesarean delivery at 25 weeks; and 4 had a term cesarean delivery at a median duration of 37 weeks (interquartile range = 37-38 weeks). The median birth weight of the 4 neonates was 3040 gm (interquartile range = 2500-3250 g). The investigators concluded from these findings that, subsequent successful pregnancy is possible when a transvaginal cervicoisthmic cerclage (specifically a polypropylene sling) is in place.

Hybrid natural orifice transluminal endoscopic cholecystectomy: prospective human series

Natural orifice transluminal endoscopic surgery (NOTES) makes it possible to perform intraperitoneal surgical procedures with a minimal number of access points in the abdominal wall. Currently, it is not possible to perform these interventions without the help of abdominal wall entryways, so these procedures are hybrids fusing minilaparoscopy and transluminal endoscopic surgery. This report presents a prospective clinical series of 25 patients who underwent transvaginal hybrid cholecystectomy for cholelithiasis. The study comprised a clinical series of 25 consecutive nonrandomized women who underwent a fusion transvaginal NOTES and minilaparoscopy procedure with two trocars for cholelithiasis: one 5-mm umbilical trocar and one 3-mm trocar in the upper left quadrant. The study had no control group. The scheduled surgical intervention was performed for all 25 women. No intraoperative complications occurred. One patient had mild hematuria that resolved in less than 12 h, but no other complications occurred during an average follow-up period of 140 days. Of the 25 women, 20 were discharged in 24 h, and 5 were discharged less than 12 h after the procedure. Hybrid transvaginal cholecystectomy, combining NOTES and minilaparoscopy, is a good surgical model for minimally invasive surgery. It can be performed in surgical settings where laparoscopy is practiced regularly using the instruments normally used for endoscopy and laparoscopic surgery. Due to the reproducibility of the intervention and the ease of vaginal closure, hybrid transvaginal cholecystectomy will permit further development of NOTES in the future.

Survey of current management of prolapse in Australia and New Zealand

To compare current practice in the treatment of pelvic organ prolapse between Australian/New Zealand and United Kingdom (UK) gynaecologists. A postal questionnaire containing questions on four case scenarios, which examined contentious areas of contemporary prolapse management, was sent to 1471 Australian and New Zealand gynaecologists in mid-2007. The results were compared with those of an identical survey conducted in the UK in 2006. The response rate was 13% as only 196 complete responses were received. For primary anterior vaginal prolapse, anterior colporrhaphy was the procedure of choice in 54% followed by vaginal repair with graft in 20%. For recurrence, 75% used a graft. Procedure of choice for uterovaginal prolapse was a vaginal hysterectomy with anterior colporrhaphy (79%) and for vault support, 54% performed uterosacral colpopexy. In women wishing to retain their fertility, 23% would operate and a laparoscopic uterosacral hysteropexy (39%) was preferred. For posterior vaginal prolapse, the procedure of choice was midline plication in 56% and site-specific repair in 24%. A graft was used in 13% for primary repair and 61% for recurrence, most preferring permanent mesh. Procedure of choice for apical prolapse was sacrospinous fixation with anterior and posterior colporrhaphy (37%), followed by vaginal mesh repair (33%) and abdominal sacrocolpopexy (11%). Few respondents objectively measured prolapse (20%) or followed up patients over one year (12%). Australian/New Zealand gynaecologists used fewer traditional transvaginal procedures and more vaginal grafts than their UK colleagues in all compartments. Most respondents favoured permanent mesh (eg mesh kits) and many are missing an opportunity to gather valuable prospective data on these new procedures.

Short Term Results of Colpotomy in Natural Orifice Transluminal Endoscopic Surgery Transvaginal Procedures

Study Objective: To assess the short term results of colpotomy in Natural Orifice Transluminal Endoscopic Surgery (NOTES) transvaginal procedures. Design: Prospective evaluation of seventeen consecutive cases of NOTES transvaginal cholescystectomy or sleeve gastrectomy. Follow up at one and six months. Setting: IRCAD/EITS and Strasbourg University Hospitals, FRANCE. Patients: Seventeen patients (ages 32 – 44 years) with symptomatic gallbladder lithiasis or obesity. Intervention: Transvaginal NOTES cholecystectomy (10 patients) and sleeve gastrectomy (7 patients). All colpotomies are done by the same gynaecologist. A 1.5 cm incision between the uterosacral ligaments is performed with a cold knife. Dissection is done bluntly with scissors. Colpotomy closure at the end of the procedure is done with absorbable sutures. Measurements and Main Results: Colpotomy is assessed by vaginal exam and direct visualization at one month and six months postoperatively. Eventual peri operative complications such as rectal injury, fever, infection and pain are reported. Patients fill a questionnaire about sexual function (SFQ 31) at six months. Dyspareunia is also rated according to visual analogous scale, if exists. Data collection is still ongoing. Primary results show a negligible rate of complications. Conclusion: It seems that fears from complications related to colpotomy in NOTES transvaginal procedures are not supported by clinical data. However, patient's acceptance should also be assessed.

Use of the Mid-Sagittal Hemi-Pelvis To Demonstrate Surgical Anatomy for Vaginal Surgery

Study Objective: To demonstrate the adaptation of the mid-sagittally cut hemi-pelvis as a teaching aid for surgical anatomy and to visually enhance the demonstration of transvaginal procedures with a low cost portable setup. Instruction in vaginal surgery is often limited to viewing the back of the primary surgeons hand while they attempt to relay relevant anatomy. Even when whole pelvis cadaveric specimens are employed the observers view is restricted. We demonstrate the use of a hemi-pelvis for surgical instruction.

Microbiological Contamination During Transgastric and Transvaginal Endoscopic Techniques

Natural orifice transluminal endoscopic surgery (NOTES) has gained widespread interest as a potentially alternative to laparoscopic surgery, but concerns over peritoneal contaminations are unsolved. The aim of our study was to assess the safety of transluminal surgery by investigating the intraperitoneal bacterial load and contamination during transgastric and transvaginal surgeries. Twelve female pigs underwent transgastric (n = 7; tubal ligation and oophorectomy) and transvaginal procedures (n = 5; cholecystectomy). All animals were sacrificed after 2 weeks. The procedures were performed by using a double-channel endoscope (GIF-2T160; Olympus, Tokyo, Japan) under general anesthesia. Peritoneal fluid sampling was taken immediately after entry into the abdomen, at the end of the surgical procedure and during the autopsy, and sent for microbiologic assessment. In the transgastric group, 6 animals completed the surgical procedures and survived. Three pigs experienced signs of postoperative peritonitis with abscesses and adhesions visible and Escherichia Coli isolated at autopsy. In the transvaginal group, a cholecystectomy was performed without technical problems in all animals. No signs of postoperative sepsis nor growth in the microbiologic samples were recorded. In conclusion, the transvaginal approach seemed to be safer and produced less intra-abdominal contamination and sepsis, compared to the transgastric approach. Although both transgastric tubal ligation and oophorectomy and transvaginal cholecystectomy were feasible using equipment and accessories currently available for conventional endoscopy, new procedure-specific instruments and equipment should be developed to allow the operator safer access into the peritoneum.

Transvaginal nephrectomy with a multichannel laparoscopic port: a cadaver study

OBJECTIVE To determine whether a novel port (QuadPort, Advanced Surgical Concepts, Wicklow, Ireland) can facilitate transvaginal nephrectomy (TN), a natural orifice transluminal surgery (NOTES) procedure, using standard and articulating laparoscopic instruments. MATERIALS AND METHODS Four fresh female cadavers were used in this feasibility study with a plan to perform two right-sided and two left-sided TN. Exclusion criteria were a history of nephrectomy and a height of >1.82 m. The cadaver was placed in the lithotomy position with the target side up 30-45 degrees . A three-channel R-port (Advanced Surgical Concepts) was placed in the umbilicus to monitor the transvaginal procedure. The four-channel QuadPort was placed through the posterior fornix into the peritoneal cavity. Regular laparoscopic instruments were used transvaginally to mobilize the colon, dissect the ureter, identify and divide the renal artery between clips, and divide the renal vein with a laparoscopic stapler. Remaining attachments of the kidney were divided and the specimen entrapped in a plastic bag before transvaginal extraction. RESULTS Three (two right- and one left-sided) TNs were performed successfully; one left-sided TN was aborted in the last cadaver due to dense pelvic adhesions from previous pelvic surgery. In the first two cadavers we required assistance from the umbilical port only to divide the attachments between the upper pole of the kidney and the diaphragm supero-posteriorly. In the third case we were able to perform this dissection completely transvaginally using a flexible gastroscope. CONCLUSIONS A completely NOTES-based TN in humans is challenging. Robust laparoscopic instruments have the requisite tensile strength when deployed through a large calibre, secure, multichannel transvaginal port. Extra-long laparoscopic instruments are helpful. The cephalad aspect of the hilum and the upper pole attachments are difficult areas. Novel and robust flexible instruments still need to be developed.

NOTES Hybrid Transvaginal Radical Nephrectomy for Tumor: Stepwise Progression Toward a First Successful Clinical Case

BackgroundNatural orifice translumenal endoscopic surgery (NOTES) has been used to perform nephrectomy in the laboratory; however, clinical reports to date have used multiple abdominal trocars to assist the transvaginal procedure. ObjectiveTo present our stepwise technique development and the first successful clinical case of NOTES transvaginal radical nephrectomy for tumor with umbilical assistance without extraumbilical skin incisions. Design, setting, and participantsThe four transvaginal NOTES procedures were performed at two institutions after obtaining institutional review board approval. Various operative steps were developed experimentally in three clinical cases, and on March 7, 2009, we performed the first successful case of NOTES hybrid transvaginal radical nephrectomy without any extraumbilical skin incisions. Using one multichannel access port in the vagina and one in the umbilicus, laparoscopic visualization, intraoperative tissue dissection, and hilar control were performed transvaginally and transumbilically. The intact specimen was extracted transvaginally. MeasurementsAll perioperative data were accrued prospectively. A stepwise progression to the successful completion of the fourth case is systematically presented. Results and limitationsIntraoperatively, at incrementally more advanced stages of the procedure, the first three NOTES clinical cases were electively converted to standard laparoscopy because of rectal injury during vaginal entry, of failure to progress, and of gradual bleeding during upper-pole dissection after transvaginal hilar control, respectively. The fourth case was successfully completed via transvaginal and umbilical access without conversion to standard laparoscopy. Operative time was 3.7h, estimated blood loss was 150cm3, and hospital stay was 1 d. Final pathology confirmed a 220-g, pT1b, 7-cm, grade 2, clear-cell renal cell carcinoma with negative margins. The patient was readmitted for an intraabdominal collection that responded to drainage and antibiotics. ConclusionsWe report our stepwise progression and the initial successful clinical case of NOTES hybrid transvaginal radical nephrectomy for tumor, assisted with only one umbilical trocar. Although transvaginal nephrectomy is feasible in the highly selected patient with favorable intraoperative circumstances, considerable refinements in technique and technology are necessary if this approach is to advance beyond mere anecdote.

Natural orifice transluminal endoscopic surgery on animal models

Objective To evaluate the safety and feasibility of natural orifice transluminal endoscop- ic surgery （NOTES） with current available techniques and endoscopic accessories. Methods Transgastric and transvaginal endoscopic abdominal cavity exploration were performed in 6 female pigs. A needle-knife and a ERCP scalpel were used to make an anterior gastric wall incision, and a dilating balloon to expand the passage, through which a therapeutic gastroscope was sent into the abdominal cavity to seek the target organ. Partial liver resection was performed in 2 cases. For incision closure, a clip was applied to the incision orifice or it was just given putting-aside therapy. One week later, the abdominal cavity was examined via vagina. Another week later, it was observed via other incision of the stomach. Four weeks after the operation, the pigs were sacrificed. Adhesion, injury to the organs and closure of the incision were evaluated. Results Transgastric procedures were performed 12 times and transvaginal procedures 6 times. Mean operation time via stomach was 33.4 _＋ 10. 9 min, and that via vagina was 10. 1 _＋ 2. 5 min. All animals recovered and gained weight after the operation. The incision healed up with no obvious complications. Re-exploration showed adhesion of various degrees, no effusion, or injury to the organs were observed. Ketamine plus propofol achieved satisfactory anesthetic effect with no complications. One of the two animals which under- went liver partial resection died of disphragmatic muscle perforation. Hemarrhage occurred twice, both in the procedures via satisfied. One case developed abdominal abscess. Conclusion It was feasible and safe to perform NOTES via transgastric and transvaginal approach to the abdominal cavity and liver resection. But development of NOTES specific instruments is essential to the procedure. Key words: Endoscopic surgical procedures; Pigs; Natural orifice transluminal endoscopic sur- gery ; Transgastric approach ; Transvaginal approach

Sexual function in women following the transvaginal tension-free tape procedure for incontinence

Sexual function in women following the transvaginal tension-free tape procedure for incontinence

Predictors of persistent detrusor overactivity after transvaginal sling procedures

Predictors of persistent detrusor overactivity after transvaginal sling procedures