title: NOTES hybrid transvaginal radical nephrectomy for tumor: stepwise progression toward a first successful clinical case.
abstract: BACKGROUND
  Natural 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.
  
  
  OBJECTIVE
  To 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.
  
  
  METHODS
  The 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.
  
  
  METHODS
  All perioperative data were accrued prospectively. A stepwise progression to the successful completion of the fourth case is systematically presented.
  
  
  CONCLUSIONS
  Intraoperatively, 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 3.7 h, estimated blood loss was 150 cm(3), 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.
  
  
  CONCLUSIONS
  We 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.
authors.affiliation: Centro de Robótica y De Invasión Mínima Unidad de Urología, Instituto Médico La Floresta, Caracas, Venezuela. renesotelo@cantv.net
authors.forename: Rene
authors.initials: R
authors.lastname: Sotelo
authors.forename: Robert
authors.initials: R
authors.lastname: de Andrade
authors.forename: Golena
authors.initials: G
authors.lastname: Fernández
authors.forename: Daniel
authors.initials: D
authors.lastname: Ramirez
authors.forename: Eugenio
authors.initials: E
authors.lastname: Di Grazia
authors.forename: Oswaldo
authors.initials: O
authors.lastname: Carmona
authors.forename: Otto
authors.initials: O
authors.lastname: Moreira
authors.forename: Andre
authors.initials: A
authors.lastname: Berger
authors.forename: Monish
authors.initials: M
authors.lastname: Aron
authors.forename: Mihir M
authors.initials: MM
authors.lastname: Desai
authors.forename: Inderbir S
authors.initials: IS
authors.lastname: Gill
mesh_terms: D000368:Aged; D016063:Blood Loss, Surgical; D001938:Brazil; D002292:Carcinoma, Renal Cell / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D005260:Female; D006801:Humans; D007680:Kidney Neoplasms / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D020706:Laparoscopes; D010535:Laparoscopy; D007902:Length of Stay; D009367:Neoplasm Staging; D009392:Nephrectomy / Q000295:instrumentation / Q000379:methods*; D009820:Ohio; D011446:Prospective Studies; D013048:Specimen Handling; D013525:Surgical Instruments; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014472:Umbilicus / Q000601:surgery*; D014621:Vagina / Q000601:surgery*