A 10-mm umbilical trocar was introduced into abdominal cavity, and a flexible-tip 5.4-mm 0° laparoscope was used. A multi-instrument access port (TriPort; Olympus Medical System Corp, Tokyo, Japan) was deployed across the vaginal incision under direct vision (Fig. 23.2, and used for a 5-mm ultrasonic dissector and a 5-mm flexible forceps.

A 5-mm trocar was introduced into the pelvic cavity through the vaginal incision, guided by a 5-mm blunt-tipped forceps, and a flexible-tip 5.4-mm 0° laparoscope was used to confirm no rectal injury. Then, a self-developed three-channel Zou-port (Zhouji Medical Instruments Co Ltd., Zhejiang, China) was deployed across the vaginal incision, into which the flexible-tip laparoscope and instruments were all introduced (Fig. 23.3).

Dissection was performed according to the method of a standard laparoscopic transabdominal nephrectomy. Using the ultrasonic dissector, the peritoneum was incised along the line of Toldt, and the colon was mobilized and retracted medially. The ureter was identified proximal to the iliac vessels and ligated using 5- or 10-mm Hem-o-lok clips (Teleflex Medical China, Shanghai, China). Proximal mobilization of the ureter up to level of the ureteropelvic junction was performed. The mobilized ureter was used for the retraction of the kidney and the lower pole of the kidney was mobilized, followed by posterior dissection. The lower pole was lifted laterally to define the renal hilum. After the hilum was identified, it was dissected using the ultrasonic dissector or pre-bent instruments and flexible forceps. The Hem-o-lok applier was used to control the artery, and then the vein. In cases of severe hydronephrosis, the collecting system was drained, as needed, to achieve better exposure to the renal pedicle. If dense adhesions around the renal artery precluded skeletonizing it, the renal artery was doubly clipped with its surrounding fibrous tissues, and the kidney was mobilized outside Gerota’s fascia. Remaining attachments of the upper pole of the kidney medially, superiorly, posteriorly, and laterally were progressively freed using straight, flexible, or pre-bent instruments to retract the dissected kidney, and the kidney was released. A homemade bag was introduced into the abdominal cavity through the 10-mm working channel of the transvaginal Zou-port. The specimen was placed inside the bag and removed through an extended incision at the posterior vaginal fornix (Fig. 23.4a, b). For hybrid transvaginal NOTES nephrectomy, one or no drain was placed at the renal bed, and one was placed at pelvic cavity through the vagina. We placed the intra-abdominal drain through the umbilical incision in order to remove the abdominal fluid, which can also help us early find postoperative problems. However, in the first 10 cases, we found that the postoperative drainage from intra-abdominal drains was little (less than 20 ml each day). Furthermore, the fluid may flow out of the pelvic drain when the patient is in the semi-recumbent position. Therefore, we consider that it is not necessary to place an intra-abdominal drain. There was no intra-abdominal drain in later patients. For pure transvaginal NOTES nephrectomy, the drain tube was placed at pelvic cavity through the vagina. The vaginal wound and the 10-mm umbilical fascial defect were closed using a 2-0 absorbable suture. Finally, a vaginal tamponade with a sterile vaginal pack dressing was applied in all the patients. Complete sexual abstinence lasting 3 months was advised for all cases.

For hybrid transvaginal NOTES nephrectomy, the mean operative time was 105 min (range: 70–280 min), and the mean estimated blood loss was 80 ml (range: 30–800 ml). There were 19 intraoperative complications. Five patients were converted to open surgery. There were 15 postoperative complications:14 minor complications (Clavien 1–2) and 1 major complication (Clavien 3b, postoperative bleeding). The patient subsequently underwent exploratory laparotomy revealing a clip dislodgment from the gonadal vein. For pure transvaginal NOTES nephrectomy, the procedures were successfully performed in all patients without additional trocars except for one patient who experienced a rectal injury caused by a forceps during the placement of the Zou-Port, and immediate repair was performed. The patient was converted to suprapubic-assisted laparoendoscopic single-site surgery (SA-LESS) nephrectomy in which 5- and 10-mm trocars were inserted at the medial margin of the umbilicus through two separate incisions and a 10-mm trocar was inserted into the abdominal cavity below the pubic hairline. The technique for the SA-LESS is similar to that of the standard laparoscopy, with conventional instruments placed in the abdominal trocars, under direct vision achieved by a 5.4-mm flexible-tip laparoscope placed through the trocar below the pubic hairline [35]. The kidney specimen was removed after the incision below the pubic hairline was enlarged. Postoperative major complications included a right external iliac artery thrombosis on postoperative day 2, which was successfully treated by thrombus removal. This complication may be related to the patient’s poor vascular condition, and the long-time compression and repeated friction injury of the vascular intima. There was no other intraoperative abdominal and pelvic organs injury. The mean operative time was 190 min (range: 160–320 min), and the mean estimated blood loss was 170 ml (range: 100–500 ml).

At a mean range follow-up of 51.8 (10–69) months, all the patients were in good condition. The posterior colpotomy incision healed well (Fig. 23.4c). The scars were nearly invisible on the abdominal wall (Fig. 23.4d). There were no infections, umbilical hernias, or uterine prolapse. All patients who underwent nephrectomy for malignant suspicion were alive without evidence of tumor recurrence or metastasis. One hundred and sixty eight patients completed the female sexual function index (FSFI) questionnaire, and analysis did not show any difference in FSFI scores before and after surgery.

Our transvaginal NOTES nephrectomy schedule has evolved as a stepwise process [36]. Prior to proceeding with NOTES in humans, we underwent extensive training in the animal laboratory to investigate operative safety and to prepare for transition to human clinical application. Different methods of peritoneal access were evaluated, and the transvaginal route was finally determined to be an ideal approach for nephrectomy. For our initial human experience, we performed five cases of transumbilical, multiport laparoscopic nephrectomy with intact specimen extraction through the vagina [37]. We think that this method is an effective technique by itself and an ideal way to train for the hybrid transvaginal NOTES technique. In our hybrid NOTES series, vaginal access was used to insert a laparoscope, and two umbilical trocars were used as main working ports. We then transitioned to a single umbilical trocar used for the laparoscope, with the transvaginal approach used for the majority of the dissection. Working toward pure transvaginal NOTES nephrectomy, we firstly performed pure transvaginal NOTES renal cyst decortication in 5 patients using extra-long pre-bent instruments [38]. Finally, we moved to a pure transvaginal NOTES nephrectomy. Based on our experience, we offer the following recommendations: