Rationale for natural orifice transluminal endoscopic surgery and current limitations.

Over the past several years, surgeons have sought to develop techniques to decrease the morbidity of various procedures. As a result, an extensive array of progressively more minimally invasive techniques now exists in the urologist's armamentarium, including smaller ('mini') incisions, laparoscopic hand-assisted surgery, as well as pure laparoscopic and robotic approaches. Theoretically, smaller incisions result in decreased pain and subsequently accelerated convalescence postoperatively. Most recently, innovative surgeons across multiple surgical specialties have pioneered the concept of eliminating incisions altogether and operating through natural orifices, which has been termed natural orifice transluminal endoscopic surgery (NOTES). The improved cosmesis associated with a pure NOTES approach is an attractive option for patients undergoing invasive therapeutic and diagnostic procedures. NOTES has significant potential for use by urological surgeons, as evidenced by multiple studies demonstrating the feasibility of pure and hybrid NOTES procedures in cadaveric, animal and human subjects. The purpose of this paper is to review the rationale for NOTES in urological surgery, and to detail the current limitations of this new technique.