title: Hybrid transureteral nephrectomy in a survival porcine model.
abstract: OBJECTIVE
  Natural-orifice approaches for nephrectomy have included access via the stomach, vagina, bladder, and rectum. Recently, the feasibility of using the ureter as a natural orifice for natural-orifice transluminal endoscopic surgery nephrectomy has been demonstrated in a nonsurvival porcine model. The purpose of this study was to assess the outcomes of transureteral laparoscopic natural-orifice transluminal endoscopic surgery nephrectomy in a survival porcine model.
  
  
  METHODS
  Three pigs underwent hybrid transureteral natural-orifice transluminal endoscopic surgery nephrectomy. An experimental balloon/dilating sheath was inserted over a wire to dilate the urethra, ureteral orifice, and ureter. Through a bariatric 12-mm laparoscopic port, the ureter was opened medially and the hilar dissection was performed. Next, 2 needlescopic ports were placed transabdominally to facilitate hilar transection. The kidney was morcellated using a bipolar sealing device and extracted via the ureter using the housing of a bariatric stapling device. The ureteral orifice was closed with a laparoscopic suturing device. The bladder was drained by a catheter for 10 to 14 days postoperatively. Pigs were euthanized on postoperative day 21.
  
  
  RESULTS
  All surgical procedures were successfully completed, with no intraoperative complications. One pig had an episode of postoperative clot retention that resolved with catheter irrigation. Each pig was healthy and eating a normal diet prior to euthanasia.
  
  
  CONCLUSIONS
  This study demonstrates the feasibility of a hybrid transureteral approach to nephrectomy in a survival porcine model. This technique avoids the intentional violation of a second organ system and the risk for peritoneal contamination. Improved instrumentation is needed prior to implementation in the human population.
authors.affiliation: Department of Urology, Loma Linda University Medical Center, Loma Linda, California, USA.
authors.forename: Kirk M
authors.initials: KM
authors.lastname: Anderson
authors.affiliation: Department of Urology, Loma Linda University Medical Center, Loma Linda, California, USA.
authors.forename: Muhannad
authors.initials: M
authors.lastname: Alsyouf
authors.affiliation: Department of Urology, Loma Linda University Medical Center, Loma Linda, California, USA.
authors.forename: Gideon
authors.initials: G
authors.lastname: Richards
authors.affiliation: Department of Urology, Loma Linda University Medical Center, Loma Linda, California, USA.
authors.forename: Gautum
authors.initials: G
authors.lastname: Agarwal
authors.affiliation: Department of Urology, Loma Linda University Medical Center, Loma Linda, California, USA.
authors.forename: Jonathan P
authors.initials: JP
authors.lastname: Heldt
authors.affiliation: Department of Urology, Loma Linda University Medical Center, Loma Linda, California, USA.
authors.forename: Amy E
authors.initials: AE
authors.lastname: Schlaifer
authors.affiliation: Department of Urology, Loma Linda University Medical Center, Loma Linda, California, USA.
authors.forename: D Duane
authors.initials: DD
authors.lastname: Baldwin
mesh_terms: D000818:Animals; D004195:Disease Models, Animal; D005240:Feasibility Studies; D005260:Female; D007674:Kidney Diseases / Q000601:surgery*; D057605:Natural Orifice Endoscopic Surgery / Q000379:methods*; D009392:Nephrectomy / Q000379:methods*; D013552:Swine; D014513:Ureter
keywords: Investigational therapy; Minimally invasive surgery; Natural-orifice endoscopic surgery; Nephrectomy