Single-incision transureteral laparoscopic nephrectomy: A proof of concept

Purpose: Single-umbilical incision laparoscopic nephrectomy has been recently advocated as an alternative to pure natural orifice transluminal endoscopic surgery. We present a novel, hybrid technique for laparoscopic nephrectomy that combines single-incision laparoscopy with natural orifice transluminal endoscopic surgery principles consisting of using the ureteral stump as a natural orifice. Materials and Methods: Six renal units were operated in a nonsurvival pig study by combining a single umbilical incision with a novel natural orifice, the divided ureter. A transurethral 16F Amplatz sleeve inserted in the ureter under cystoscopic guidance became a natural orifice port after transection of the ureter. Regular laparoscopic instruments and scopes were used through two adjacent single-incision umbilical ports. The camera was placed in one of the umbilical ports and two operating instruments were introduced through the additional umbilical port and the "natural orifice port," respectively. Results: Right and left laparoscopic nephrectomy were successfully performed. No complications occurred except one case of a periureteral hematoma due to the dilation of the ureter. The hylar blood vessels were thoroughly dissected and controlled by either clips or vascular staplers. The operative time decreased from 140 minutes in the first procedure to 70 minutes in the last (median time: 85 minutes). The learning curve was short because the basic principles of laparoscopy such as correct instrument angulation and geometry could be achieved through the inferior, natural orifice port. Conclusions: Laparoscopic nephrectomy combining a single umbilical incision with a natural orifice provided by the ipsilateral ureter is technically feasible in a large animal model. Further studies in human patients together with assessment of advantages over classic laparoscopic nephrectomy are needed.