Natural orifice translumenal endoscopic surgical radical prostatectomy: Proof of concept

Background and Purpose: Innovations in minimally invasive surgery have led to the proposal of incision-free natural orifice translumenal endoscopic surgery (NOTES). The purpose of this manuscript is to describe the initial technique of natural orifice translumenal endoscopic surgical radical prostatectomy (NOTES-RP). Materials and Methods: NOTES-RP was performed on four male cadavers in a surgical simulation laboratory setting. The 100 W holmium:yttrium-aluminum- garnet laser, 550m end-firing laser fiber, 26F resectoscope, 7F laser stabilizing catheter, and continuous irrigation were used to radically resect and deliver the prostate of each cadaver into the bladder. The neurovascular bundles were preserved bilaterally, as well as the dorsal venous complex, bladder neck, and external sphincter. The entire resection was performed with the laser, while a rigid offset 27F nephroscope was used to perform the vesicourethral anastomosis using a laparoscopic suture device and knot pusher in an interrupted fashion. The prostate tissue was removed endoscopically with a tissue morcellator. After the initial NOTES-RP, a pelvic exploration with biopsy of neurovascular bundles, bladder, and urethral margins was performed. Results: NOTES-RP was successfully executed in the cadaveric model. Pathologic evaluation of tissue demonstrates complete removal of all prostate tissue with preservation of the neurovascular bundles bilaterally as well as the external urinary sphincter. Conclusion: The present work demonstrates the feasibility of NOTES-RP in the cadaver model. While further testing and instrument modification are necessary before clinical application, this concept demonstrates the evolving nature of minimally invasive surgery and what could be possible for patients.