Transvaginal natural orifice specimen extraction surgery (NOSES) in 3D laparoscopic partial or radical nephrectomy: a preliminary study

Abstract

Background: With the development of minimally invasive technology, more and more people pay attention to aesthetics of the wound after operation. This study is aim to introduce a new surgical technique of transvaginal natural orifice specimen extraction surgery (NOSES) in 3D laparoscopic partial or radical nephrectomy and evaluate the safety, feasibility and clinical effect.

Methods: Eleven patients who underwent 3D laparoscopic partial nephrectomy (n = 7) or radical nephrectomy (n = 4) and NOSES were included in this study. The surgical procedures and techniques, especially the NOSES operation, are reported in detail. In addition, the basic clinical data, perioperative related data, perioperative complications were analyzed.

Results: All 11 patients were performed successfully without conversion to open surgery. The mean total operative time was 133 (84, 150) min. NOSES time was 15 (13, 16) min, and the postoperative hospital stay was 5 (5, 5) d. The mean visual analogue score (VAS) was 3 (2, 4) point and 1 (0, 1) point at 24 h and 48 h after operation, respectively. No patient had recurrence, metastasis and death during the follow-up period of 3 to 17 months. The median Vancouver Scar Scale (VSS) was 1 (1, 1) point. The mean of Female Sexual Function Index (FSFI) was 21.60 (20.20, 21.60), 21.80 (19.80, 21.80) respectively between preoperative and postoperative 3 months, which has no statistical difference (P = 0.179). There was no statistical difference in the Pelvic Floor Distress Inventory-short form 20 (PFDI-20) score between preoperative and postoperative 3 months (P = 0.142).

Conclusions: Transvaginal NOSES is safe and feasible in 3D laparoscopic partial or radical nephrectomy. Furthermore, it results in low incision-related pain without affecting the pelvic floor and sexual function.

Keywords: Laparoscopy; Natural orifice specimen extraction surgery (NOSES); Partial nephrectomy; Radical nephrectomy; Renal carcinoma.

Fig. 1

The patient's position and location of trocar. The patient was placed in an oblique position of 70°. The location of trocar: A hole is located under the costal margin of the mid-clavicular line on the affected side, and 5 mm cannula is punctured into the abdominal cavity; B hole is located around the umbilicus and makes a longitudinal incision about 1 cm, and 10 mm Trocar cannula is placed into the laparoscope; C, D and E holes are located at the midpoint of the anterior superior iliac crest and umbilicus line on the affected 12 mm, 12 mm and 5 mm Trocar cannulas were placed at the horizontal intersection of axillary front line and umbilical cord for the placement of operating instruments

Fig. 2

Surgical procedures of laparoscopic radical nephrectomy. A Free fascial tissue of colon and abdominal cavity with ultrasound scalpel, and expose retroperitoneal tissue. B Peel off the lower part of Gerota fascia with an ultrasonic scalpel, free the ureter, clamp with Hem-o-lock clip and cut off the ureter. C, D Free along ureter and genital vein toward proximal end, expose renal vein, renal artery behind it, clip renal artery with 3 Hem-o-locks and cut it, renal veins were treated in the same way

Fig. 3

Surgical procedures of laparoscopic partial nephrectomy. a. Exposure of retroperitoneal tissue: Release the fascial tissue of the colon and abdominal cavity with an ultrasound scalpel, turn the hepatic or splenic flexure of the colon to the opposite side, expose the retroperitoneal tissue (A1-2). b. Separate the renal artery and vein: Separate the plane of the renal vein along the retroperitoneal and Gerota fascial space, free the renal vein, and find the renal artery behind the renal vein, free the renal artery (B1-2). c. Location of the tumor: Cut the perirenal fat capsule in the middle of the kidney to find the location of the tumor, free the adipose tissue around the tumor, expose the tumor at the boundary of normal kidney tissue, preserve the adipose tissue above the tumor (C), d. Resect the tumor: Block the main renal artery with vascular clips, and resect the tumor with scissors and aspirator 1 cm outside the edge of the tumor, together with part of normal kidney tissue (D). e. Hemostasis and suture: Initial hemostasis using bipolar electrocoagulation on the wound surface. The inner layer was sutured with 3-0 barbed suture, and the renal wound was sutured with 2-0 barbed coil layer, and the suture was fixed intermittently with Hem-o-lock (E). f. Restore blood flow and observe blood supply: Loosen the renal artery blocking clamp, observe whether the blood supply, color, elasticity of renal tissue are normal, whether there are obvious bleeding foci, and explore whether the ureter is normal, whether the urine color is normal (F). Protein glue can be used to plug the wound to assist hemostasis if necessary, and the perirenal fat capsule can be re-sutured

Fig. 4

Surgical procedures of laparoscopic transvaginal NOSES. The laparoscopic field of view was transferred to the pelvis, the posterior vaginal fornix was exposed (A), 12 mm Trocar was placed in the vagina which had been fully sterilized by gauze strips, and the posterior vaginal fornix was closely attached to the posterior vaginal fornix. The posterior vaginal fornix was transversely cut (B) with an electrocoagulation knife to both sides, so that the incision was about 2–3 cm long. The specimen band (C) was placed in the transvaginal Trocar, and the excised kidney and part of the ureter were placed into the specimen. Take out the band, hang the vagina with 2-0 barbed thread, and suture the vaginal incision and the posterior fornix exactly (D), and suture the lateral peritoneum with 2-0 barbed thread