Introduction: Bladder leiomyomas (BL) are rare benign tumors, with roughly 250 cases reported worldwide. Surgical excision is the recommended treatment, classically through open partial cystectomy. As alternatives, minimally invasive approaches, such as laparoscopic (lap), robot-assisted and transurethral (TU) resection (TUR), are arising. In parallel, TU cystorraphy has been reported for vesicovaginal fistulas or traumatic perforations. Thus, to the best of our knowledge, we report the 1st Human Natural Orifice Transluminal Endoscopic Surgery (NOTES) with a purely TU approach for BL enucleation and cystorraphy, without transvesical access, gas insufflation, neither extracorporeal knot tying. Methods: A 68-year-old woman presented an incidental 22mm lesion on the left posterolateral bladder wall on MRI, highly suspicious for BL. After cystocopic confirmation of a submucosal lesion, TUR was proposed. We performed a pioneer NOTES with total TU BL enucleation and cystorraphy using: 30º lens, white light only, saline irrigation, 26Ch resectoscope, operative cystoscope, Collin’s knife and standard resection loop, bipolar energy, 5mm lap needle holder and 3-0 V-Loc 23cm length suture. Results: BL complete enucleation was done with bipolar energy on Collin’s knife and standard resection loop. Then, V-Loc suture was completely placed inside the bladder through the operative cystoscope, and with the lap needle holder inserted through it, a total intravesical cystorraphy with single hand continuous suture was performed. Operative time was 40min. Patient was discharged on the next day, with bladder catheter for 5 days. There were no complications. Conclusions: TUR has been used for BL, but without cystorraphy, which is a limitation for bigger or more profound infiltrative lesions. Cystorraphy techniques combining TU, transperitoneal and/or transmural bladder access were reported. A purely TU cystorraphy recently reported required extracorporeal sliding knot techniques, so, it was only possible in women. Thus, our approach may be the most minimally invasive possible for the safest treatment of BL. We combined several techniques aiming to reach an ideal one. Using only regular material, a single urethral route, and no gas insufflation, we achieved a quick and safe procedure, with no need for continuous bladder irrigation and short catheterization. Yet, it requires advanced skills such as single hand lap suturing. Our technique seems also feasible in small bladder perforations, fistulas, or other lesions (e.g.: endometriosis). Additionally, with total intravesical suture, it may also be viable in men. SOURCE OF Funding: None
