Original Paper

Urologia Internationalis

Received: October 11, 2012 Accepted after revision: September 30, 2013 Published online: April 9, 2014

Urol Int 2014;92:407–413 DOI: 10.1159/000356099

Transumbilical Multiport Laparoscopic Nephrectomy with Specimen Extraction through the Vagina Xiaofeng Zou Guoxi Zhang Yijun Xue Yuanhu Yuan Rihai Xiao Gengqing Wu Xiaoning Wang Yuting Wu Dazhi Long Jun Yang Hui Xu Folin Liu Min Liu Department of Urology, First Affiliated Hospital of Gannan Medical University, Ganzhou, PR China

Abstract Objectives: To report our initial experience with transumbilical multiport laparoscopic nephrectomy (TMLN) with transvaginal specimen extraction. Patients and Methods: Between January and July 2010, 5 married and parous female patients were submitted to TMLN with transvaginal specimen extraction in our center. All data referring to patient demographics, surgery, pathology and perioperative outcomes were recorded. Sexual function was assessed with the Female Sexual Function Index questionnaire before and after surgery. The cosmetic result was investigated by administering the Patient Scar Assessment Questionnaire and Scoring System (PSAQ). Results: All procedures were completed successfully. The mean operative time was 136 min (range 110–160 min, standard deviation [SD] 20.7). The mean estimated blood loss was 66 ml (range 40–100 ml, SD 24.1). The mean postoperative hospitalization stay was 4.8 days (range 4–6 days, SD 0.8). All patients reported unaltered sexual function after surgery. The better cosmetic results were

© 2014 S. Karger AG, Basel 0042–1138/14/0924–0407$39.50/0 E-Mail [email protected] www.karger.com/uin

confirmed by the PSAQ score. Conclusions: TMLN with transvaginal specimen extraction is feasible and safe for married and parous female patients. This technique is a natural evolution towards natural orifice transluminal endoscopic surgery (NOTES). By acting as an intermediate-type procedure, it provides a bridge through which NOTES may ultimately gain clinical acceptance. © 2014 S. Karger AG, Basel

Introduction

Laparoendoscopic single-site surgery (LESS) represents an evolution of minimally invasive surgery and is being reported with increasing frequency [1–6]. Although at present confirmatory clinical data from multicenter, prospective and randomized comparative studies are lacking in the literature, it appears as though this technique may have promise compared with its conventional laparoscopic counterpart in terms of shorter hospital stay, less postoperative pain, improved cosmesis and earlier return to daily occupation [7–10].

X. Zou, G. Zhang and Y. Xue contributed equally to this work.

Xiaofeng Zou and Yuanhu Yuan Department of Urology First Affiliated Hospital of Gannan Medical University No. 23, Qing Nian Road, Ganzhou 341000 (PR China) E-Mail gyfyurology @ 126.com

Downloaded by: Selçuk Universitesi 193.255.248.150 - 1/4/2015 2:55:25 AM

Key Words Laparoendoscopic single-site surgery · Natural orifice transluminal endoscopic surgery · Transvaginal surgery · Transumbilical surgery · Nephrectomy

Patients and Methods Patients Between January and July 2010, 5 married and parous female patients were submitted to TMLN with transvaginal specimen extraction in our center, including 3 patients with benign renal disease and 2 patients with malignant renal disease. Radical nephrectomy was performed for cases not amenable to nephron-sparing surgery. Each patient with simple nephrectomy had similar disease etiology of renal calculus disease leading to a nonfunctioning pyonephrotic kidney. The patients’ baseline characteristics and indications are summarized in table 1.

408

Urol Int 2014;92:407–413 DOI: 10.1159/000356099

Table 1. Baseline characteristics of the 5 patients

Mean age, years (range) Mean body mass index, kg/m2 (range) Affected kidney Left Right Patients with tumors Tumor size, cm Patients with nonfunctional pyonephrotic kidneys Mean ASA score (range)

38 (32–45) 23.5 (19.8–27.6) 2 3 2 (40%) 5.4, 6.2 3 (60%) 1.3 (1–2)

ASA = American Society of Anesthesiologists.

All cases were preoperatively evaluated with ultrasonography, nephrography, intravenous urography and computed tomography. All patients had normal function in the contralateral kidney. All data referring to patient demographics, surgery, pathology and perioperative outcomes were recorded. The study was approved by the Ethics Committee of Gannan Medical University. All patients were adequately informed of the possible risks and benefits of this new approach and signed written consent agreeing to undergo the described procedure and allowing the use of their data prospectively. All procedures were performed by a surgeon with advanced laparoscopic skills (X. Zou). Exclusion criteria were pelvic inflammatory disease, stenosis of the vagina, BMI >30, nulliparous and previous major abdominal surgery. Preoperative Preparation In cases of nonfunctioning pyonephrotic kidney, ultrasoundguided mini-percutaneous nephrostomy drainage for >4 weeks was performed and culture-appropriate antibiotics were given. Vaginal irrigation with iodophors was performed once a day for 3 days before surgery. Each patient underwent mechanical bowel preparation with the use of enema the morning of surgery, along with a clear liquid diet a day prior to surgery. Surgical Technique Under general anesthesia, the patients were placed in the lithotomy position with the affected side elevated by 60°. Three separate 5-mm incisions were made within the umbilical ring, including one at the 6 o’clock position and the two other at the 3 and 9 o’clock position, respectively. The incision divided only the skin and was not deepened into the subcutaneous fatty tissue or the fascia. Pneumoperitoneum was achieved using the Veress needle technique with maintenance of an intra-abdominal pressure of 15 mm Hg. Three 5-mm bladeless trocars were inserted into the abdominal cavity through the three incisions by direct puncture (fig. 1a). Visualization was obtained using a 5-mm 30° rigid laparoscope (Stortz Medical System, Tuttlingen, Germany) via the trocar at the 6 o’clock position of the umbilicus. The entire procedure was performed using standard laparoscopic instruments and a 5-mm harmonic scalpel (Ethicon Endosurgery, Cincinnati, Ohio, USA). Transperitoneal laparoscopic nephrectomy was performed according to the technique previously described [22]. The peritoneum

Zou/Zhang/Xue/Yuan/Xiao/Wu/Wang/ Wu/Long/Yang/Xu/Liu/Liu

Downloaded by: Selçuk Universitesi 193.255.248.150 - 1/4/2015 2:55:25 AM

While acknowledging these results, the removal of the surgical specimen in LESS is usually accomplished by enlarging the initial umbilical incision, which does not only implicate cosmetic drawbacks but can also increase the risk of incisional hernia formation. Natural orifice transluminal endoscopic surgery (NOTES) is another exciting development in minimally invasive surgery. Theoretically, NOTES may permit some surgical procedures, including surgical specimen removal, to be performed without skin incisions. Nevertheless, numerous technical, visual and safety issues need to be overcome before widespread acceptance of this technique. Natural orifice specimen extraction, a NOTES-related concept [11], refers to the procedure in which the organ/ tissue is extracted through a natural orifice after a conventional laparoscopic procedure, with avoidance of an extraction mini-laparotomy. The vagina was considered a viable route for specimen removal after abdominal surgery. The combination of conventional laparoscopic nephrectomy with an incision in the vagina and vaginal extraction of the intact kidney has been described in the urologic literature [12, 13]. In 2008, Branco et al. [14] reported the first case of hybrid NOTES nephrectomy where vaginal access was used not only for specimen extraction but also as a working port. Since then, several other investigators have reported their clinical experience with hybrid NOTES nephrectomy using adjunctive transabdominal laparoscopic ports or a single umbilical port [15–21]. Nevertheless, experience using this technique is extremely limited, with only a few case reports and small series reported in the literature. Herein, we describe our techniques and results of transumbilical multiport laparoscopic nephrectomy (TMLN) with transvaginal specimen extraction in a series of 5 cases. Even though it cannot be considered as true NOTES, we aim to assess the feasibility, safety and efficacy of this technique and its use as a conduit or bridge to fill the gap between laparoscopic surgery and NOTES.

extraction through the vagina.

b

c

d

was incised using a harmonic scalpel along the line of Toldt and the colon was mobilized and retracted medially. The dissection proceeded until the renal hilum was exposed, at which time the right 5-mm trocar was exchanged for a 10-mm trocar to accommodate a Hemo-lok applier. The renal artery, vein and ureter were secured after positioning Hem-o-lok clips (Weck Closure Systems, Research Triangle Park, N.C., USA) and then divided (fig. 1b). The kidney was placed inside a homemade bag (fig. 1c). The vaginal mucosa in the posterior vaginal fornix was opened by a chiastic 3-cm incision, and an oval forceps was inserted into the abdominal cavity and captured the homemade bag under direct vision from the laparoscope at the umbilicus and with the help of two forceps at the umbilicus retracting the uterus and facilitating visualization of the vaginal posterior wall. The intact specimen was removed via the vagina (fig. 1d). A silicone drain was placed in the nephrectomy bed after achieving hemostasis in all cases. The vaginal wound was closed under direct vision using a 2-0 absorbable suture (Ethicon Endosurgery) transvaginally. The umbilical fascial defect was closed with a 2-0 absorbable suture, and the skin incision was closed using a running 5-0 absorbable subcuticular suture (Ethicon Endosurgery). Finally, a vaginal tamponade with a sterile vaginal pack dressing was applied in all patients, which was removed 24–48 h after the operation. Complete sexual abstinence lasting 3 months was advised for all patients.

months postoperatively. The FSFI is a detailed 19-item anonymous questionnaire including sexual desire (score range 2–10), arousal (score range 0–20), lubrication (score range 0–20), orgasm (score range 0–15), satisfaction (score range 2–15) and pain during sexual intercourse (score range 0–15). The total score was obtained by adding the six domain scores and was calculated multiplying the sum by the domain. Factors were 0.6 for desire, 0.3 for arousal and lubrication, and 0.4 for orgasm, satisfaction and pain. Therefore, the total FSFI score range was 2–36. The cosmetic result was investigated by administering the Patient Scar Assessment Questionnaire and Scoring System (PSAQ) [24] 3 months after surgery. The PSAQ is divided into the following five categories (with possible scores in parentheses): appearance (9–36), symptoms (6–24), scar consciousness (6–24), satisfaction with appearance (8–32) and satisfaction with symptoms (5–20). Each category contains a number of questions with four possible responses. These responses are scored from 1 (best response) to 4 (worst response) and totaled to give a score for each section. Therefore, a low score for each category indicates a favorable cosmetic outcome. Each category also has a global question scored from 5 points for the first two categories and from 4 points for the remainder. Again, a lower score indicates a favorable cosmetic outcome.

Postoperative Follow-Up Follow-up visits were scheduled on postoperative days 10, 20 and 30 and then in postoperative months 4, 8 and 12. Sexual function was evaluated according to the Female Sexual Function Index (FSFI) [23] at four time points: preoperatively and 4, 8 and 12

Statistical Analysis Statistical analysis was performed using SPSS 14.0 (SPSS Inc., Chicago, Ill., USA) for Windows. The paired t test was used to compare difference between pre- and postoperative FSFI total score, with p < 0.05 considered to indicate statistical significance.

LESS Nephrectomy with Specimen Extraction through the Vagina

Urol Int 2014;92:407–413 DOI: 10.1159/000356099

409

Downloaded by: Selçuk Universitesi 193.255.248.150 - 1/4/2015 2:55:25 AM

Color version available online

Fig. 1. a Three 5-mm transumbilical trocars. b The renal artery was ligated with Hem-o-lok clips. c The specimen bag was grasped with an oval clamp. d Specimen

a

Color version available online

a

Table 2. Perioperative data of the 5 patients

Mean operative time, min (range, SD) Simple nephrectomy Radical nephrectomy Intraoperative complications Mean estimated blood loss, ml (range, SD) Patients receiving transfusion Surgical drain removal, mean days (range, SD) Mean full ambulation, days Mean oral feeding, days Postoperative complications Mean postoperative hospital stay, days (range, SD)

136 (110–160, 20.7) 140 (120–160, 20.0) 120 (110–130, 14.1) 0 66 (40–100, 24.1) 0 1.6 (1–2, 0.5) 1 1 0 4.8 (4–6, 0.8)

Results

The intraoperative and early postoperative outcomes of the 5 patients are summarized in table 2. All procedures were completed successfully without conversion to conventional laparoscopic or open surgery. Furthermore, no additional trocars or instruments were required. The mean operative time was 136 min (range 110– 160 min, standard deviation [SD] 20.7). The mean operative time for simple nephrectomy seemed longer than that for radical nephrectomy. The mean estimated blood loss was 66 ml (range 40–100 ml, SD 24.1). None of the patients required a blood transfusion. All patients were ambulatory and resumed food intake on postoperative day 1. The drain was removed on postoperative days 1–2. The mean hospital stay was 4.8 days (range 4–6 days, SD 0.8). We did not record any intraoperative complications, postoperative stays were uneventful, and no complica410

Urol Int 2014;92:407–413 DOI: 10.1159/000356099

b

tions were recorded during follow-up, suggesting the safety of this procedure. Simple nephrectomy was performed for nonfunctioning pyonephrotic kidneys in 3 of 5 cases, with final pathology consistent with marked thinning of the cortex, destruction of the renal parenchyma and calices containing purulent material without evidence of malignancy. Two patients underwent a radical nephrectomy for enhancing renal masses with a tumor size of 5.4 and 6.2 cm, respectively. Both tumors were located on the lower pole of the kidney. Pathological examination observed two T1b and grade II tumors. Histology revealed organ-confined renal cell carcinoma in both cases. The mean follow-up period was 12 months (range 9–17 months, SD 3.2). All patients were in good condition. The scars on the abdominal wall were nearly invisible (fig. 2a). The posterior colpotomy incision healed up well (fig. 2b). All patients responded to the FSFI questionnaire, and analysis did not reveal differences in the total score for sexual function between preoperatively and postoperatively among the individual domains (table 3). In terms of cosmetic results, the results for each category are summarized in table 4. For each category the mean score is low, indicating a favorable cosmetic outcome. These results are supported by the global question score, which is 1 for all, indicating an excellent cosmetic outcome.

Discussion

Raman et al. [3] reported the first LESS nephrectomy in 2007. Since then, several other clinical series from multiple academic institutions have continued to report their Zou/Zhang/Xue/Yuan/Xiao/Wu/Wang/ Wu/Long/Yang/Xu/Liu/Liu

Downloaded by: Selçuk Universitesi 193.255.248.150 - 1/4/2015 2:55:25 AM

Fig. 2. a Appearance of the incision 1 month postoperatively. b Appearance of the posterior colpotomy incision 1 month postoperatively.

Table 3. Comparison of pre- and postoperative sexual function of patients undergoing TMLN with transvaginal

specimen extraction according to the FSFI instrument Parameter

Desire

Arousal

Lubrication Orgasm

Satisfaction Pain

Total

Preop. Postop. month 4 p value Postop. month 8 p value Postop. month 12 p value

4.56±0.68 4.56±0.71 0.82 4.56±0.32 0.85 4.56±0.46 0.88

4.56±0.65 4.40±0.63 0.36 4.62±0.65 0.78 4.58±0.62 0.85

4.98±0.40 4.99±0.39 0.86 4.92±0.45 0.73 4.96±0.41 0.84

4.84±0.89 4.92±0.92 0.34 4.88±0.86 0.68 4.90±0.82 0.46

28.70±4.16 28.54±4.08 0.58 28.98±3.48 0.48 28.81±3.60 0.52

5.12±0.71 5.15±0.65 0.88 5.28±0.44 0.66 5.17±0.56 0.72

4.64±0.83 4.52±0.78 0.32 4.72±0.76 0.54 4.64±0.73 0.87

Data were given as mean ± SD. Preop. = Preoperatively; Postop. = postoperatively. p value: relative to Preop.

experiences and the concept of LESS has gained increasing popularity among urologists. Overall, these series suggested that LESS nephrectomy has some advantages over conventional laparoscopy nephrectomy in terms of perioperative outcomes, and revealed an encouraging trend towards less postoperative pain and better cosmesis [7–10]. Despite these potential advantages, a crucial clinical question surrounding the use of LESS nephrectomy also remains: What is the optimal method to extract the specimen? In reviewing the current state of the art of LESS nephrectomy, extending the umbilical incision up to 4–6 cm has been reported to extract the intact specimen, which may compromise the cosmetic outcome of LESS and increase the risk of incision-related morbidity such as hernia, pain and infection [7, 8]. To avoid expanding the abdominal incision, specimen morcellation has been used in some institutions. However, accurate pathological staging and postoperative risk stratification are not possible for malignant tumors, and there is a risk of intra-abdominal and port site infection for pyonephrotic kidneys, which restricted its use. Another alternative to avoid enlargement of the abdominal incision was the use of natural orifices, such as the vagina. In 1993, vaginal extraction of an intact kidney following laparoscopic nephrectomy was first described by Breda et al. [12]. In 2002, Gill et al. [13] reported the technical details and results of transvaginal specimen extraction after laparoscopic radical nephrectomy in a series of 10 patients. The expected benefit of natural orifice specimen extraction in laparoscopic surgery, especially in procedures with a large specimen, is to prevent the need for an enlarged port site or mini-laparotomy. In an attempt to maintain the benefits of LESS and diminish this incision-related morbidity, we performed

Table 4. Patient scores for scars after TMLN with transvaginal specimen extraction for 5 patients

LESS Nephrectomy with Specimen Extraction through the Vagina

Urol Int 2014;92:407–413 DOI: 10.1159/000356099

Section (score range)

Appearance (9–36) Mean Median (range) Symptoms (6–24) Mean Median (range) Scar consciousness (6–24) Mean Median (range) Satisfaction with appearance (8–32) Mean Median (range) Satisfaction with symptoms (5–20) Mean Median (range)

Total section score

Overall question score

12.4 12 (9–18)

1.2 1 (1–2)

6.4 6 (6–10)

1.2 1 (1–2)

8.0 7 (6–12)

1.2 1 (1–2)

9.8 9 (8–14)

1.2 1 (1–2)

5.4 5 (5–6)

1.2 1 (1–2)

5 successful procedures of TMLN nephrectomy with transvaginal specimen extraction. Our transvaginal specimen extraction after nephrectomy somewhat varies from that of Breda et al. [12] and Gill et al. [13] in that our patients had no extra-umbilical skin incisions, which maintains the cosmetic advantage of LESS. The 411

Downloaded by: Selçuk Universitesi 193.255.248.150 - 1/4/2015 2:55:25 AM

The PSAQ is divided into five categories, with the range of possible scores in parentheses. Each category contains several questions with four possible responses, which are scored from 1 (best response) to 5 (worst response), with the scores combined to give a total section score. The overall question for each section is scored from 1 to 5 points and does not contribute to the total section score. For both the total section score and the overall question score, the lower the value, the better the response.

412

Urol Int 2014;92:407–413 DOI: 10.1159/000356099

separate umbilical incisions by direct puncture. This method allowed us to diminish the amount of air leakage to a negligible level and to save costs. A major concern of the transvaginal procedure is the possibility of postoperative sexual dysfunction. However, the current literature suggests that sexual dysfunction is a rare event after vaginal surgery [26]. Our experience confirmed this because all the patients in this study had an unchanged FSFI 4 months postoperatively. Of course, additional studies using larger sample sizes are needed to confirm the result. There were no perioperative complications, postoperative stays were uneventful, and no complications were recorded during follow-up, suggesting the safety of this procedure. The feasibility of hybrid or pure transvaginal NOTES nephrectomy has already been demonstrated using currently available instruments [14–21]. However, experience with this technique is still largely limited when compared to LESS. While awaiting engineering and technical solutions to many challenges surrounding NOTES, a progressive approach allows establishing a successful NOTES program. Any LESS procedure ultimately could be considered for a NOTES approach because both are examples of inline surgery and potentially challenge the traditional laparoscopic surgical paradigm of instrument triangulation. Thus, the transumbilical approach provides an excellent start to gain experience to eventually perform NOTES. Furthermore, transvaginal specimen extraction involves using a natural orifice, which is important to establish basic familiarization with NOTES. Also, the transvaginal route could be used to perform part of the dissection in a hybrid NOTES procedure and give surgeons a confidence-building skill. Based on the above clinical work in our center, we have made a safe transition from LESS nephrectomy to transvaginal NOTES nephrectomy for properly selected patients, which was presented as a video oral presentation at AUA 2011 [27]. In addition, we also performed 11 even more challenging transvaginal NOTES adrenalectomies with promising results [28]. In these two studies, the renal and adrenal specimens were all removed through the vagina, which led to good cosmetic outcomes and no dyspareunia. We believe that TMLN nephrectomy with transvaginal specimen extraction can provide a bridge to NOTES, perhaps lessening part of the learning curve associated with the adoption of this new technique. There are a few limitations to the present study that should be mentioned. First, there was a significant selection bias in that patients in this study were relatively Zou/Zhang/Xue/Yuan/Xiao/Wu/Wang/ Wu/Long/Yang/Xu/Liu/Liu

Downloaded by: Selçuk Universitesi 193.255.248.150 - 1/4/2015 2:55:25 AM

better cosmetic results were confirmed by the PSAQ score. The use of laparoscopic instruments, when inserted in parallel through the same site, often results in loss of triangulation, decreased maneuverability and trocars fighting for space. A combination of articulating and bent instruments can allow the surgeon to partially overcome those shortcomings. Branco et al. [25] evaluated LESS urologic surgery using conventional laparoscopic instruments, claiming that articulating instruments might not be strictly necessary, which is consistent with our experience. In the present study, only conventional laparoscopic instruments and trocars were used and all procedures were successful within a reasonable time. The conventional laparoscopic instruments have two advantages: surgeon familiarity and cost savings. Of course, conditions permitting, pre-bent or flexible instruments and modified trocars may be helpful to overcome the difficulties in the loss of triangulation and the interference among the laparoscope and the instruments or trocars. Laparoscopic nephrectomy for nonfunctioning pyonephrotic kidneys remain technically challenging because of the obliterated tissue planes with inflammatory involvement of the renal hilum and surrounding structures. However, we could successfully treat pyonephrotic kidneys with LESS. In the present study, the patients with a pyonephrotic kidney had similar perioperative outcomes compared to those with radical nephrectomy, apart from the procedure being slightly more time-consuming. In our experience, adequate mini-percutaneous nephrostomy drainage in combination with appropriate antibiotics was used in the 3 patients with pyonephrotic kidney to help stabilize and improve the patient’s clinical condition preoperatively and allow inflammation to subside, making subsequent surgery safer. Furthermore, careful and slow patient dissection is extremely important in such cases. We also believe that, whenever feasible, the renal vessels should be controlled as soon as possible, which will significantly reduce bleeding and allow for additional dissection. Yet, keeping a clear mind for conversion to conventional laparoscopic or open nephrectomy and assigning priority to the safety of patients over cosmesis will help avoid serious complications when surgeons encounter difficulties during this type of operation. If LESS is performed with multiple individual trocars, CO2 leakage around the trocars is a common issue. Some authors used commercially available ports, such as Triport, to minimize air leakage and obtained good results. In our series, three trocars were inserted through three

young, nonobese and had had no previous major abdominal surgery. Second, although the current study assessed the safety and feasibility of this technique, the population remains low for drawing any firm conclusions. Third, this study included a single surgeon with advanced laparoscopic experience. Therefore, the results may not be applicable to the general urologist. Another limitation is the lack of a long follow-up period, which would be needed to assess late complications.

Conclusions

TMLN with transvaginal specimen extraction is feasible and safe for both benign and malignant diseases of the kidney in married and parous female patients. This technique is a natural evolution towards NOTES. By acting as an intermediate-type procedure, it provides a bridge through which NOTES may ultimately gain clinical acceptance.

References

LESS Nephrectomy with Specimen Extraction through the Vagina

10 Tugcu V, Ilbey YO, Mutlu B, et al: Laparoendoscopic single-site surgery versus standard laparoscopic simple nephrectomy: a prospective randomized study. J Endourol 2010; 24: 1315–1320. 11 Christian J, Barrier BF, Schust D, et al: Culdoscopy: a foundation for natural orifice surgery – past, present and future. J Am Coll Surg 2008;207:417–422. 12 Breda G, Silvestre P, Giunta A, et al: Laparoscopic nephrectomy with vaginal delivery of the intact kidney. Eur Urol 1993;24:116–117. 13 Gill IS, Cherullo EE, Meraney AM, et al: Vaginal extraction of the intact specimen following laparoscopic radical nephrectomy. J Urol 2002;167:238–241. 14 Branco AW, Branco Filho AJ, Kondo W, et al: Hybrid transvaginal nephrectomy. Eur Urol 2008;53:1290–1294. 15 Sotelo R, de Andrade R, Fernandez G, et al: NOTES hybrid transvaginal radical nephrectomy for tumor: stepwise progression toward a first successful clinical case. Eur Urol 2010; 57:138–144. 16 Kaouk JH, White WM, Goel RK, et al: NOTES transvaginal nephrectomy: first human experience. Urology 2009;74:5–8. 17 Autorino R, Haber GP, White MA, et al: Pure and hybrid natural orifice transluminal endoscopic surgery (NOTES): current clinical experience in urology. BJU Int 2010; 106: 919– 922. 18 Alcaraz A, Peri L, Molina A, et al: Feasibility of transvaginal NOTES-assisted laparoscopic nephrectomy. Eur Urol 2010;57:233–237. 19 Liatsikos E, Kyriazis I, Kallidonis P, et al: Pure single-port laparoscopic surgery or mix of techniques? World J Urol 2012;30:581–587.

Urol Int 2014;92:407–413 DOI: 10.1159/000356099

20 Sotelo R, Giedelman C, Carmona O, et al: Hybrid-NOTES transvaginal hemi-nephrectomy for duplicated renal collecting system in the adult patient. Actas Urol Esp 2011; 35: 363–367. 21 Porpiglia F, Fiori C, Morra I, et al: Transvaginal natural orifice transluminal endoscopic surgery-assisted minilaparoscopic nephrectomy: a step towards scarless surgery. Eur Urol 2011;60:862–866. 22 Fornara P, Doehn C, Miglietti G, et al: Laparoscopic nephrectomy: comparison of dialysis and non-dialysis patients. Nephrol Dial Transplant 1998;13:1221–1225. 23 Meston CM: Validation of the Female Sexual Function Index (FSFI) in women with female orgasmic disorder and in women with hypoactive sexual desire disorder. J Sex Marital Ther 2003;29:39–46. 24 Durani P, McGrouther DA, Ferguson MW: The Patient Scar Assessment Questionnaire: a reliable and valid patient-reported outcomes measure for linear scars. Plast Reconstr Surg 2009;123:1481–1489. 25 Branco AW, Kondo W, Stunitz LC, et al: Transumbilical laparoscopic urological surgery: are special devices strictly necessary? BJU Int 2009;104:1136–1142. 26 Tunuguntla HS, Gousse AE: Female sexual dysfunction following vaginal surgery: a review. J Urol 2006;175:439–446. 27 Zou X, Zhang G, Yuan Y, et al: Transvaginal NOTES-assisted laparoscopic nephrectomy in humans (AUA video presentation). J Urol 2011;184(suppl 4):836. 28 Zou X, Zhang G, Xiao R, et al: Transvaginal natural orifice transluminal endoscopic surgery (NOTES)-assisted laparoscopic adrenalectomy: first clinical experience. Surg Endosc 2011;25:3767–3772.

413

Downloaded by: Selçuk Universitesi 193.255.248.150 - 1/4/2015 2:55:25 AM

1 Gettman MT, Box G, Averch T, et al: Consensus statement on natural orifice transluminal endoscopic surgery and single-incision laparoscopic surgery: heralding a new era in urology? Eur Urol 2008;53:1117–1120. 2 Autorino R, Cadeddu JA, Desai MM: Laparoendoscopic single-site and natural orifice transluminal endoscopic surgery in urology: a critical analysis of the literature. Eur Urol 2011;59:26–45. 3 Raman JD, Bensalah K, Bagrodia A, et al: Laboratory and clinical development of single keyhole umbilical nephrectomy. Urology 2007;70:1039–1042. 4 Kaouk JH, Haber GP, Goel RK, et al: Singleport laparoscopic surgery in urology: initial experience. Urology 2008;71:3–6. 5 Stolzenburg JU, Kallidonis P, Hellawell G, et al: Technique of laparo-endoscopic singlesite surgery radical nephrectomy. Eur Urol 2009;56:644–650. 6 White WM, Haber GP, Goel RK, et al: Singleport urological surgery: single-center experience with the first 100 cases. Urology 2009;74: 801–804. 7 Canes D, Berger A, Aron M, et al: Laparoendoscopic single site (LESS) versus standard laparoscopic left donor nephrectomy: matched-pair comparison. Eur Urol 2010; 57: 95–101. 8 Raman JD, Bagrodia A, Cadeddu JA: Singleincision, umbilical laparoscopic versus conventional laparoscopic nephrectomy: a comparison of perioperative outcomes and shortterm measures of convalescence. Eur Urol 2009;55:1198–1206. 9 Tracy CR, Raman JD, Bagrodia A, et al: Perioperative outcomes in patients undergoing conventional laparoscopic versus laparoendoscopic single-site pyeloplasty. Urology 2009;74:1029–1034.

Transumbilical multiport laparoscopic nephrectomy with specimen extraction through the vagina.

To report our initial experience with transumbilical multiport laparoscopic nephrectomy (TMLN) with transvaginal specimen extraction...
531KB Sizes 0 Downloads 3 Views