Transvaginal natural orifice transluminal endoscopic surgery (NOTES)–assisted laparoscopic partial nephrectomy

Objective To describe the initial clinical experience of transvaginal NOTES–assisted laparoscopy for partial nephrectomy, and evaluate its feasibility and efficacy. Methods Between Aug. 2013 and Aug. 2014, 6 females underwent transvaginal NOTES–assisted laparoscopic partial nephrectomy. All patients were married and delivered. The median age was 37 (30 to 48) yrs. The median tumour size was 3.5 (2.5 to 6.5) cm. Under general anesthesia, the patient was placed in the lithotomy position with the affected side elevated by 60°. Two trocars were placed at the medial margin on both sides of umbilicus. A trocar was placed through the vagina into the abdominal cavity under the direct vision from a flexible–tip 5.4 mm 0° laparoscope. The patients underwent surgeries with main renal artery clamping, segmental renal artery clamping and renal artery unclamping, respectively. The mass was excised using the laparoscopic scissors maintaining a 0.5 cm margin. The inner layer was sutured for closing the collecting system and the second layer was sutured for closing the renal parenchyma with the Quill self–retaining suture. Specimen was placed inside a homemade bag and removed through the posterior vaginal fornix incision. Results Five procedures were completed successfully. One patient with a right upper–pole tumor was converted to radical nephrectomy for continuous bleeding after removing the bulldog clip. All the procedures were finished without conversion to conventional laparoscopy and with no additional trocar. The warm ischaemia time (WIT) was 20, 25 and 28 min for the three patients who underwent surgeries with main renal artery clamping, respectively. The WIT was 35 and 40 min for the two patients who underwent surgeries with segmental renal artery clamping, respectively. One patient underwent surgeries with renal artery unclamping. The median operating time was 130 (110 to 190) min. The estimated blood loss was 150 (100 to 400) ml. One patient who was subjected to postoperative bleeding recovered with conservative treatment. There were no other complications. Pathology indicated that all the tumors were clear cell renal cell carcinoma and all surgical margins were negative. During the follow–up of 3–14 mon, there was no recurrence. The median PSAQ score was 42 (39 to 48). All the patients completed the FSFI questionnaire. The median FSFI score was 27.7 (26.2 to 30.4). Conclusions Transvaginal NOTES–assisted laparoscopic partial nephrectomy is safe and feasible for small renal tumors with less pain, quick recovery and excellent cosmetic results. It does not cause negative effect on the female sexual function. Key words: Natural orifice transluminal endoscopic surgery; Transvaginal surgery; Partial nephrectomy