Gettman, Matthew T.

Natural orifice translumenal endoscopic surgery (NOTES) is a novel surgical concept that may provide a multitasking platform for minimally invasive surgery in the 21st century. With NOTES, natural hollow organs are used to gain access to body cavities via the mouth, anus, vagina, and urethra, thereby eliminating skin incisions. Access to the body cavity through the entry portal for the NOTES procedure and closure of the portal after surgery are important treatment considerations. In this review, access and closure techniques for NOTES-related procedures are discussed. Technical descriptions for access are also described. Closure techniques using experimental and commercially available devices are also reviewed. Based on the experimental and early clinical experiences to date, the future of NOTES appears quite promising. Nonetheless, ongoing fundamental research is necessary to determine the safety and benefit of these procedures. While technical challenges are currently present, the issues are being resolved with the development of optimal instrumentation and techniques. We believe that once standardized safe and reliable access and closure techniques are established, a major shift in minimally invasive surgery will likely be inevitable.

Tremendous attention and energy have been put toward development of minimally invasive techniques in urology to decrease the morbidity of surgery without compromising outcomes. Urologists have remained on the cutting edge of technology, performing procedures via laparoscopic, robotic, and transurethral approaches in procedures that were formerly only performed with an open approach. As the treatment paradigm shifts toward less invasive procedures, the concept of performing surgery through natural body openings has been recognized. Natural orifice translumenal endoscopic surgery (NOTES) eliminates the need for abdominal incisions, theoretically resulting in decreased pain, faster convalescence, improved cosmesis, and absence of wound infections and hernias. While transvesical NOTES has the potential to develop into a viable technology in the clinical setting, it is still in its infancy. Initial studies have demonstrated the feasibility of transvesical NOTES; however, further work must be dedicated to this subject before its routine application in humans. The purpose of this review is to detail the experimental, cadaveric, and clinical work that has been accomplished with transvesical NOTES, in addition to discussing the advantages and disadvantages, technical obstacles, and potential risks that accompany the use of the bladder as a portal for surgery.