Urological applications of natural orifice transluminal endoscopic surgery (NOTES)

Key Points

• Natural orifice transluminal endoscopic surgery (NOTES) nephrectomy, prostatectomy, and partial cystectomy are novel surgical techniques with tremendous promise as innovative approaches to the treatment urological diseases

• NOTES techniques have undergone extensive preclinical development over the past decade, which has increased understanding and led to refinement of the methodology

• NOTES can be performed via transgastric, transurethral, transrectal, and transvaginal routes, and either alone as 'pure NOTES', or in combination with laparoscopy surgery as 'hybrid NOTES'

• In humans, NOTES procedures have primarily been used in proof-of-principle studies in cadavers or select patients; however, these have proven the feasibility of NOTES nephrectomy and prostatectomy

• Considerable challenges continue to limit the widespread adoption of NOTES, including potential safety concerns, an unmet need for dedicated, specifically designed instruments, and the shortage of suitably skilled surgeons

• Furthermore, stringent validation and comparison with laparoscopy and open-surgery techniques is needed to ensure that the current enthusiasm for NOTES techniques is supported by measureable improvements in patient outcomes

Abstract

Improvements in surgical techniques, and particularly the development and widespread clinical introduction of laparoscopy in the past two decades, have revolutionized the management of urological disease. Natural orifice transluminal endoscopic surgery (NOTES) holds promise in further advancing treatment outcomes in urology. This novel minimally invasive surgical approach can negate the requirement for skin incisions and, therefore, could potentially improve morbidity, convalescence, and cosmesis. After considerable preclinical development, the feasibility of 'hybrid' NOTES—involving concurrent laparoscopy—and 'pure' NOTES nephrectomy and prostatectomy procedures has now been successfully demonstrated in patients with urological conditions, whereas proof-of-concept studies of NOTES partial cystectomy have been performed in animal models. Whether such procedures offer therapeutic and safety benefits compared with traditional laparoscopic techniques remains unknown; indeed, concerns remain over the potential perioperative and postoperative adverse events associated with NOTES, such as incomplete closure of the entry-point incision, infection, and haemorrhage. In particular, however, the requirement for the development of specific rationally designed NOTES instrumentation as well as specially trained, highly skilled personnel to perform the surgery continues to restrict the utility of NOTES. Thus, considerable effort is now needed to shift the focus of research to refining NOTES methodologies to enable translation of these promising proof-of-principle studies into the clinic.