Transvaginal nephrectomy with a multichannel laparoscopic port: a cadaver study

To determine whether a novel port (QuadPort, Advanced Surgical Concepts, Wicklow, Ireland) can facilitate transvaginal nephrectomy (TN), a natural orifice transluminal surgery (NOTES) procedure, using standard and articulating laparoscopic instruments. Four fresh female cadavers were used in this feasibility study with a plan to perform two right-sided and two left-sided TN. Exclusion criteria were a history of nephrectomy and a height of > 1.82 m. The cadaver was placed in the lithotomy position with the target side up 30-45 degrees. A three-channel R-port (Advanced Surgical Concepts) was placed in the umbilicus to monitor the transvaginal procedure. The four-channel QuadPort was placed through the posterior fornix into the peritoneal cavity. Regular laparoscopic instruments were used transvaginally to mobilize the colon, dissect the ureter, identify and divide the renal artery between clips, and divide the renal vein with a laparoscopic stapler. Remaining attachments of the kidney were divided and the specimen entrapped in a plastic bag before transvaginal extraction. Three (two right- and one left-sided) TNs were performed successfully; one left-sided TN was aborted in the last cadaver due to dense pelvic adhesions from previous pelvic surgery. In the first two cadavers we required assistance from the umbilical port only to divide the attachments between the upper pole of the kidney and the diaphragm supero-posteriorly. In the third case we were able to perform this dissection completely transvaginally using a flexible gastroscope. A completely NOTES-based TN in humans is challenging. Robust laparoscopic instruments have the requisite tensile strength when deployed through a large calibre, secure, multichannel transvaginal port. Extra-long laparoscopic instruments are helpful. The cephalad aspect of the hilum and the upper pole attachments are difficult areas. Novel and robust flexible instruments still need to be developed.