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array:23 [ "pii" => "S2173578615000268" "issn" => "21735786" "doi" => "10.1016/j.acuroe.2015.02.010" "estado" => "S300" "fechaPublicacion" => "2015-04-01" "aid" => "679" "copyright" => "AEU" "copyrightAnyo" => "2014" "documento" => "article" "subdocumento" => "fla" "cita" => "Actas Urol Esp. 2015;39:188-94" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 247 "formatos" => array:3 [ "EPUB" => 6 "HTML" => 204 "PDF" => 37 ] ] "Traduccion" => array:1 [ "es" => array:18 [ "pii" => "S0210480614002009" "issn" => "02104806" "doi" => "10.1016/j.acuro.2014.05.007" "estado" => "S300" "fechaPublicacion" => "2015-04-01" "aid" => "679" "copyright" => "AEU" "documento" => "article" "subdocumento" => "fla" "cita" => "Actas Urol Esp. 2015;39:188-94" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 245 "formatos" => array:3 [ "EPUB" => 10 "HTML" => 213 "PDF" => 22 ] ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Destreza e ingenio</span>" "titulo" => "La opción óptima: nefrectomía radical LESS umbilical con extracción vaginal" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "188" "paginaFinal" => "194" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "The best option: Umbilical LESS radical nephrectomy with vaginal extraction" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figura 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1424 "Ancho" => 1028 "Tamanyo" => 262768 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Transferencia, bajo visión desde el puerto umbilical, del hilo que cierra la bolsa del espécimen desde la cavidad abdominal a una pinza incluida por el puerto vaginal.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "G. Andrés, J.M. García-Mediero, A. García-Tello, I. Arance, P.M. Cabrera, J.C. Angulo" "autores" => array:6 [ 0 => array:2 [ "nombre" => "G." "apellidos" => "Andrés" ] 1 => array:2 [ "nombre" => "J.M." "apellidos" => "García-Mediero" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "García-Tello" ] 3 => array:2 [ "nombre" => "I." "apellidos" => "Arance" ] 4 => array:2 [ "nombre" => "P.M." "apellidos" => "Cabrera" ] 5 => array:2 [ "nombre" => "J.C." "apellidos" => "Angulo" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2173578615000268" "doi" => "10.1016/j.acuroe.2015.02.010" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173578615000268?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210480614002009?idApp=UINPBA00004N" "url" => "/02104806/0000003900000003/v2_201503280410/S0210480614002009/v2_201503280410/es/main.assets" ] ] "itemSiguiente" => array:18 [ "pii" => "S2173578615000244" "issn" => "21735786" "doi" => "10.1016/j.acuroe.2015.02.008" "estado" => "S300" "fechaPublicacion" => "2015-04-01" "aid" => "686" "copyright" => "AEU" "documento" => "simple-article" "subdocumento" => "crp" "cita" => "Actas Urol Esp. 2015;39:195-200" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 152 "formatos" => array:3 [ "EPUB" => 12 "HTML" => 102 "PDF" => 38 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Casuistry</span>" "titulo" => "Transumbilical laparoendoscopic single-site ureteral reimplantation" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "195" "paginaFinal" => "200" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Reimplantación ureteral laparoendoscópica por puerto único transumbilical" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1043 "Ancho" => 1402 "Tamanyo" => 213852 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Various moments of surgery. (A) Placement of hydrophilic guidewire into the spatulated ureter through a percutaneously inserted needle. (B) Placement of double-J catheter over the wire. (C) Ureteral reimplantation in the bladder by means of continuous suture. (D) End of the suture.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "H. Gimbernat, C. Redondo, A. García-Tello, E. Mateo, J.M. García-Mediero, J.C. Angulo" "autores" => array:6 [ 0 => array:2 [ "nombre" => "H." "apellidos" => "Gimbernat" ] 1 => array:2 [ "nombre" => "C." "apellidos" => "Redondo" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "García-Tello" ] 3 => array:2 [ "nombre" => "E." "apellidos" => "Mateo" ] 4 => array:2 [ "nombre" => "J.M." "apellidos" => "García-Mediero" ] 5 => array:2 [ "nombre" => "J.C." "apellidos" => "Angulo" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0210480614002915" "doi" => "10.1016/j.acuro.2014.06.003" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210480614002915?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173578615000244?idApp=UINPBA00004N" "url" => "/21735786/0000003900000003/v2_201503280430/S2173578615000244/v2_201503280430/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S2173578615000256" "issn" => "21735786" "doi" => "10.1016/j.acuroe.2015.02.009" "estado" => "S300" "fechaPublicacion" => "2015-04-01" "aid" => "708" "copyright" => "AEU" "documento" => "article" "subdocumento" => "fla" "cita" => "Actas Urol Esp. 2015;39:183-7" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 193 "formatos" => array:3 [ "EPUB" => 7 "HTML" => 128 "PDF" => 58 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Skill and talent</span>" "titulo" => "Outcomes of transurethral resection (TUR) of intravesical mesh after suburethral slings in the treatment of urinary stress incontinence" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "183" "paginaFinal" => "187" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Resultados de la resección transuretral (RTU) de malla intravesical tras tratamiento con cintillas suburetrales para la incontinencia urinaria de esfuerzo" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 773 "Ancho" => 990 "Tamanyo" => 61722 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Resection bed without visible mesh.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "F. Castroviejo-Royo, L.A. Rodríguez-Toves, J.M. Martínez-Sagarra-Oceja, C. Conde-Redondo, J.A. Mainez-Rodríguez" "autores" => array:5 [ 0 => array:2 [ "nombre" => "F." "apellidos" => "Castroviejo-Royo" ] 1 => array:2 [ "nombre" => "L.A." "apellidos" => "Rodríguez-Toves" ] 2 => array:2 [ "nombre" => "J.M." "apellidos" => "Martínez-Sagarra-Oceja" ] 3 => array:2 [ "nombre" => "C." "apellidos" => "Conde-Redondo" ] 4 => array:2 [ "nombre" => "J.A." 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Andrés, J.M. García-Mediero, A. García-Tello, I. Arance, P.M. Cabrera, J.C. Angulo" "autores" => array:6 [ 0 => array:2 [ "nombre" => "G." "apellidos" => "Andrés" ] 1 => array:2 [ "nombre" => "J.M." "apellidos" => "García-Mediero" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "García-Tello" ] 3 => array:2 [ "nombre" => "I." "apellidos" => "Arance" ] 4 => array:2 [ "nombre" => "P.M." "apellidos" => "Cabrera" ] 5 => array:4 [ "nombre" => "J.C." "apellidos" => "Angulo" "email" => array:1 [ 0 => "javier.angulo@salud.madrid.org" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Urología, Hospital Universitario de Getafe, Madrid, Spain; Departamento Clínico, Facultad de Ciencias Biomédicas, Universidad Europea de Madrid, Laureate Universities, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La opción óptima: nefrectomía radical LESS umbilical con extracción vaginal" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1376 "Ancho" => 991 "Tamanyo" => 243153 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Surgical specimen, piece of left radical nephrectomy.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Laparoendoscopic single-site surgery (LESS) in Urology began in 2007 with renal surgery,<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">1</span></a> probably due to the familiarity of the professional with the transperitoneal laparoscopic approach to perform nephrectomy. Several studies show the benefits of LESS renal surgery regarding multiport laparoscopy,<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">2–4</span></a> although it seems necessary to carry out a greater volume of prospective comparative studies to confirm that the results achieved by centers of excellence can be generalized by the rest of the group.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The more recent addition of robotics to single-site surgery<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">5,6</span></a> has been a new progress for the approach through this pathway, but the reality is that very few highly specialized centers have this technique in their portfolio of services, because it requires substantial provision of equipment and great training.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">7</span></a> There is no doubt that performing single-site surgery is a technological renovation challenge which is currently under slow expansion. In fact, most urologic procedures have already been developed through single port: adrenalectomy, radical nephrectomy, partial nephrectomy, nephroureterectomy, living donor nephrectomy, ureteral replacement, ureteral reimplantation, increase enterocystoplasty, radical cystectomy, and radical prostatectomy.<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">8–15</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">This relative success of LESS surgery contrasts with the lack of acceptance and very poor reproducibility of the dazzling transluminal endoscopic surgery through natural orifices (NOTES). There have been many evolutionary pathways of minimally invasive surgery to achieve the desired purpose of performing surgery without incision, conceptually using different approaches: transvaginal, transgastric, and transvesical.<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">16,17</span></a> Here nephrectomy has been a paradigmatic technique as well. We present an option other than hybrid transvaginal nephrectomy with material of conventional laparoscopy<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">18,19</span></a> or minilaparoscopy.<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">20,21</span></a> Likewise, the option we describe also differs from NOTES, either in its assisted<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">22</span></a> or pure<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">23</span></a> variant. In all these techniques, the lens, rigid or flexible, is positioned through the vagina. The technique presented here is implementation of nephrectomy through the navel with specimen extraction vaginally. Actually, more than a NOTES, it is a LESS hybrid technique<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">24</span></a>; but strictly speaking of a two-trocar technique where the main port is placed in the navel and the accessory one into the vagina. It can also be called LESS nephrectomy assisted by transvaginal NOTES.<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">21</span></a> The functional result is equivalent to pure NOTES: Minimally invasive surgery without visible incision.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Casuistry</span><p id="par0020" class="elsevierStylePara elsevierViewall">34-year-old woman with 8-cm left renal mass in diameter and completely mesorenal location (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) which is incidentally discovered. She presented no family or personal history of interest, except for prior appendectomy and two normal vaginal deliveries. The BMI was 26. Radical nephrectomy using umbilical LESS approach and vaginal specimen extraction (hybrid LESS) was proposed, to which the patient consented. She was operated as described below.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Surgical technique</span><p id="par0025" class="elsevierStylePara elsevierViewall">The technique of single-site left radical nephrectomy with vaginal extraction is displayed step by step (see supplementary material). With the patient in the lateral decubitus, a 2.5-cm incision is made inside the navel to place the multichannel KeyPort single port (Richard Wolf GmbH, Knittingen, Germany), through which the 5.3-mm lens is inserted as well as curved instruments that allow for minimal crush and/or conflict of space (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The double rotation of the instrumental gets great precision of movement. Umbilical adaptation provides a watertight system without the need for external fixation. The posterior parietal peritoneum is opened and the left colon is repaired to reach the retroperitoneal space. The renal artery and vein are identified, which are carefully dissected and which are placed double proximal and simple distal Hem-o-lok (Weck Closure Systems, Research Triangle Park, NC, USA) to be sectioned subsequently. We proceed to fully open the parietal peritoneum and the upper renal pole is released with 10-mm Ligasure (Covidien Surgical Solutions, Mansfield, MA, USA). The ureter is dissected and nephrectomy is completed, bagging the specimen and closing the thread with Hem-o-lok.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Then the patient is placed supine with lithotomy and the field work is taken to the perineum with visual control from the navel. The vaginal walls are retraced and the cervix is pushed anteriorly to expose the posterior fornix. A trocar of 15<span class="elsevierStyleHsp" style=""></span>mm diameter (Applied Medical Rancho Santa Margarita, CA, USA) is placed through the vagina piercing the posterior fornix, guided by the fingers and under direct vision from the umbilical lens. It is very important to place the posterior transvaginal port and in the midline to avoid damaging the uterine vessels. In some cases retraction of the uterus with a 5-mm grasper from the umbilical trocar can be useful. The thread of the bag with its Hem-o-lok is introduced into the abdominal cavity and is transferred back to the outside through the vaginal port (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Then, the port is removed.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The inclusion of the index and middle fingers to dilate the vaginal incision on both sides will greatly facilitate the recovery of the bag so that the sample can be extracted (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). The posterior cul-de-sac of the vagina from the perineum with continuous 2–0 vicryl suture is then closed. Successful closure in a single plane is viewed from the umbilical port. Even the suture can be performed laparoscopically, but it is much easier vaginally. It is very important to carefully review the surgical bed to confirm the absence of active bleeding. Once this check is made, surgical drainage may not even be left. The umbilical port KeyPort is removed and the umbilical incision is closed with quick 3/0 vycril.</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0040" class="elsevierStylePara elsevierViewall">The total duration of the procedure was 180<span class="elsevierStyleHsp" style=""></span>min and the estimated blood loss did not reach 100<span class="elsevierStyleHsp" style=""></span>ml. Postoperative evolution showed no complications, with a hospital stay of one day and without taking painkillers. The pathology revealed large renal lesion (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>) corresponding to clear cell renal cell carcinoma. One year after surgery, the patient is under review, free of disease, with blood test, abdominal CT and normal chest X-ray. There has been no complication and she is very satisfied. Specifically questioned, she showed no sexual dysfunction or disorder derived from the vaginal incision. Both the umbilical incision and the vaginal one were invisible. <a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a> shows the appearance of her navel after 6 weeks.</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0045" class="elsevierStylePara elsevierViewall">Pure transluminal endoscopic nephrectomy performed through the vagina was described in 2010<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">23</span></a> by Kaouk et al., after a long journey of attempts to carry out this milestone in our specialty. Many of the divergent paths of evolution are doomed to extinction. The development of multichannel surgery through a single umbilical placement site has rescued the concept of embryonic NOTES (E-NOTES).<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">24,25</span></a> Thus, strictly speaking, all pure umbilical LESS surgery is a NOTES, if the navel is conceived as obliterated embryonic hole. No anatomical structure is broken for its opening except for middle aponeurosis and the skin incision is hidden in the umbilical scar itself. In fact, at least from a cosmetic point of view, is not the scar itself the best surgical approach in a patient that already has a scar?</p><p id="par0050" class="elsevierStylePara elsevierViewall">The need to develop in minimally invasive surgery what is today at the limit of our possibilities leads us to reach new heights.<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">17</span></a> The vagina as a means of extracting specimens in abdominal surgery is an excellent choice for every surgeon (gynecologist, digestive, urologist) in women who do not wish to have a scar, and it has been widely used in gynecological surgery thanks to the fact that the distensible properties of the vagina allow for the extraction of large volumes.<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">26</span></a> Performing vaginal specimen extraction involves no added morbidity in sexually active women, especially in those who have previously given birth. In fact, even in complex laparoscopic surgeries, vaginal extraction has shown good acceptance for demanding patients who want minimal invasiveness and speedy recovery, such as female living donor nephrectomy.<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">27</span></a> An alternative in living donor nephrectomy in men is the use of material of minilaparoscopy with extraction by means of small Pfannenstiel incision,<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">28</span></a> which also tries to bring minimal invasiveness and cosmetic surgery to its maximum expression.</p><p id="par0055" class="elsevierStylePara elsevierViewall">LESS surgery through a single umbilical port and vaginal specimen extraction is an excellent alternative, with evident advantages in cosmetic terms and without increasing the risk of the LESS surgery itself. Different authors have performed multiport laparoscopy or minilaparoscopy with vaginal extraction as substitutes of NOTES,<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">18,19,21</span></a> even Sotelo et al. came to use two multichannel single-port systems, one located in the navel and the other in the vagina combining LESS and NOTES with equal opportunities.<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">29</span></a> We think that this display is unnecessary and that the surgeon must decide whether they will work laparoscopically or laparoendoscopically. If they choose the former, they can use conventional material or minilaparoscopy material. If they choose the second one, they can use a multiport device within the vagina and help themselves from the abdomen or use a multiport device in the navel and help themselves from the vagina. Of course we consider the latter option is the most logical, ergonomic (obviously not without difficulty), and the safest of all possible options to perform surgery without incision. The new proposal avoids the LESS and NOTES concepts, as defined<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">24,25</span></a> for better thinking of a ‘2-port’ technique. This new concept is also applicable to complex techniques such as radical cystectomy with urinary diversion.<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">15</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">LESS nephrectomy has advantages in terms of functional recovery, stay, analgesic requirements, bleeding, and sometimes cosmetic regarding multiport laparoscopy,<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">2–4</span></a> and it often allows for the extraction of the surgical specimen with minimal extension of the umbilical incision. However, removal of large parts is not possible without this maneuver. On the other hand, from a technical point of view, multichannel LESS surgery with curved elements is more complex than multiport laparoscopy and, that is why, it requires special training.<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">30</span></a> Nevertheless, the development of instruments to be able to perform it is very advanced, currently having reusable platforms with which we can work safely and cost-effectively.<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">9,11,14,31,32</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflict of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres467355" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patient and method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec490135" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres467356" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Paciente y método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec490134" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Casuistry" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Surgical technique" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Results" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interest" ] 10 => array:2 [ "identificador" => "xack139714" "titulo" => "Acknowledgements" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-05-19" "fechaAceptado" => "2014-05-26" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec490135" "palabras" => array:4 [ 0 => "Radical nephrectomy" 1 => "Laparoendoscopic single-site surgery (LESS)" 2 => "Vaginal extraction" 3 => "Natural orifice transluminal endoscopic surgery (NOTES)" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec490134" "palabras" => array:4 [ 0 => "Nefrectomía radical" 1 => "Cirugía laparoendoscópica por puerto único (LESS)" 2 => "Extracción vaginal" 3 => "Cirugía transluminal endoscópica por orificios naturales (NOTES)" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Umbilical laparoendoscopic single-site (LESS) surgery represents an excellent alternative to laparoscopic or robotic multiport surgery. LESS surgery offers faster recovery, less postoperative pain and optimal cosmetic results. The reusable nature of its instruments also has significant economic advantages.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patient and method</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We present a 34-year-old patient with a solid mesorenal lesion measuring 8<span class="elsevierStyleHsp" style=""></span>cm in the left kidney treated with pure LESS radical nephrectomy assisted by vaginal extraction of the specimen. The umbilical approach using a single-site multichannel KeyPort (Richard Wolf GmbH, Knittlingen, Germany) with DuoRotate curved instruments allows for minimum crushing and fewer spatial conflicts. Its perfect umbilical adaptation provides a hermetic system. The instrument's double rotation provides considerable movement precision. Vaginal extraction avoids damage to the abdominal wall and the need for widening the umbilical incision.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">After the placement of the device and triangulation of the clips, we proceeded to operate on posterior parietal peritoneum. The descending colon was mobilized to access the retroperitoneum and dissect the renal hilum. Hem-o-lok clips were placed on the artery and vein, which were subsequently sectioned. The specimen was inserted into a laparoscopic bag. Under direct vision, we placed a 15-mm trocar through the bottom of the vaginal posterior fornix to facilitate the extraction of the bag's thread. The incision was widened with the fingers, and the specimen was extracted, closing the vagina from the perineum with visualization from the navel. Abdominal drainage was not employed. The surgical time was 180<span class="elsevierStyleHsp" style=""></span>min. The patient was discharged the following day without needing analgesia. A year later, the patient was disease-free and had no complications.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Umbilical LESS radical nephrectomy with vaginal extraction is feasible in selected cases. The procedure is oncologically safe, avoids scars and facilitates early recovery. From a practical point of view, this approach greatly simplifies natural orifice transluminal endoscopic surgery (NOTES) and enables a minimally invasive equivalent result.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patient and method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La cirugía laparoendoscópica a través de puerto único (LESS) umbilical constituye una excelente alternativa a la cirugía laparoscópica o robótica multipuerto. Ofrece precoz recuperación, menos dolor postoperatorio y óptimo resultado cosmético. La naturaleza reutilizable de los instrumentos implica también importantes ventajas económicas.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Paciente y método</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Presentamos una paciente de 34 años con lesión sólida mesorrenal de 8<span class="elsevierStyleHsp" style=""></span>cm en riñón izquierdo tratada con nefrectomía radical LESS pura asistida por extracción vaginal del espécimen. El abordaje umbilical a través de dispositivo de puerto único multicanal KeyPort (Richard Wolf GmbH, Knittingen, Alemania) con instrumentos curvos DuoRotate permite mínimo agolpamiento y/o conflicto de espacio. Su perfecta adaptación umbilical proporciona un sistema estanco. La doble rotación del instrumental consigue gran precisión de movimientos. La extracción vaginal respeta la pared abdominal y evita la necesidad de ampliar la incisión umbilical.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Tras la colocación del dispositivo y la triangulación de las pinzas se procedió a incidir el peritoneo parietal posterior. El colon descendente fue movilizado para acceder al retroperitoneo y disecar el hilio renal. Se colocaron Hem-o-loks en arteria y vena, que posteriormente fueron seccionadas. La pieza se introdujo en bolsa laparoscópica. Bajo visión directa se colocó trócar de 15<span class="elsevierStyleHsp" style=""></span>mm a través del fondo del saco posterior vaginal para facilitar la extracción del hilo de la bolsa. Se amplió la incisión con los dedos y se extrajo el espécimen cerrándose la vagina desde el periné con visualización desde el ombligo. No se dejó drenaje abdominal. El tiempo quirúrgico fue 180<span class="elsevierStyleHsp" style=""></span>min. La paciente fue dada de alta al día siguiente sin necesidad alguna de analgesia. Un año después se encuentra libre de enfermedad y sin complicaciones.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La nefrectomía radical LESS umbilical con extracción vaginal resulta viable en casos seleccionados. Consigue seguridad oncológica, evita cicatrices y facilita la recuperación temprana. Desde un punto de vista práctico, este abordaje simplifica mucho la cirugía transluminal endoscópica por orificios naturales (NOTES) y permite alcanzar un resultado mínimamente invasivo equivalente.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Paciente y método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Andrés G, García-Mediero JM, García-Tello A, Arance I, Cabrera PM, Angulo JC. La opción óptima: nefrectomía radical LESS umbilical con extracción vaginal. Actas Urol Esp. 2015;39:188–194.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0080" class="elsevierStylePara elsevierViewall">The following is the supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0040" ] ] ] ] "multimedia" => array:7 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1469 "Ancho" => 995 "Tamanyo" => 117270 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Transverse MRI image (A) and coronal (B) showing mesorenal 8-cm left renal mass.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1379 "Ancho" => 995 "Tamanyo" => 327026 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">KeyPort multichannel single port placed at the umbilical level at the start of surgery. Note the absence of conflict of space (external or internal) with the instrumental.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1379 "Ancho" => 995 "Tamanyo" => 270038 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Transfer, under vision from the umbilical port, of the thread which closes the specimen bag from the abdominal cavity to a clamp included through the vaginal port.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1379 "Ancho" => 995 "Tamanyo" => 290593 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Vaginal extraction of the bagged material once the vaginal trocar is removed.</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1376 "Ancho" => 991 "Tamanyo" => 243153 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Surgical specimen, piece of left radical nephrectomy.</p>" ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 1279 "Ancho" => 995 "Tamanyo" => 191672 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Appearance of the navel of the patient at 6 weeks after surgery (A) and detail thereof (B).</p>" ] ] 6 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc1.mp4" "ficheroTamanyo" => 91025231 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc1.flv" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:2 [ "fichero" => "mmc1.m4v" "poster" => "mmc1.jpg" ] ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:32 [ 0 => array:3 [ "identificador" => "bib0165" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Laboratory and clinical development of single keyhole umbilical nephrectomy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "J.D. 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