title: Transvaginal Natural Orifice Transluminal Endoscopic Nephrectomy in a Series of 63 Cases: Stepwise Transition From Hybrid to Pure NOTES.
abstract: BACKGROUND
  The feasibility of hybrid transvaginal NOTES (natural orifice transluminal endoscopic surgery) nephrectomy (HTNN) has already been demonstrated. However, pure transvaginal NOTES nephrectomy (PTNN) has been limited to animal experiments with only one report of its use in humans.
  
  
  OBJECTIVE
  To describe our initial experience with HTNN and a stepwise transition towards PTNN.
  
  
  METHODS
  Between May 2010 and September 2011, 63 patients underwent nephrectomy (60 HTNNs and 3 PTNNs) in our institution, including 45 patients with benign renal disease and 18 patients with malignant renal disease.
  
  
  METHODS
  Of the HTNNs, 33 were performed using two umbilical trocars and one transvaginal trocar, and 27 were performed using one umbilical trocar and a transvaginal multi-instrument access port; 3 PTNNs were performed using a self-developed, three-channel ZOU-port without any transumbilical assistance.
  
  
  METHODS
  All data referring to patient demographics, surgery, pathology, and perioperative outcomes were recorded. Sexual function was assessed with the Female Sexual Function Index (FSFI) questionnaire before and after surgery. The cosmetic result was investigated by administering the Patient Scar Assessment Questionnaire and Scoring System (PSAQ).
  
  
  CONCLUSIONS
  A total of 59 HTNNs and 3 PTNNs were successfully performed. One patient was converted to open surgery because of injury to the inferior vena cava. The mean operative time was 130min (range: 100-260min) for HTNN and 193min (range: 180-210min) for PTNN. The mean estimated blood loss was 150ml. The mean postoperative hospital stay was 7.4 d. Forty-eight patients completed the FSFI questionnaire, and analysis did not show differences in FSFI scores before and after surgery. The better cosmetic results were confirmed by the PSAQ score.
  
  
  CONCLUSIONS
  HTNN is feasible and safe in appropriate patients. Existing instruments are adequate for HTNN, but significant improvement is still needed. PTNN is technically challenging, but is feasible and may be performed safely. Further improvement of instruments is necessary for PTNN. Clinical investigation in comparison to the established techniques should take place to evaluate the outcome of technique.
  
  
  RESULTS
  Pure transvaginal natural orifice transluminal endoscopic nephrectomy (PTNN) is technically challenging but feasible and may be performed safely. Further improvements in instruments are necessary for PTNN.
authors.affiliation: Department of Urology, First Affiliated Hospital of Gannan Medical University, Ganzhou, People's Republic of China.
authors.forename: Yijun
authors.initials: Y
authors.lastname: Xue
authors.affiliation: Department of Urology, First Affiliated Hospital of Gannan Medical University, Ganzhou, People's Republic of China. Electronic address: gyfyurology@126.com.
authors.forename: Xiaofeng
authors.initials: X
authors.lastname: Zou
authors.affiliation: Department of Urology, First Affiliated Hospital of Gannan Medical University, Ganzhou, People's Republic of China.
authors.forename: Guoxi
authors.initials: G
authors.lastname: Zhang
authors.affiliation: Department of Urology, First Affiliated Hospital of Gannan Medical University, Ganzhou, People's Republic of China.
authors.forename: Yuanhu
authors.initials: Y
authors.lastname: Yuan
authors.affiliation: Department of Urology, First Affiliated Hospital of Gannan Medical University, Ganzhou, People's Republic of China.
authors.forename: Rihai
authors.initials: R
authors.lastname: Xiao
authors.affiliation: Department of Urology, First Affiliated Hospital of Gannan Medical University, Ganzhou, People's Republic of China.
authors.forename: Yunfeng
authors.initials: Y
authors.lastname: Liao
authors.affiliation: Department of Urology, First Affiliated Hospital of Gannan Medical University, Ganzhou, People's Republic of China.
authors.forename: Xin
authors.initials: X
authors.lastname: Zhong
authors.affiliation: Department of Urology, First Affiliated Hospital of Gannan Medical University, Ganzhou, People's Republic of China.
authors.forename: Bo
authors.initials: B
authors.lastname: Jiang
authors.affiliation: Department of Urology, First Affiliated Hospital of Gannan Medical University, Ganzhou, People's Republic of China.
authors.forename: Ruiquan
authors.initials: R
authors.lastname: Xu
authors.affiliation: Department of Urology, First Affiliated Hospital of Gannan Medical University, Ganzhou, People's Republic of China.
authors.forename: Yuhua
authors.initials: Y
authors.lastname: Zou
authors.affiliation: Department of Urology, First Affiliated Hospital of Gannan Medical University, Ganzhou, People's Republic of China.
authors.forename: Gang
authors.initials: G
authors.lastname: Xu
authors.affiliation: Department of Urology, First Affiliated Hospital of Gannan Medical University, Ganzhou, People's Republic of China.
authors.forename: Kunlin
authors.initials: K
authors.lastname: Xie
authors.affiliation: Department of Urology, Clinical Division of Surgery, Chinese PLA General Hospital, Beijing, People's Republic of China.
authors.forename: Xu
authors.initials: X
authors.lastname: Zhang
mesh_terms: D000328:Adult; D016063:Blood Loss, Surgical; D002681:China; D061887:Conversion to Open Surgery; D019723:Endoscopes; D004867:Equipment Design; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D007674:Kidney Diseases / Q000175:diagnosis / Q000601:surgery*; D007680:Kidney Neoplasms / Q000175:diagnosis / Q000601:surgery*; D007902:Length of Stay; D008875:Middle Aged; D057605:Natural Orifice Endoscopic Surgery / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*; D009392:Nephrectomy / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*; D061646:Operative Time; D017060:Patient Satisfaction; D011183:Postoperative Complications / Q000209:etiology; D012307:Risk Factors; D011795:Surveys and Questionnaires; D013997:Time Factors; D016896:Treatment Outcome; D014621:Vagina / Q000601:surgery*
keywords: Minimally invasive surgery; NOTES; Natural orifice transluminal endoscopic surgery; Nephrectomy; Transvaginal surgery