title: Transvaginal hybrid natural orifice transluminal surgery robotic donor nephrectomy: first clinical application.
abstract: OBJECTIVE
  To report a novel surgical approach of transvaginal hybrid natural orifice transluminal surgery (NOTES) living donor nephrectomy. We conceptualized this approach by incorporating 2 existing concepts: laparoendoscopic single-site surgery and NOTES.
  
  
  METHODS
  After thorough consent and under institutional review board approval, a 61-year-old woman volunteered to donate her kidney through hybrid transvaginal NOTES. Under general anesthesia, she was placed in a modified right lateral decubitus position. A SILS port and an 8-mm trocar were placed through the same umbilical incision. The GelPoint port was placed transvaginally via the posterior fornix, and the robot was docked. After dissection of the left kidney in preparation for extraction, the robot was undocked, and the retrieval bag was inserted through the GelPoint port. The graft was bagged before vessel stapling and extracted without breaching the bag. The kidney was delivered to the perfusion table with a clean pair of gloves without contamination with the bag exterior.
  
  
  RESULTS
  Donor nephrectomy was successfully completed without conversion or perioperative complications. The total operative time was 240 minutes, the warm ischemic time was 5.8 minutes, and the estimated blood loss was 75 mL. No complications occurred and extra ports were not needed. The patient was discharged after an uneventful 48-hour stay. Her creatinine was 1.0 mg/dL at 4 weeks of follow-up. The recipient was given pulse steroids for biopsy-proven acute rejection, and her serum creatinine was 1.16 mg/dL at 4 weeks postoperatively.
  
  
  CONCLUSIONS
  Transvaginal hybrid NOTES robotic donor nephrectomy is feasible. Additional advances in robotic technology are awaited for development of this approach and to foster its clinical application.
authors.affiliation: Center for Advanced Laparoscopic and Robotic Surgery, Glickman Urologic and Kidney Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA. kaoukj@ccf.org
authors.forename: Jihad H
authors.initials: JH
authors.lastname: Kaouk
authors.forename: Ali
authors.initials: A
authors.lastname: Khalifeh
authors.forename: Humberto
authors.initials: H
authors.lastname: Laydner
authors.forename: Riccardo
authors.initials: R
authors.lastname: Autorino
authors.forename: Shahab P
authors.initials: SP
authors.lastname: Hillyer
authors.forename: Kamol
authors.initials: K
authors.lastname: Panumatrassamee
authors.forename: Charles
authors.initials: C
authors.lastname: Modlin
authors.forename: Howard B
authors.initials: HB
authors.lastname: Goldman
mesh_terms: D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000601:surgery; D016030:Kidney Transplantation; D019520:Living Donors; D008875:Middle Aged; D057605:Natural Orifice Endoscopic Surgery / Q000379:methods*; D009392:Nephrectomy / Q000379:methods*; D012371:Robotics / Q000379:methods*; D014621:Vagina