title: Third-generation nephrectomy by natural orifice transluminal endoscopic surgery.
abstract: OBJECTIVE
  Recently there has been increasing enthusiasm for performing simple abdominal procedures by transgastric surgery. We previously reported the usefulness of a combined transgastric and transvesical approach to cholecystectomy. In this study we assessed the feasibility of combined transgastric and transvesical approach for performing a more complex surgical procedure, such as nephrectomy, in a porcine model.
  
  
  METHODS
  In a nonsurvival study combined transgastric and transvesical approaches were established in 6 female pigs. Under ureteroscope guidance we installed a transvesical 5 mm over tube into the peritoneal cavity and a flexible gastroscope was passed orally into the peritoneal cavity by a gastrotomy. We performed right or left nephrectomy with instruments introduced by the 2 devices that worked in the renal hilum, alternating device intervention for dissection and retraction procedures.
  
  
  RESULTS
  Four right and 2 left nephrectomies were performed. There were no complications during the creation of transvesical and transgastric access. In all animals we visualized the 2 kidneys. The renal vessels and ureter were reasonably individualized and ligated separately with ultrasonic scissors, which were introduced through the transvesical port. In 2 early cases mild hemorrhage occurred after ultrasonic ligation. To overcome this complication we applied clips successfully before ultrasonic ligation in the remaining animals. Thus, complete renal release and mobilization to the stomach were achieved in all animals.
  
  
  CONCLUSIONS
  Nephrectomy by natural orifices using the combined transgastric and transvesical approach is technically feasible, although to our knowledge there is no reliable method for removing the specimen with current instruments.
authors.affiliation: Life and Health Sciences Research Institute, School of Health Sciences, University of Minho, Braga, Portugal.
authors.forename: Estevao
authors.initials: E
authors.lastname: Lima
authors.forename: Carla
authors.initials: C
authors.lastname: Rolanda
authors.forename: José M
authors.initials: JM
authors.lastname: Pêgo
authors.forename: Tiago
authors.initials: T
authors.lastname: Henriques-Coelho
authors.forename: David
authors.initials: D
authors.lastname: Silva
authors.forename: Luís
authors.initials: L
authors.lastname: Osório
authors.forename: Ivone
authors.initials: I
authors.lastname: Moreira
authors.forename: José L
authors.initials: JL
authors.lastname: Carvalho
authors.forename: Jorge
authors.initials: J
authors.lastname: Correia-Pinto
mesh_terms: D000818:Animals; D003131:Combined Modality Therapy; D004195:Disease Models, Animal; D004724:Endoscopy / Q000379:methods*; D005260:Female; D020699:Gastroscopes; D019060:Minimally Invasive Surgical Procedures / Q000379:methods; D009392:Nephrectomy / Q000295:instrumentation / Q000379:methods*; D012680:Sensitivity and Specificity; D013552:Swine; D020709:Ureteroscopes