UROLOGY NOTES: A Review Of The Technical Problems Encountered And Their Solutions

Main Category: Urology / Nephrology
Article Date: 26 Sep 2008 - 5:00 PDT

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UroToday.com - Natural orifice translumenal endoscopic surgery (NOTES) is the new "darling" of the hour. It has spawned numerous other approaches to try to reduce the incisions associated with port placement in laparoscopic surgery, most notably single incision laparoscopic surgery (SILS) which entails use of novel umbilical multiports either alone or in association with nonumbilical needlescopic ports.

The actual benefit of any of these newer approaches versus standard laparoscopy has yet to be proven as to date, only Phase I (i.e. safety) and early Phase II (i.e. efficacy) clinical experiences have been reported. While there is clinical work beginning to evolve in urology for SILS, true NOTES has yet to enter the clinical realm of urology. NOTES procedures use exclusively nonabdominal accesses alone or in combination: transgastric, transrectal, transvesical, and/or transvaginal.

The authors cite a host of challenges with NOTES as it has been applied to general surgery for the removal of the appendix or gallbladder: blind primary incision through a hollow viscus, an uncontrolled pneumoperitoneum achieved with room air, lack of support for the flexible endoscope, poor endoscopic vision as usually only a flexible endoscope is used, limited retraction and exposure capabilities, and difficulty with suturing. A pure NOTES nephrectomy has been accomplished in the laboratory via a transgastric and transvesical route, but the specimen was not removed at the end of the procedure, calling into question the translational utility of this acute laboratory exercise.1 Nonetheless, what we are currently witnessing is nothing more than the moving frontier of discovery, populated by creative and tireless surgeons who will bring forth ever more versatile instrumentation to overcome the aforementioned challenges.

The answer to the question "It's new, but is it better?"
Similar to the advent of laparoscopic surgery, it may well take a decade before the answer is known.

(1) Lima, E. L., Rolanda, C., and Correia-Pinto, J.: Transvesical endoscopic peritoneoscopy: intra-abdominal scarless surgery for urologic applications. Curr Urol Rep. 9(1):50-4, 2008.

Mintz Y, Horgan S, Cullen J, Stuart D, Falor E, Talamini MA

J Laparoendosc Adv Surg Tech A. 2008 Aug;18(4):583-7

Reported by UroToday.com Medical Editor Ralph V. Clayman, MD

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