The Infancy of Robotic Laparoendoscopic Single-Site Renal Surgery: Waiting for Needed Technological Improvements

Abstract

Traditional open surgery has provided us with an impressive heritage of proven oncologic and functional results, establishing principles that will be hard to surpass and a standard to which any other technique is compared. Nonetheless, large incisions with extended dissection accompanied by prolonged surgical stress are some of the drawbacks of conventional surgery, with a direct relationship to the patient’s convalescence. In an effort to overcome these disadvantages, pioneering surgeons in the early 1990s introduced laparoscopy in urology [1]. Although many agreed about its feasibility, few really believed it could replace conventional open surgery. Over time, laparoscopy evolved and expanded from nephrectomy to other fields of urology, thanks to the experience of leading surgical teams and technical innovations in instrumentation. Today, laparoscopy is well established but with a significant learning curve. Recently, with the advent of the robotic platform, even open surgeons with minimal training in laparoscopy can add a laparoscopic environment to their armamentarium and offer their patients a minimally invasive procedure [2]. With widespread acceptance of minimal access operations among patients and surgeons in the urologic community, surgical evolution has gone one step further by reducing access to a single port. Although single-access surgery is still in its infancy, in a multi-institutional study, >1000 laparoendoscopic single-site surgery (LESS) procedures were reported [3]. In an effort to achieve intraabdominal triangulation, crossing of the instruments is needed, forcing the surgeon to use counterintuitive movements. Flexible and prebent laparoscopic instruments accompanied by flexible optics only partially restore the triangulation and alleviate the ergonomic challenge posed