title: Robotic NOTES (Natural Orifice Translumenal Endoscopic Surgery) in reconstructive urology: initial laboratory experience.
abstract: OBJECTIVE
  To present an initial experience with robotic natural orifice translumenal surgery (R-NOTES) in reconstructive urology using the da Vinci surgical system.
  
  
  METHODS
  In 10 female farm pigs (mean weight, 34.5 kg), 10 pyeloplasties (right 5, left 5), 10 partial nephrectomies (right 5, left 5), and 10 radical nephrectomies (right 5, left 5) were performed. The robot telescope and the first robotic arm were placed through a single 2-cm umbilical incision, and the second robotic arm was placed through the vagina.
  
  
  RESULTS
  All 30 R-NOTES procedures were performed successfully without any addition of laparoscopic port or open conversion. Mean length of the umbilical incision was 2.6 cm. Mean operative time was 154 minutes, and mean estimated total blood loss was 72 mL. Mean warm ischemia time in the partial nephrectomy group was 25.4 minutes. There were no intraoperative complications. There were no robotic system failures during the entire experiment. We did not find any significant difference when comparing right-side and left-side procedures. When analyzing the learning curve, only robot preparation time reached a statistically significant inverse correlation with increasing number of cases (r = -0.72, P = .018).
  
  
  CONCLUSIONS
  Robotic NOTES pyeloplasty, partial nephrectomy, and radical nephrectomy are feasible and safe in the porcine model. This approach has the potential for a less morbid and scarless outcome. Intracorporeal suturing is significantly enhanced using the robot, especially through the challenging translumenal natural orifice approach. Further development of robots adaptive to NOTES would boost efforts toward clinical NOTES applications.
authors.affiliation: Section of Laparoscopic and Robotic Surgery, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA.
authors.forename: Georges-Pascal
authors.initials: GP
authors.lastname: Haber
authors.forename: Sebastien
authors.initials: S
authors.lastname: Crouzet
authors.forename: Kazumi
authors.initials: K
authors.lastname: Kamoi
authors.forename: Andre
authors.initials: A
authors.lastname: Berger
authors.forename: Monish
authors.initials: M
authors.lastname: Aron
authors.forename: Raj
authors.initials: R
authors.lastname: Goel
authors.forename: David
authors.initials: D
authors.lastname: Canes
authors.forename: Mihir
authors.initials: M
authors.lastname: Desai
authors.forename: Inderbir S
authors.initials: IS
authors.lastname: Gill
authors.forename: Jihad H
authors.initials: JH
authors.lastname: Kaouk
mesh_terms: D000818:Animals; D004724:Endoscopy / Q000379:methods*; D005260:Female; D007682:Kidney Pelvis / Q000601:surgery*; D009392:Nephrectomy / Q000379:methods*; D012371:Robotics; D013552:Swine; D014472:Umbilicus; D014621:Vagina