Laparoendoscopic Single-site Surgery In Urology Research Articles

Laparoendoscopic single-site surgeries: A multicenter experience of 469 cases in Japan.

To report on a multi-institutional series of non-robotic urological laparoendoscopic single-site surgery in Japan. Consecutive cases of laparoendoscopic single-site surgery carried out between February 2009 and December 2012 at nine academic institutions were included. We examined the surgical outcomes, including conversion and complications rates. Four hundred and sixty-nine cases were included in the analysis. The most common procedure was adrenalectomy (n = 177) and the second most common procedure was radical nephrectomy (n = 143). The procedures also included nephroureterectomy (n = 40), living donor nephrectomy (n = 40), pyeloplasty (n = 30), urachal remnant excision (n = 9), simple nephrectomy (n = 7), radical prostatectomy (n = 6) and others (n = 17). The access sites included umbilicus (n = 248, 53%) and other sites (n = 221, 47%). A transperitoneal approach was used in 385 cases (82%), and retroperitoneal approach in 84 cases (18%). The median operation time of all procedures was 198 min. Conversion to reduced port surgery, conventional laparoscopy, or open surgery was noted in 27 cases (5.8%), 12 cases (2.6%), and two cases (0.4%), respectively, with an overall conversion rate of 8.7%. Intraoperative complications occurred in 10 cases (2.1%). Post-operative complications were noted in 29 cases (6.2%), including five major complications (1.1%). No mortality was recorded in this series. Non-robotic laparoendoscopic single-site surgery is technically feasible and safe for various urologic diseases in Japan. Furthermore, urological laparoendoscopic single-site surgery is a promising minimally invasive surgical option that is feasible for experienced urological surgeons in intermediate-volume centers as well as high-volume centers.

Upper Tract Urological Laparoendoscopic Single-Site Surgery (LESS).

Background and Objectives:Our objective is to report intermediate-term outcomes for patients who have undergone upper tract urologic laparoendoscopic single-site surgery (LESS) at a single institution.Methods:From January 1, 2008, through November 30, 2012, 107 cases treated with LESS were identified, including pyeloplasty (n = 30), ureterolithotomy (n = 32), nephrectomy (n = 35; simple = 31, partial = 4), and cyst decortication (n = 10). Perioperative data were reviewed, and conversion and complication rates were noted.Results:The median follow-up was 21.5 months for pyeloplasty, 20.5 for ureterolithotomy, 28.0 for simple nephrectomy, 14.0 for partial nephrectomy, and 19.0 for cyst decortication. Major complications were encountered in 8 patients, including 3 intraoperative complications (2 bowel injury with serosal tearing and 1 intraoperative bleeding), which were recognized and repaired with LESS or conversion to conventional laparoscopy (CL). During the intermediate postoperative period (30–90 days) major complications occurred in 5 patients: 4 ureteral strictures (Clavien-Dindo grade [CG] IIIb) and 1 urinoma formation (CG IIIa). During the early postoperative period (<30 days), the most common minor complications were flank pain (CG I) in 16 patients and urinary tract infection (CG II) in 11, followed by urinary leakage (CG I) in 8.Conclusions:Intermediate-term functional outcomes of this single-center study confirm that upper tract LESS is a challenging procedure that can be safe and effective when performed by an experienced team. Prospective studies with longer follow-up periods are needed to investigate the safety of LESS in the treatment of various upper urinary tract conditions.

Pediatric urological laparoendoscopic single site surgery: Single surgeon experience

ObjectiveThe aim was to assess the feasibility and outcomes of pediatric urological laparoendoscopic single site (LESS) surgery. Materials and methodsA retrospective review was performed of all children who underwent LESS surgery at a single pediatric institution from September 2010 to July 2013. Patient demographics, intraoperative details, narcotic usage, and complications were reviewed. The umbilicus was used as the surgical site in all cases. All procedures were performed with a flexible tip laparoscope, a multichannel port, standard 3- or 5-mm laparoscopic instrumentation, and articulating instruments. ResultsSixty-one patients (50 male, 11 female) were identified. Procedures included 18 orchidopexies, 15 nephrectomies, 11 varicocelectomies, nine nephroureterectomies, four partial nephrectomies, one ureterectomy, one ureterolithotomy, one orchiectomy, and one utricle excision. The ureterolithotomy was converted to open surgery for failure to progress. The utricle excision was converted to conventional laparoscopy by adding one accessory port and one skin puncture because of the close proximity of the vas deferens to the utricle. Intraoperative complications included one vas deferens injury during orchidopexy in a postpubertal male. Postoperative complications occurred in six patients: five grade II and one grade IIIb. ConclusionsPediatric urological LESS procedures are technically feasible, safe, and effective. Further evaluation is warranted to better define its role in pediatric urological surgery.

Initial Experiences of a Novel Self-Retaining Intracorporeal Retractor Device for Urologic Laparoendoscopic Single-Site Surgery

Laparoendoscopic single-site surgery (LESS) is a surgical option for a number of urologic operations, although it does carry technical limitations. One of the major obstacles in performing LESS is accomplishing optimal retraction of adjacent organs. The aim of this study was to investigate the feasibility of a novel self-retaining intracorporeal retractor device, the Internal Organ Retractor (IOR), and to describe our experience using this device in LESS. A total of 23 patients who underwent LESS using IOR between December 2012 and July 2013 were identified. Among these patients, 11 nephrectomies, 9 adrenalectomies, 1 pyeloplasty, and 2 nephroureterectomies were performed. Perioperative outcomes including operative time, complications related to use of the IOR, and amount of time needed for the application and removal of the IOR were measured during each operation. Adequate retraction was accomplished in all surgical cases. The IOR helped to maintain a consistent operative field throughout the surgery. A median application time of a single IOR was 85.0 (range 44.5-187.5) seconds and removal time was 50.0 (20-400) seconds. The median number of IOR sets used was 2.0 (range 1-4), and the median total application and removal time in a single operation were 170.0 (45-750) seconds and 95.0 (20-400) seconds, respectively. There were no perioperative complications associated with use of the IOR. The IOR provided satisfactory retraction during LESS, and its application/removal was uncomplicated and needed a minimal amount of time. The IOR reduced the need for additional laparoscopic ports for retraction. We believe that the IOR is a useful retraction tool for LESS and possibly multiport laparoscopic surgeries.

IJU this issue

In this issue of the journal, we have four Review Articles, six Original Articles, one Short Communication, one Case Report and two Letters to the Editor. I would like to pay close attention to the interesting papers that reported and discussed current topics of prostate cancer. Masuda et al. (Tokyo, Japan) explored the relationship between body mass index (BMI) and prostate cancer risk at biopsy in Japanese men, and compared the risk with that of Caucasian men. They retrospectively evaluated Japanese men with prostate-specific antigen (PSA) levels from 2.5 to 19.9 ng/mL undergoing an initial extended prostate biopsy. There was a significant positive relationship between BMI and prostate cancer risk at biopsy, with an increased risk observed in men whose BMI was ≥27.0, compared with the reference group. A significantly increased risk starting at BMI ≥25.0 was found in high-grade disease. In contrast to their results, there has been no reported increase in the risk of prostate cancer at biopsy in Caucasians within the overweight range (BMI of 25.0–29.9). The authors concluded that Japanese men within the overweight BMI range who have an elevated PSA also have a significant risk of harboring prostate cancer, especially high-grade disease, and that overweight Japanese might be at greater prostate cancer risk at biopsy than overweight Caucasians. The accuracy of the Japan Cancer of the Prostate Risk Assessment (J-CAPRA) score, which was developed as a risk stratification instrument for patients undergoing primary androgen deprivation therapy, was externally validated for predicting cause-specific survival (CSS) among patients in the USA community-based Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) registry; however, there have been no investigations to validate the accuracy of the J-CAPRA score in predicting progression-free survival (PFS) along with analysis of clinical situation. Kitagawa et al. (Kanazawa, Japan) examined whether the clinical outcomes of patients treated by combined androgen blockade (CAB) with bicalutamide could be stratified using the J-CAPRA score. The factors used in the J-CAPRA points were significant predictors of PFS, and clinical T stage and M stage were also significant predictors of PFS. The probabilities of PFS and CSS were significantly different among the groups categorized according to the J-CAPRA risk strata. The authors concluded that the J-CAPRA score is a useful tool for predicting the clinical outcomes of patients with prostate cancer treated by CAB including bicalutamide. Several papers of laparoendoscopic single-site surgery in urology have been published, but just a few cases of radical prostatectomy have been reported. Nakane et al. (Anjo, Japan) showed the early outcomes of an original two-port laparoendoscopic approach for radical prostatectomy. A multichannel port with three 5-mm trocars, providing easier instrument handling, was inserted extraperitoneally through a 2.5-cm lower umbilical “U” incision. An additional 12-mm port was inserted into the left fossa to allow an adequate working angle. The operation was successfully completed in all 22 patients with early-stage prostate cancer; only one patient required an additional 5-mm port to control bleeding. There were no intraoperative complications. The authors concluded that this new procedure can be safely carried out if the surgeon is familiar with conventional five-port laparoscopic radical prostatectomy. Paraneoplastic limbic encephalitis (PLE) is a rare tumor-related syndrome, and the prognosis for neurological recovery and survival is poor. The neoplasms most frequently associated with PLE are small cell lung cancer and testicular cancer. Jakobsen et al. (Viborg, Denmark) reported a rare case of prostate cancer-related PLE. The authors showed that high-risk prostate cancer can trigger PLE, a rapidly progressive neurological syndrome with a bad prognosis. None declared.

Complications of laparo-endoscopic single-site surgery in urology

The objective was to give a general overview of common complications and rates reported in the current literature during performance of a variety of urologic procedures using laparo-endoscopic single-site surgery or LESS. A search of published reports using Pubmed and MEDLINE was performed with the following search terms: laparo-endoscopic single-site surgery, LESS or laparo-endoscopic single-site surgery complications within the date range of 2005--2011. Studies that were deemed appropriate and relevant to the current symposium were chosen for review. Overall complication rates were reported as ranging between 10% and 25%. In general, reconstructive procedures had consistently higher rates of complications than their extirpative/ablative counterparts (27% vs. 8%). There remain insufficient data to comment on differences in the rates or types of complications related to variations in the approach (transperitoneal vs. retroperitoneal), site of surgery (upper tract vs. lower tract) or specific technique used (instruments, access devices, robotic platforms, etc.). Complication rates associated with LESS in urology appear only slightly higher than with conventional laparoscopy. However, with proper patient selection and careful application of these techniques, proofs of concept and technical feasibility have been shown in several series. There continues to be a need for more standardization of the technique and reporting as well as more collaborative efforts to fully address questions of safety and efficacy of these new procedures.

Editorial Comment

The model builder who assembles a ship in a bottle takes on the challenge of working through a small opening. The difficulty of the approach is its appeal. In contrast, the ability to do major procedures through small incisions and ports has defined benefits beyond working with reduced exposure and the loss of haptic feedback. It improves cosmesis, decreases recovery time, lessens discomfort, and shortens the hospital stay. If an operation can be performed through a series of ports, it is logical to extend the basic idea and question whether it is possible to work through fewer ports, a single large port or a number of closely situated ports. The benefits, cosmetically, are clear; however, the potential risk of steric hindrance between the camera and instruments is increased. How this method is superior to the standard minimally invasive method (outside of cosmesis) is still unclear. Transumbilical Multiport Laparoscopic Orchiopexy in Children: Comparison With Standard Laparoscopic OrchiopexyUrologyVol. 80Issue 6PreviewTo compare the clinical outcomes of transumbilical multiport laparoscopic orchiopexy (TMLO) vs standard laparoscopic orchiopexy (SLO) for 1-stage management of impalpable testes in children. Full-Text PDF ReplyUrologyVol. 80Issue 6PreviewWe appreciate the insightful comments on our report. After the first description of urologic laparoendoscopic single-site surgery (LESS) in 2007,1 emerging studies have reported the lower postoperative morbidity and improved cosmetic outcome of LESS for almost all urologic procedures. However, the expensive cost of the specific devices and the long learning curve of LESS have severely limited its application in many countries, especially the developing countries. Thus, it is currently urgent to seek a feasible and alternative procedure. Full-Text PDF

Analysis of cumulative series of laparoendoscopic single-site surgery in urology : with 209 consecutive cases report

Objective To report a 4-year cumulative series (209 cases) of laparoendoscopic singlesite surgery (LESS) in urology and assess its clinical utilization. Methods Consecutive LESS cases done between December 2008 and July 2012 at our institution were prospectively recorded and retrospective analyzed in this study.Demographic data,main perioperative outcomes,and information related to the surgical technique were collected and analyzed.There were 209 patients ( 121 males and 88 females) with a mean age of (52.8 ±14.5) years,a mean B MIof (23.5 ±3.12) kg/m2 and a mean ASA score of (2.0±0.3).20.1％ (42 cases) of patients had previous abdominal or pelvic surgeries.29.2％ (61 cases) and 12.9％(27 cases) of patients had diabetes mellitus and hypertension. Indications were renal tumors (70 cases,33.5％),adrenal tumors (42,20.1％),renal cyst (22 cases,10.5％),ureteral calculi (22 cases,10.5％),nonfunctional kidneys (19 cases,9.1％),BPH (10 cases,4.8％),and others (24 cases,11.5％ ).Surgical conversions were evaluated,as well as intraoperative and postoperative complications.Two periods were arbitrarily dcfined:the first was from December 2008 to Septcmber 2010 (22 mon) and the second.was from October 2010 to July 2012 (22 mon).A comparative analysis between these two periods was conducted. Results There were 209 LESS surgeries included in this study.Most common procedures ( 92.3％ ) were done on the upper urinary tract,with 55.5％ of the whole cohort being tumor-related indications and only 16.3％ being reconstructive procedures.The transperitoneal approaches were preferentially adopted in 80.9％ cases,and transvesical access in 5.3％ cases. The transumbilical access was used in 46.9％ of cases.The overall conversion rate was 8.1％,with 4.3％ of cases converted to reduced - port laparoscopy,1.9％ to conventional laparoscopy,and 1.9％ to open surgery.The intraoperative complication rate was 4.8％ ( 10/209 ) and postoperative complications,mostly low grade,were encountered in 11.5％(24/209) of cases.There was a significant increase in the number of LESS cases during the second study period; the rate of some procedures (ie,transumbilical LESS,renal cyst decortication and transvesical single-port enucleation of the prostate) was lower,whereas some other procedures were performed more frequently (ie,tumor-related LESS procedures,radical nephrectomy and adrenalectomy). Conclusions A broad range of urological procedures can be finished with LESS technique in the experienced hands of a laparoscopic surgeons.However,LESS is still in its infancy with a certain risk of surgical complication and conversion.Stringent patient selection criteria should be applied,especially during the learning curve.Complex reconstructive procedures or malignant tumor related indications are not appropriate as the start of this kind of procedure.We need always put patient's safety and treatment efficacy first. Key words: Laparoendoscopic single-site surgery; Laparoscopy; Urologic surgery

Application and innovation of urological laparoendoscopic single-site surgery in China

Objective To evaluate the status of urological laparoendoscopic single-site surgery (LESS) technique in China. Methods We had conducted a systematic review of literatures of urological laparoendoscopic single-site surgery published from Chinese institutions using WanFang,CNKI,VIP,CBM,GoogleScholar and MEDLINE databases.All relevant articles were selected with consensus and analyzed according to the inclusion and exclusion criteria. Results Overall,205 articles from 66 different centers all over China published between January 2009 and June 2012 were included in the analysis. Of which,there were 26 articles of science citation index papers and 179 articles from Chinese academic journals.The included literature was mainly composed of case series reports ( 133 articles,64.9％ ),comparison studies (13 articles,6.3％ ),reviews or comments (20 papers,9.8％ ),nursing related papers (28 pieces,13.7％ ),animal surgery studies (6 articles,2.9％ ),and training (5 articles,2.4％ ).A total of 1790 clinical cases were reported during the study period,56.9％ of these were procedures done in the upper urinary tract,only 5.8％ were in the lower urinary tract,and 37.3％ were genital or other procedures.Procedures of tumor-related and reconstruction required accounted for 18.8％ and 18.7％,respectively.Pure single-port technique was applied on 58.3％ of cases.In cases of a single-port platform used,45.6％ used the commercially available devices and 54.4％ used homemade devices.Transperitoneal accesses were adopted in 59.5％ of cases and the other 40.5％ were performed through extraperitoneal approaches.The umbilicus was used as the site of access in 58.5％ of cases.A total of 25 indications were reported,including adrenalectomy,nephrectomy and ureterolithotomy,etc. in the upper urinary tract,radical cystectomy,radical prostatectomy and transvesical enucleation of the prostate,etc.in the lower urinary tract,and varicocelectomy,orchidopexy and others. The three most often done procedures were varicocelectomy (601 cases,33.6％ ),renal cyst decortication (408 cases,22.8％ ) and adrenalectomy ( 179 cases,10.0％ ).The overall conversion rate was 5.5％,and complications were encountered in 3.4％ of cases. Conclusions Laparoendoscopic single-site surgery has been widely adopted by Chinese urologists and largely covered the spectrum of conventional urologic laparoscopic procedures,with most of these being non-reconstructive operations for the treatment of benign diseases.In large,we are still under the initial stage of LESS application in urology.And more work on creative innovation and well-designed studies are needed to further evaluate its role in the urological minimally invasive surgery. Key words: Laparoendoscopic single-site surgery, LESS; Minimally invasive surgery; Urologic surgery

Urological Laparoendoscopic Single Site Surgery: Multi-Institutional Analysis of Risk Factors for Conversion and Postoperative Complications

We analyzed the incidence of and risk factors for complications and conversions in a large contemporary series of patients treated with urological laparoendoscopic single site surgery. The study cohort consisted of consecutive patients treated with laparoendoscopic single site surgery between August 2007 and December 2010 at a total of 21 institutions. A logistic regression model was used to analyze the risks of conversion, and of any grade and only high grade postoperative complications. Included in analysis were 1,163 cases. Intraoperatively complications occurred in 3.3% of cases. The overall conversion rate was 19.6% with 14.6%, 4% and 1.1% of procedures converted to reduced port laparoscopy, conventional laparoscopic/robotic surgery and open surgery, respectively. On multivariable analysis the factors significantly associated with the risk of conversion were oncological surgical indication (p=0.02), pelvic surgery (p<0.001), robotic approach (p<0.001), high difficulty score (p=0.004), extended operative time (p=0.03) and an intraoperative complication (p=0.001). A total of 120 postoperative complications occurred in 109 patients (9.4%) with major complications in only 2.4% of the entire cohort. Reconstructive procedure (p=0.03), high difficulty score (p=0.002) and extended operative time (p=0.02) predicted high grade complications. Urological laparoendoscopic single site surgery can be done with a low complication rate, resembling that in laparoscopic series. The conversion rate suggests that early adopters of the technique have adhered to the principles of careful patient selection and safety. Besides facilitating future comparisons across institutions, this analysis can be useful to counsel patients on the current risks of urological laparoendoscopic single site surgery.

Ergonomic and geometric tricks of laparoendoscopic single-site surgery (LESS) by using conventional laparoscopic instruments

The aim of this study was to explore the feasibility and safety of performing laparoendoscopic single-site surgery (LESS) with conventional laparoscopic instruments. We retrospectively reviewed our data from 175 patients who underwent various urological LESS procedures via the same ergonomic and geometric principles between 2008 and 2011. LESS procedures performed included adrenalectomy (N = 23), radical nephrectomy (N = 5), radical nephroureterectomy with bladder cuff resection (N = 5), varicocelectomy (N = 12), nephropexy (N = 4), lumbar sympathectomy (N = 4), orchiectomy for intra-abdominal testis (N = 1), pyeloureterostomy (N = 1), dismembered pyeloplasty (N = 1), and adult inguinal hernia mesh repair (N = 119). All procedures were completed successfully without the use of ancillary ports or articulating instruments except two cases that required laparoscopic conversion. The mean patient age was 48.9 years. Mean operative time was 99.7 min, mean estimated blood loss was 17.3 ml, and mean hospital stay was 2.1 days. There were no intraoperative complications. According to our ergonomic and geometric principles, use of conventional laparoscopic instruments is feasible and safe in LESS procedures.

Robotic Laparoendoscopic Single Site Urological Surgery: Analysis of 50 Consecutive Cases

We present our cumulative experience with robotic laparoendoscopic single site urological surgery at a single institution. Medical records of patients undergoing robotic laparoendoscopic single site procedures between May 2008 and December 2010 were analyzed. The da Vinci® S or Si systems and 3 different multichannel single port devices were used. Demographic, intraoperative and postoperative data were assessed. Overall, 50 patients were scheduled to undergo robotic laparoendoscopic single site urological surgery during the study period, representing 36% of the total patients undergoing laparoendoscopic single site surgery at our institution. Mean ± SD patient age was 60.2 ± 13.6 years. Mean body mass index was 27.0 ± 4.5 kg/m(2). Specifically, 24 patients underwent robotic laparoendoscopic single site renal surgery and the same method was used in 26 patients undergoing pelvic surgery. Mean operative time was 207 ± 74 minutes and mean estimated blood loss was 140 ± 111 ml. Four cases were converted to laparoscopy (2 standard, 2 robotic assisted) and 6 cases required at least 1 additional trocar outside of the single site incision. A rectal injury occurred during radical cystectomy, which was recognized intraoperatively and closed primarily without sequelae. Postoperative complications occurred in 8 cases and 1 was Clavien grade IV. Mean length of hospital stay was 2.9 ± 1.7 days. Our preliminary experience with robotic laparoendoscopic single site surgery has demonstrated feasibility and safety in the realm of urological surgery. Widespread adoption of this new approach will likely require redesign of the robotic system or development of a task specific robotic platform, and should be limited to centers with significant robotic, laparoscopic and laparoendoscopic single site surgery experience.

Initial experience of transumbilical laparoendoscopic single-site surgery in urology

Objective To summarize the initial experience of transumbilical laparoendoscopic single-site surgery of urology. Methods From February 2010 to March 2011,21 patients underwent laparoendoscopic single-site surgery using transumbilical single-site and common surgical instruments of laparoendoscopic.Nine patients underwent single-site laparoscopic ureterolithotomy,5 underwent transumbilical single-site laparoscopic ureteral stricture resection and anastomosis,5 underwent transumbilical single-site laparoscopic renalcyst unroofing and 2 had a nephrectomy.All of the cases were definitely diagnosed.A single umbilical incision of 1.5 cm to 2.5 cm was made for Triport.The procedures were performed according to the methods used in classical laparoscope methods using general instruments. Results All the operations were successfully completed without conversion to open surgery.The mean operative time of ureterolithotomy was 143 (120-230) min,the mean operative time of ureteral stricture resection and anastomosis was 157 (120 -180) min,the mean operative time of unroofing of renal cysts was 110 (95 -132) min,and the operative time of the nephrectomy was from 95 to 120 min.The intestinal tract function recovered within 1 -2 d,the drainage tube was removed within 2 -3 d and the postoperative hospitalization duration was 4 -7 d.The symptoms were reduced or disappeared and no major intraoperative or postoperative complications occurred within 4 - 6 months. Conclusions Transumbilical laparoendoscopic single-site surgery represents a safe and feasible operation for urologic patients.With more clinical practice,laparoendoscopic single-site surgery could be generally applied. Key words: Laparoscopes; Transumbilical; Single-site; Conventional laparoscopic instruments; Surgery

94 Risk factors for conversions and postoperative complications in urologic laparoendoscopic single-site surgery (LESS): Worldwide multi-institutional analysis of 1163 cases

94 Risk factors for conversions and postoperative complications in urologic laparoendoscopic single-site surgery (LESS): Worldwide multi-institutional analysis of 1163 cases

ENDOUROLOGY Laparo-endoscopic single-site surgery: recent advances in urology

Significant advances have been achieved in the field of urologic laparo-endoscopic single-site surgery (LESS) since the first reported clinical series in 2007. The aim of the present review paper is to summarize and critically analyze the most recent advances in the field of urologic LESS. A literature review was performed using PubMed to retrieve publications related to LESS in urology over the last two years (from January 2011 to May 2012). In the free-text protocol, the following terms were applied: LESS; single port laparoscopy; single incision laparoscopy. Despite unsolved challenges, LESS can be regarded as an emerging trend in minimally invasive urologic surgery and it has significantly evolved, becoming a widely applicable technique in a relatively short time. Outcomes demonstrate that a broad range of procedures can be effectively and safely done, given a solid laparoscopic surgical background and stringent patient-selection criteria. The recent introduction of a purpose-built instrumentation is likely to further foster the application of robotics to LESS. Further improvements are needed before this technique might reach a widespread adoption. Future advances in the field of robotic technology are expected to overcome the current limitations of LESS.

Upper tract urologic LaparoEndoscopic Single-Site surgery.

LaparoEndoscopic Single-Site (LESS) surgery has been developed as an extension of conventional laparoscopy to provide a minimally invasive option with fewer incisions, minimizing scars and potentially improving postoperative convalescence. These techniques have been adopted in the practice of urologic surgery, and largely employed to date for upper tract surgery by urologists in specialized centers with advanced laparoscopic practices. Herein, we review the current experience with upper tract urologic LESS surgery.

Current Status of Laparoendoscopic Single-Site Surgery in Urologic Surgery

Since the introduction of laparoscopic surgery, the promise of lower postoperative morbidity and improved cosmesis has been achieved. Laparoendoscopic single-site surgery (LESS) potentially takes this further. Following the first human urological LESS report in 2007, numerous case series have emerged, as well as comparative studies comparing LESS with standard laparoscopy. However, comparative series between conventional laparoscopy and LESS for different procedures suggest a non-inferiority of LESS over standard laparoscopy, but the only objective benefit remains an improved cosmetic outcome. Challenging ergonomics, instrument clashing, lack of true triangulation, and in-line vision are the main concerns with LESS surgery. Various new instruments have been designed, but only experienced laparoscopists and well-selected patients are pivotal for a successful LESS procedure. Robotic-assisted LESS procedures have been performed. The available robotic platform remains bulky, but development of instrumentation and application of robotic technology are expected to define the actual role of these techniques in minimally invasive urologic surgery.

Laparoendoscopic single-site surgery in urology: a single-center experience

Objective To present our experience on the first 100 cases receiving urological laparoendoscopic single-site surgery(LESS).Methods Between Dec.2008 and May 2011,a cohort of 98patients received a total of 100TriPort TM LESS urologic surgeries for various indications,including 2patients undergoing bilateral surgeries.The proceducres included radical nephrectomy(n=24),partial nephrectomy(n=3),simple nephrectomy(n=10),kidney cyst excision(n=21),adrenlectomy(n=12),transvesical simple prostatectomy(n=9),ureterolithotomy(n=6),and others(n=15).The demographics,perioperative outcomes,and follow-up data were prospectively analyzed.Results Of the 100surgeries,87were smoothly completed.A 5mm ancillary trocar was required in 9cases.Conversion to standard laparoscopy and open surgery were needed in 1and 3patients,respectively.The overall complication rate was 15%,with 6%intraoperatively and 9% postoperatively.The complication rate was 5%for the first 50cases and 10%for the second 50cases.The patients were followed up for 9.9± 5.61(ranging 3-24)months.At the latest follow-up,all patients remained clinically healthy with a delightedly hidden scar.No evidence of recurrence or metastasis was detected in patients receiving tumor resection.Conclusion The LESS is safe and technically feasible for urological surgery,with minimal invasiveness and better cosmesis.Emphasis should be made on patient selection and indication criteria.Improvement in instrumentation,accumulation of clinical practice,and well-designed multicenter prospective clinical trials will promote the use of LESS surgery for treatment of urologic diseases.

Pure single-port laparoscopic surgery or mix of techniques?

Laparoendoscopic single-site surgery (LESS) has emerged in the recent years as an alternative approach to conventional laparoscopic surgery which is accompanied by additional advantages over laparoscopy. In this work we attempt to review the current literature and to investigate the possible combination of LESS to other currently available approaches such as natural orifice transluminal endoscopic surgery (NOTES), needlescopic and robotic laparoscopic surgery. Extensive literature search on the topics of LESS, hybrid and pure NOTES, Needlescopic-assisted LESS and "Robot-assisted LESS" took place. Additionally, the accumulated experience from 118 LESSs performed in our departments is presented in an attempt to provide evidence regarding the mix of technique in LESS in urology. The challenging nature of LESS limits the broader application and acceptance. Expanding experience in single-site surgery has currently provided tools such as transvaginal access, needlescopic instruments and robot assistance that can aid LESS and enhance its efficiency without compromising any of its advantages. A mix of these techniques with LESS could ease the stiff learning curve of the second and benefit not only its performance but also the adaptation of LESS as a standard practice. Pure LESS although feasible, remains a technical challenge for the surgeon, preventing the widespread application of the technique. The goal of urologists on LESS surgery should not be the purity of LESS approach, but the superiority against already established techniques. A mix of techniques could be a key for the documentation of the advantages of LESS over conventional laparoscopy.

: Urologic LESS: complications and risk factors

The aim of laparoendoscopic single-site surgery (LESS) is to reduce the morbidity and scarring associated with regular laparoscopic procedures. Over the past 4 years, a number of urological LESS procedures have been shown to be feasible, and have been taken up by surgeons worldwide. According to current recommendations, suitable candidates for these procedures are generally thinner, with limited previous abdominal surgery. However, detailed, specific analyses of the complication rates of these techniques—and the most important risk factors associated with these complications—has not yet been performed. Greco et al. retrospectively evaluated the morbidity outcomes and risk factors associated with complications in 192 patients who underwent LESS for upper urinary tract disease.