title: Hybrid Natural Orifice Translumenal Endoscopic Surgery Transvaginal Nephrectomy in a Low-Resource Setting.
abstract: BACKGROUND
  Hybrid natural orifice translumenal endoscopic surgery (NOTES(®); American Society for Gastrointestinal Endoscopy [Oak Brook, IL] and Society of American Gastrointestinal and Endoscopic Surgeons [Los Angeles, CA]) reduces the invasiveness of conventional laparoscopic surgery and overcomes the limitation of pure NOTES, especially in the absence of angulated instruments.
  
  
  METHODS
  The patients were 66-, 69-, and 32-year-old women with complaints of recurrent flank pain and urinary tract infection due to an obstructed nonfunctioning kidney. Materials used were standard laparoscopic instruments and a 30° 10-mm high-definition laparoscope. Under general anesthesia, each patient was placed in a lithotomy position with the affected side up at 45°. A Veress needle was initially inserted through the umbilicus and was later replaced with a 10-mm laparoscopic port, with an additional 5-mm port also inserted at the affected lower quadrant site. The patient was then positioned in a steep Trendelenburg position, and a 10-mm port was inserted through the posterior vaginal wall under direct vision from the abdominal cavity that was later used for the laparoscope. Nephrectomy proceeded despite noted severe adhesions, and the kidney was placed in the specimen retrieval bag. The vaginal port site was enlarged to 3 cm for extraction of the specimen. A Penrose drain was placed at the lower quadrant 5-mm trocar site. The vaginal wound was repaired using running 2-0 absorbable sutures.
  
  
  RESULTS
  Three cases of transvaginal hybrid NOTES nephrectomy were successfully completed with a median operative time of 310 minutes and mean estimated blood loss of 300 mL. Median renal dimensions were as follows: craniocaudal, 10.2 (range, 10.6-9) cm; laterolateral, 6.5 (range, 7-5.3) cm; and anteroposterior, 4.8 (range, 6.5-3.9) cm. The patients resumed regular diet as early as Day 1 postoperatively. The drain was removed prior to discharge. The mean date of discharge was Day 3 postoperatively. There were no noted surgical complications according to the Clavien-Dindo grading system.
  
  
  CONCLUSIONS
  Hybrid NOTES transvaginal nephrectomy is a feasible and reproducible procedure in selected patients regardless of laterality for better cosmesis, reduced postoperative pain, and early recovery.
authors: Department of Urology, Jose R. Reyes Memorial Medical Center , Manila, The Philippines .
authors: Paul Nimrod B
authors: PN
authors: Firaza
authors: Department of Urology, Jose R. Reyes Memorial Medical Center , Manila, The Philippines .
authors: Enrique Ian S
authors: EI
authors: Lorenzo
authors: Department of Urology, Jose R. Reyes Memorial Medical Center , Manila, The Philippines .
authors: Juan Godofredo R
authors: JG
authors: Bardelosa
authors: Department of Urology, Jose R. Reyes Memorial Medical Center , Manila, The Philippines .
authors: Edgardo L
authors: EL
authors: Reyes
authors: Department of Urology, Jose R. Reyes Memorial Medical Center , Manila, The Philippines .
authors: Nelson A
authors: NA
authors: Patron
mesh_terms: D000328:Adult; D000368:Aged; D003906:Developing Countries; D005260:Female; D006801:Humans; D008875:Middle Aged; D057605:Natural Orifice Endoscopic Surgery / Q000379:methods*; D009392:Nephrectomy / Q000379:methods*; D010679:Philippines; D051437:Renal Insufficiency / Q000601:surgery*; D016896:Treatment Outcome; D014621:Vagina / Q000601:surgery*