Transgastric NOTES: Current experience and potential implications for urologic applications

Natural orifice translumenal endoscopic surgery (NOTES) in its current form uses flexible endoscopy technology to perform surgical procedures in the abdomen. NOTES is emerging as a potential alternative to both open and laparoscopic surgery, and the technique eliminates the requirement of abdominal incisions. To date, multiple intraperitoneal procedures have been reported in animal models while only a few reports of NOTES performed in humans exist. Several potential advantages of NOTES include the elimination of visible scars, less postoperative pain, and the reduction of postoperative complications, such as wound infection, abdominal wall pain, hernias, and adhesions. Current clinical applications of NOTES that are being studied heavily include its use in percutaneous endoscopic gastrostomy tube rescue and diaphragmatic pacing in intensive care unit patients. A number of barriers still exist regarding the technical challenges of transgastric NOTES, including access to the peritoneal cavity, the need for endoscope retroflexion for upper abdominal procedures, and endoscopic closure of the gastrotomy. The application of transgastric NOTES in urology has been limited to case reports in the porcine model, and no urologic procedure has been performed solely through a transgastric route. This article discusses the rationale of transgastric NOTES, its potential advantages and disadvantages, past and present work performed, current clinical applications, and its potential use in the future of urology.