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International braz j urol

On-line version ISSN 1677-6119

Int. braz j urol. vol.37 no.6 Rio de Janeiro Nov./Dec. 2011 



Natural orifice transluminal endoscopic radical prostatectomy: initial perioperative and pathologic results



Humphreys MR; Sauer JS; Ryan AR; Leslie KO; Castle EP; Lingeman JE; Andrews PE

Mayo Clinic, Phoenix, Arizona

Urology. 2011; 78: 1211-7



OBJECTIVE: To describe the first clinical experience, pathologic, and perioperative outcomes of natural orifice transluminal endoscopic surgery (NOTES) radical prostatectomy. NOTES represents the evolution of minimally invasive surgery. The conceptual feasibility has been shown in careful laboratory and animal studies, but a scarcity of information regarding clinical applications exists.
METHODS: After institutional review board approval, 2 patients agreed to undergo NOTES radical prostatectomy for localized prostate cancer. The prostate was radically resected using a 26F resectoscope, 550-μm laser fiber, and holmium laser. The prostate was delivered into the bladder and removed at the conclusion of the procedure through a suprapubic cystotomy for histopathologic analysis. The vesicourethral anastomosis was completed using a cannula scope, urethral-vesical suturing device, and titanium knot applier. Cystograms were taken immediately postoperatively and at catheter removal.
RESULTS: Both patients tolerated the procedure without operative complications. All intraoperative cystograms showed watertight anastomoses. The pathologic examination revealed Gleason score 3 + 3 and Stage pT2aNx- Mx for 1 patient and Gleason score 3 + 4 and Stage pT2cNxMx for 1 patient, with negative margins for both.
No blood transfusions were required. Patient 2 experienced some left-sided gluteal and suprapubic pain postoperatively.
CONCLUSION: NOTES radical prostatectomy appears to be a safe and feasible option for the management of carefully selected, organ-confined prostate cancer. The perioperative and pathologic outcomes show promise with this new technique; however, the high standards of oncologic and functional outcomes demand close and longer follow-up before adoption into the surgical armamentarium can be recommended.


Editorial Comment

The authors must be congratulated for their pioneer work. The advancement of minimally invasive urological surgery has pushed the technology and surgical instruments industry to collaborate with surgeons allowing better care of our patients.

Although the idea of transurethral radical prostatectomy has been studied by others previously (Kavoussi et al.); this report of 2 patients with localized prostate cancer with negative margins using this novel NOTES approach may have been possible due to the great experience of the authors with laser prostate enucleation and new instrumentation for suturing endoscopically.

I am certain longer follow-up will determine the validity of this novel technique but undoubtedly, this innovating work has to be recognized as breaking ground.


Dr. Fernando J. Kim
Chief of Urology, Denver Health Med. Ctr.
Associate Professor, Univ. Colorado Health Sci. Ctr.
Director of Minimally Invasive Urol. Oncology, UCHSC
Denver, Colorado, USA

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