title: Robotic retroperitoneal transvaginal natural orifice translumenal endoscopic surgery (NOTES) nephrectomy: feasibility study in a cadaver model.
abstract: OBJECTIVE
  To evaluate the feasibility of pure robotic natural orifice translumenal endoscopic surgery (R-NOTES) nephrectomy.
  
  
  METHODS
  Two R-NOTES nephrectomy approaches were attempted in 3 female cadavers. A single-port device was inserted through an incision in the posterior vaginal fornix. In the first approach, the peritoneal cavity was accessed in the lithotomy position. In the second approach, the retroperitoneum of 2 cadavers was accessed in the prone jackknife position. The ureter was identified and followed cranially. The hilum was stapled and the kidney was dissected. The specimen was extracted into a bag. The incision was closed with an open approach.
  
  
  RESULTS
  The first approach was not possible because of collision of the robotic arms against the legs and limited bowel retraction. After modifying the approach, a right transvaginal R-NOTES retroperitoneal nephrectomy was successfully completed, without adding extra ports. Time for setup was 128 minutes. Time to identify the ureter was 53 minutes. Dissection and control of the renal pedicle was completed in 21 minutes. Time to complete the dissection and extraction of the kidney was 36 minutes. Time to complete the procedure was 238 minutes. There were no injuries to retroperitoneal organs or vessels. In the third cadaver, there was rectal injury during the access. We were unable to complete the procedure because of the cadaver height.
  
  
  CONCLUSIONS
  Transvaginal R-NOTES nephrectomy is technically challenging but feasible in select female cadavers. Retroperitoneal approach in the prone jackknife position was instrumental in facilitating robotic access to the kidney through the vagina. Improvements in the technique and instrumentation are necessary to make this approach safe and reproducible.
authors.affiliation: Center for Laparoscopic and Robotic Surgery-Urology-Cleveland Clinic, Cleveland, OH 44195, USA.
authors.forename: Humberto
authors.initials: H
authors.lastname: Laydner
authors.forename: Riccardo
authors.initials: R
authors.lastname: Autorino
authors.forename: Wahib
authors.initials: W
authors.lastname: Isac
authors.forename: Ali
authors.initials: A
authors.lastname: Khalifeh
authors.forename: Kamol
authors.initials: K
authors.lastname: Panumatrassamee
authors.forename: Ahmad
authors.initials: A
authors.lastname: Kassab
authors.forename: Jean-Alexandre
authors.initials: JA
authors.lastname: Long
authors.forename: Remi
authors.initials: R
authors.lastname: Eyraud
authors.forename: Emad
authors.initials: E
authors.lastname: Rizkala
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Stein
authors.forename: Jihad H
authors.initials: JH
authors.lastname: Kaouk
mesh_terms: D001827:Body Height; D002102:Cadaver; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D057605:Natural Orifice Endoscopic Surgery / Q000379:methods*; D009392:Nephrectomy / Q000379:methods*; D061646:Operative Time; D056888:Patient Positioning; D012187:Retroperitoneal Space / Q000601:surgery; D012371:Robotics; D014621:Vagina / Q000601:surgery