Centro de Robótica y De Invasión Mínima Unidad de Urología, Instituto Médico La Floresta, Caracas, Venezuela.
Eur Urol. 2010 Jan;57(1):138-44. doi: 10.1016/j.eururo.2009.04.031. Epub 2009 Apr 22.
Natural orifice translumenal endoscopic surgery (NOTES) has been used to perform nephrectomy in the laboratory; however, clinical reports to date have used multiple abdominal trocars to assist the transvaginal procedure.
To present our stepwise technique development and the first successful clinical case of NOTES transvaginal radical nephrectomy for tumor with umbilical assistance without extraumbilical skin incisions.
DESIGN, SETTING, AND PARTICIPANTS: The four transvaginal NOTES procedures were performed at two institutions after obtaining institutional review board approval. Various operative steps were developed experimentally in three clinical cases, and on March 7, 2009, we performed the first successful case of NOTES hybrid transvaginal radical nephrectomy without any extraumbilical skin incisions. Using one multichannel access port in the vagina and one in the umbilicus, laparoscopic visualization, intraoperative tissue dissection, and hilar control were performed transvaginally and transumbilically. The intact specimen was extracted transvaginally.
All perioperative data were accrued prospectively. A stepwise progression to the successful completion of the fourth case is systematically presented.
Intraoperatively, at incrementally more advanced stages of the procedure, the first three NOTES clinical cases were electively converted to standard laparoscopy because of rectal injury during vaginal entry, of failure to progress, and of gradual bleeding during upper-pole dissection after transvaginal hilar control, respectively. The fourth case was successfully completed via transvaginal and umbilical access without conversion to standard laparoscopy. Operative time was 3.7 h, estimated blood loss was 150 cm(3), and hospital stay was 1 d. Final pathology confirmed a 220-g, pT1b, 7-cm, grade 2, clear-cell renal cell carcinoma with negative margins. The patient was readmitted for an intraabdominal collection that responded to drainage and antibiotics.
We report our stepwise progression and the initial successful clinical case of NOTES hybrid transvaginal radical nephrectomy for tumor, assisted with only one umbilical trocar. Although transvaginal nephrectomy is feasible in the highly selected patient with favorable intraoperative circumstances, considerable refinements in technique and technology are necessary if this approach is to advance beyond mere anecdote.
经自然腔道内镜外科（NOTES）已被用于实验室中的肾切除术；然而，迄今为止的临床报告都使用多个腹部套管来辅助经阴道手术。
介绍我们的逐步技术发展以及首例成功的经阴道NOTES 根治性肾切除术的临床病例，该手术通过脐部辅助进行，无需额外的脐部皮肤切口。
设计、地点和参与者：在获得机构审查委员会批准后，在两个机构进行了四次经阴道NOTES 手术。在三个临床病例中进行了各种手术步骤的实验性开发，并且在 2009 年 3 月 7 日，我们成功地完成了首例无任何额外脐部皮肤切口的经阴道NOTES 混合式根治性肾切除术。使用阴道中的一个多通道接入端口和脐部中的一个端口，经阴道和经脐部进行腹腔镜可视化、术中组织解剖和肾门控制。完整的标本经阴道取出。
所有围手术期数据均前瞻性收集。系统地呈现了逐步完成第四例手术的进展。
术中，在手术程序的递增更高级阶段，前三个NOTES 临床病例分别因阴道进入时直肠损伤、无法进展以及经阴道肾门控制后上极解剖逐渐出血而选择性转换为标准腹腔镜。第四例病例成功地通过经阴道和脐部入路完成，无需转换为标准腹腔镜。手术时间为 3.7 小时，估计失血量为 150cm³，住院时间为 1 天。最终病理证实为 220g、pT1b、7cm、2 级、透明细胞肾细胞癌，切缘阴性。患者因腹腔内积液再次入院，经引流和抗生素治疗后得到缓解。
我们报告了我们的逐步进展和首例成功的经阴道NOTES 混合式根治性肾切除术的临床病例，仅辅助一个脐部套管。虽然经阴道肾切除术在具有有利术中情况的高度选择患者中是可行的，但如果要超越单纯的轶事，还需要对技术进行相当大的改进和发展。
