Introductions and Objectives
Natural orifice transluminal endoscopic surgical radical prostatectomy (NOTES RP) is a novel technique based on our extensive experience with holmium laser enucleation of the prostate (HoLEP) for BPH. Our objective is to illustrate the surgical technique for NOTES RP.

The patient is a 46 year old male with a history of prostatitis. PSA was 10.5. 12-core biopsy revealed Gleason 6 (3+3) carcinoma of the prostate in 5% of 1 core. The NOTES RP dissection is performed with standard HoLEP instruments and the 550µ end fire laser fiber. Laser settings: 2 Joules/pulse; rate of 20 Hertz. The anastomosis is performed with a newly designed offset telescope (6mm working channel) and the RD180 and Ti-Knot suturing devices (LSI Solutions, Inc. NY, USA).

Dissection begins at the 9 o'clock position just proximal to the urinary sphincter. The incision is continued through the capsule of the prostate into the retroperitoneum. The levator muscles are identified and the incision is extended anteriorly and posteriorly. Dissection continues from the 7 to 5 o'clock location. The veru is left attached to the sphincter to allow leverage in manipulating the gland. The anterior dissection is extended into the bladder at 12 o'clock and the lateral attachments to the bladder neck (BN) are taken down. The base of the prostate is dissected bilaterally. The veru is then divided just proximal to the urinary sphincter. Posterior to the BN, the seminal vesicles (SVs) and ampulla of the vas deferens are identified. Both ampulla are divided. The SVs are amputated leaving their proximal stumps in place to minimize risk of injury to the neurovascular bundles. The prostate is displaced into the bladder and the final attachments at the BN are divided. The resectoscope is exchanged for the offset telescope and the RD180 suturing device. 2-0 PDS sutures are used to perform the anastomosis. Sutures are first placed at the BN and then at the urethral stump. The Ti-Knot device then secures each suture with a titanium clip as it simultaneously cuts the suture. After completing the anastomosis, a Foley catheter is placed over a guide wire. Currently, we are removing the specimen intact through a small cystotomy for pathologic staging. A cystogram on post-op day 14 showed no extravasation and the catheter was removed.

NOTES RP was successfully performed in this patient. If intact specimen retrieval continues to support the completeness of the dissection, we hope to eventually perform morcellation of the specimen in the bladder for a true NOTES procedure.

Funding: None