Instrumentation for natural orifice translumenal endoscopic surgery and laparoendoscopic single-site surgery

OBJECTIVE: To describe the evolution of instrumentation and technology for natural orifice translumenal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS) as applied to urologic procedures. MATERIALS AND METHODS: We performed a search of published reports on PubMed and MEDLINE for the search terms NOTES, single-port, single-incision, single-site, natural orifice + surgery, SPA, LESS, incisionless, and scarless from 1990-2009. Studies relevant to this urologic symposium were chosen for detailed review. RESULTS: Multiple case reports, case series, and review articles relevant to NOTES and LESS utilized for urologic surgery dating from 1991 to 2009 were identified. We were subsequently able to chronicle the technological advances in instrumentation utilized for NOTES, including transvaginal nephrectomy, transvesical NOTES, combination or hybrid NOTES, and robotic-assisted NOTES or R-NOTES. For LESS, we detailed the development of various access ports and operating platforms to facilitate performing urologic procedures through a single-port access site. CONCLUSIONS: Significant progress has been made in developing new, multi-lumenal access ports and articulating or curved instruments to aid in triangulation necessary for certain urologic procedures. Magnetic anchoring guidance systems (MAGS) have further enhanced the approach to LESS, with the potential for future application to NOTES. NOTES and LESS have future implications for the armamentarium of urologic surgeons, although much more research is necessary to further improve instrumentation and overcome the learning curve necessary for new technology.