title: Pure natural orifice translumenal endoscopic surgery partial cystectomy: intravesical transurethral and extravesical transgastric techniques in a porcine model.
abstract: OBJECTIVE
  To describe 2 pure natural orifice translumenal endoscopic surgery (NOTES) techniques for partial cystectomy in a porcine model. NOTES is a new minimally invasive modality for performing abdominal surgery without transcutaneous incision.
  
  
  METHODS
  Transurethral-A rigid cystoscope is inserted into the porcine bladder with CO(2) insufflation. With an endoscopic loop device and a grasping device, the targeted area of the bladder is manipulated into the loop. The bladder segment is excised with electrocautery. Transgastric-A gastrotomy is made with a dual channel endoscope in the porcine stomach. The endoscope is inserted and pneumoperitoneum is established by insufflation through a channel. After identifying bladder, 2 endoscopic loops are placed at the intended area of resection. An incision is made between the loops to excise the specimen. In both cases, full-thickness specimen is removed en bloc with the scope and the defect is reapproximated with endoscopic clips.
  
  
  RESULTS
  Transurethral and transgastric NOTES approaches were achieved using standard endoscopic equipment in a porcine model. Transurethral NOTES partial cystectomy was successful in acute (n = 2) and chronic (n = 2) models. The transgastric NOTES approach was successfully performed in an acute animal.
  
  
  CONCLUSIONS
  NOTES partial cystectomy could potentially reduce morbidity of conventional methods of partial cystectomy. Transurethral NOTES may be the least invasive method possible for partial cystectomy. Potential advantages of a transgastric NOTES approach include visualization of adjacent structures, access to sites difficult to reach transurethrally, and lymph node sampling. However, a gastrotomy could be a source of morbidity. Further investigation is required to assess safety, efficacy, and adequate bladder healing.
authors.affiliation: Department of Urology, Center for Urologic Oncology and Minimally Invasive Therapies, University Hospitals Case Medical Center, Cleveland, Ohio 44106 , USA.
authors.forename: Mark D
authors.initials: MD
authors.lastname: Sawyer
authors.forename: Edward E
authors.initials: EE
authors.lastname: Cherullo
authors.forename: B Joseph
authors.initials: BJ
authors.lastname: Elmunzer
authors.forename: Steve
authors.initials: S
authors.lastname: Schomisch
authors.forename: Lee E
authors.initials: LE
authors.lastname: Ponsky
mesh_terms: D000818:Animals; D015653:Cystectomy / Q000379:methods*; D003558:Cystoscopy / Q000379:methods*; D005260:Female; D013270:Stomach; D013552:Swine; D014521:Urethra