Transvaginal access: current experience and potential implications for urologic applications.

Natural orifice translumenal endoscopic surgery (NOTES) has been introduced as a less invasive approach to performing intra-abdominal surgery. Any natural orifice may be used, although the ideal portal remains to be determined. Transvaginal surgery has been performed by gynecologists for decades and there is abundant literature supporting the efficacy and safety using this approach. Surgeons have also used the vagina for specimen removal after laparoscopic surgery to minimize the transabdominal incision. More recently, several animal NOTES experiments have used the transvaginal approach to complete a variety of gastrointestinal and urologic surgeries. Given the success with animal experiments, the transition to clinical surgery has begun, with several groups reporting their success with transvaginal cholecystectomy. At present, it appears that the transvaginal approach may be the best suited NOTES portal in those patients in whom it is possible. Future studies are needed to address NOTES' specific concerns, and these potentially less invasive techniques will ultimately need to be compared with standard laparoscopic surgery before their true value can be ascertained.