Pure Natural Orifice Translumenal Endoscopic Surgery Partial Cystectomy: Intravesical Transurethral and Extravesical Transgastric Techniques in a Porcine Model

OBJECTIVES To describe 2 pure natural orifice translumenal endoscopic surgery (NOTES) techniques for partial cystectomy in a porcine model. NOTES is a new minimally invasive modality for performing abdominal surgery without transcutaneous incision. METHODS Transurethral-A rigid cystoscope is inserted into the porcine bladder with CO2 insufflation. With an endoscopic loop device and a grasping device, the targeted area of the bladder is manipulated into the loop. The bladder segment is excised with electrocautery. Transgastric-A gastrotomy is made with a dual channel endoscope in the porcine stomach. The endoscope is inserted and pneumoperitoneum is established by insufflation through a channel. After identifying bladder, 2 endoscopic loops are placed at the intended area of resection. An incision is made between the loops to excise the specimen. In both cases, full-thickness specimen is removed en bloc with the scope and the defect is reapproximated with endoscopic clips. RESULTS Transurethral and transgastric NOTES approaches were achieved using standard endoscopic equipment in a porcine model. Transurethral NOTES partial cystectomy was successful in acute (n = 2) and chronic (n = 2) models. The transgastric NOTES approach was successfully performed in an acute animal. CONCLUSIONS NOTES partial cystectomy could potentially reduce morbidity of conventional methods of partial cystectomy. Transurethral NOTES may be the least invasive method possible for partial cystectomy. Potential advantages of a transgastric NOTES approach include visualization of adjacent structures, access to sites difficult to reach transurethrally, and lymph node sampling. However, a gastrotomy could be a source of morbidity. Further investigation is required to assess safety, efficacy, and adequate bladder healing. UROLOGY 74: 1049-1053, 2009. (C) 2009 Elsevier Inc.