Safety Study of Umbilical Single-port Laparoscopic Radical Prostatectomy with a New DuoRotate System

Laparoscopic single port radical prostatectomy in the 2020: Why not? Our experience

OBJECTIVES

To analyze the feasibility, safety and advantages of Laparo-Endoscopic Single-site Surgery radical prostatectomy (LESS-RP) based on our personal experience.

PATIENTS AND METHODS

Details of 520 patients were retrospectively analyzed, from 2009 to 2019. Extraperitoneal approach, with only two accesses (2.5 cm and 5 mm respectively) was used to perform radical prostatectomy. Perioperative characteristics and postoperative oncologic and functional outcomes are reported.

RESULTS

The mean age was 66.6 ± 5.6 years. Mean PSA level was 9 ± 3.5 ng/ml. According to D'Amico classification, the percentage of patients with low-, intermediate-, and high-risk disease cases were 116 (22.4%), 275 (52.8%), and 129 (24.8%) respectively. Mean operative time was 156 ± 43 min. Mean estimated blood loss was 214 ± 93 ml. Positive surgical margins (PSMs) were detected in 110 (21.2%) patients. PSM rates in pT2 and pT3 stages were 20.1% and 22.9%, respectively. The overall complication rate was 9.2%, based on the modified Clavien classification. The 12 months continence and potency rates were 90.9% and 49.1%, respectively. The biochemical recurrence rate was 6.8%, at the median follow-up time of 26.7 months (IQR 12-32).

CONCLUSIONS

Our analyses show that LESS-RP is a safe procedure, if performed by surgeons with adequate experience and skills. Unlike the classic laparoscopic prostatectomy, this technique allows better aesthetic and psychological results, reduced postoperative pain, and a faster return to normal daily activity with the same functional and oncological results.

Initial Experience with da Vinci Single-port Robot-assisted Radical Prostatectomies

BACKGROUND

Single-port robotic surgery is being adopted for various surgical procedures. There have been interest in and clinical use of single-port robot-assisted radical prostatectomy (spRARP), but little reported data on feasibility and early outcomes.

OBJECTIVE

To describe our institution's initial experience with spRARP utilizing the da Vinci single-port (SP) robotic system.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective review of the initial experience of three high-volume robotic prostate surgeons performing an spRARP utilizing the da Vinci SP robotic system was carried out.

SURGICAL PROCEDURE

An spRARP using the da Vinci SP robotic system was performed following the traditional retropubic or Retzius-sparing approach.

MEASUREMENTS

Patient demographics, operative time, blood loss, postoperative hospital stay, complications, and catheter duration were obtained and analyzed.

RESULTS AND LIMITATIONS

In a cohort of 49 patients undergoing spRARP, median age was 62yr and prostate-specific antigen 6.4. Of the patients, 35 (71%) had cT1c disease on presentation, 92% had Gleason grade group ≥2 disease, and 85% were pT2 on final pathology. Median operative time was 161min. Median blood loss was 200ml. Seven Retzius-sparing cases were performed. Four Clavien 2 complications occurred (complication rate 8.1%). Median hospital stay was 1d and median catheter duration 7d. Operative time was <200min for all three surgeons by their third case.

CONCLUSIONS

The da Vinci SP system spRARP is safe and feasible, with acceptable operative time and blood loss. Further research is needed to establish noninferiority to the da Vinci Xi and Si systems, and impact of spRARP on patient-assessed cosmesis and pain.

PATIENT SUMMARY

Robotic prostatectomy using a purpose-built da Vinci single-port robotic system is safe and feasible, and warrants further study to determine whether it can improve patient outcomes.

Laparoscopic radical prostatectomy in 2018: 20 years of worldwide experiences, experimentations, researches and refinements

INTRODUCTION

After the first feasibility report in 1997, a growing interest has risen in the urologic community for laparoscopic radical prostatectomy (LRP) and several authors have contributed to the evolution of the technique. We attempt a review of the available evidences and provide a broad framework of different technical refinements considering their impact on pentafecta.

EVIDENCE ACQUISITION

The PubMed/Medline database was searched. Duplicates and "Expert opinion" papers were removed. Studies were included according to the aim of the present paper to present a selected review on LRP and report our personal experience.

EVIDENCE SYNTHESIS

In 1999 Guillonneau et al. codified their transperitoneal-posterior-antegrade technique for LRP. Since then, several modifications of the transperitoneal approach were published and the extraperitoneal route was also proposed. Sparing the bladder neck and reconstructing the posterior muscolofascial plate were proven to improve continence rate. Nerve-sparing LRP were performed in order to maximize postoperative recovery of the sexual function. Novel techniques to ligate the Santorini plexus and sew the urethrovesical anastomosis provided improvement in operative time, intraoperative blood loss and reduced the incidence of postoperative urinary-leakages. In the recent years, the single-site approach as pushed the limits of LRP and three-dimensional (3D) systems for endoscopic surgery were developed.

CONCLUSIONS

Thanks to several technical improvements, LRP provides brilliant oncologic and functional outcomes and it is now considered the treatment of choice in many institutions worldwide. Although it is a technically demanding procedure, the recent introduction of 3D systems will reduce the steepness of its learning curve.

Transumbilical laparoendoscopic single-site radical prostatectomy and cystectomy with the aid of a transurethral port: a feasibility study

OBJECTIVE

To describe the surgical technique and report early outcomes of transurethral assisted laparoendoscopic single-site (LESS) radical prostatectomy (RP) and LESS radical cystectomy (RC) in a single institution.

MATERIALS AND METHODS

Between December 2014 and March 2016, a total of 114 LESS RPs and RCs were performed, comprising 68 LESS RPs, 38 LESS RCs with cutaneous ureterostomy (CU) and eight LESS RCs with orthotopic ileal neobladder (OIN). Access was achieved via a single-port, with four channels placed through a transumblical incision. After the apex of prostate was separated from the urethra, a self-developed port ('Zhu's port') was inserted through the urethra to facilitate resection of prostate and urethrovesical anastomosis. The peri-operative and postoperative data were collected and analysed retrospectively. Patients were followed up postoperatively for evidence of long-term side effects.

RESULTS

All the procedures were completed successfully. No conversion to conventional laparoscopic surgery was necessary. For LESS RP, the average operating time was 152 min. Estimated blood loss was 117 mL. The mean hospital stay was 16.4 days after surgery. For LESS RC with CU and LESS RC with OIN, the mean operating times were 215 and 328 min, mean estimated blood loss was 175 and 252 mL, and mean hospital stay was 9.4 and 18.2 days, respectively. Six patients required blood transfusion (5.26%). Intra-operative complications occurred in two patients (1.75%), and postoperative complications in nine (7.89%). Fourteen out of 68 (20.6%) patients who underwent LESS RP had positive surgical margins. Follow-up ranged from 10 to 30.6 months. In the prostate cancer cases, good urinary control was observed in 35.3%, 97.1% and 100% of patients at 1, 6 and 12 months after the operation, respectively, while biochemical recurrence was observed in 11.8% patients. In the bladder cancer cases, two patients had local recurrence and two patients had distant metastasis.

CONCLUSION

Our results showed that LESS RP and LESS RC are feasible and safe with the aid of a transurethral port. Operating through the transurethral port might overcome the challenges posed by the single-port laparoscopic approach.

Comparative study of hybrid laparoendoscopic single-site (LESS) partial nephrectomy and conventional multiport laparoscopy

OBJECTIVE

To investigate the surgical and oncological outcomes of hybrid laparoendoscopic single-site (LESS) in partial nephrectomy with reusable components compared with multiport laparoscopy.

MATERIAL AND METHOD

Hybrid LESS technique with auxiliary 3.5mm trocar (n=20) was compared with conventional multiport laparoscopy (n=26) by a prospective, paired, nonrandomized, and comparative study in partially nephrectomized patients.

RESULTS

Follow-up average was 31±18.6 months. In one case, LESS was converted to laparoscopy. No differences were found regarding age, sex, body mass index, laterality, localization, tumor size or use of double J stent. Dominance of Loop-I (P=0.09) and benign histology (P=0.05) were observed in the LESS group. Neither there were differences regarding operating time, ischemia time, use of hemostatic materials, estimated blood loss, postoperative hemoglobin levels, transfusion or other complications. In any case, to extend the skin incision for specimen extraction was not necessary. Drainage time (P=0.006) and hospital stay (P=0.003) were better in LESS patients. Concerning complications, no significant differences were observed according Clavien-Dindo scale. In laparoscopic group one patient died of pulmonary embolism after hospital discharge. No positive margins were observed in any case. During follow-up neither tumor recurrence nor disease progression were observed.

CONCLUSIONS

Regarding surgical outcomes, partial nephrectomy by LESS technique does not imply improvements, excepting shorter hospital stay, probably due to accurate surgical hemostasis and/or selection of cases. No surgical and oncological risks are involved, as well as no improvement in ischemia time, blood loss or transfusion rate. We find no significant difference in cosmetic outcomes.

Comparative study of multiport laparoscopy and umbilical laparoendoscopic single-site surgery with reusable platform for treating renal masses

INTRODUCTION

Umbilical laparoendoscopic single-site (LESS) surgery is an increasingly used modality for treating renal masses. We present a prospective comparison between LESS renal surgery and conventional laparoscopy.

MATERIAL AND METHOD

A comparative paired study was conducted that evaluated the surgical results and complications of patients with renal neoplasia treated with LESS surgery (n=49) or multiport laparoscopy (n=53). The LESS approach was performed with reusable material placed in the navel and double-rotation curved instruments. An additional 3.5-mm port was employed in 69.4% of the cases. We assessed demographic data, the type of technique (nephrectomy, partial nephrectomy and nephroureterectomy), surgical time, blood loss, haemoglobin, need for transfusion, number and severity of complications (Clavien-Dindo), hospital stay, histological data and prognosis.

RESULTS

There were no differences in follow-up, age, sex, body mass index, preoperative haemoglobin levels or type of surgery. Conversion occurred in 2 cases (1 in each group). The surgical time was equivalent (P=.6). Intraoperative transfusion (P=.03) and blood loss (P<.0001) was lower with LESS, postoperative haemoglobin levels were higher (P<.0001) and haemostatic agents were used more frequently (P<.0001). There were no differences in the number (P=.6) or severity (P=.47) of complications. The length of stay (P<.0001), the proportion of patients with drainage (P=.04) and the number of days with drainage (P=.0004) were lower in LESS. Twenty-five percent of the lesions operated on with LESS were benign, but the mean size was similar in the 2 groups (P=.5). Tumour recurrence and/or progression were more frequent in multiport laparoscopy (P=.0013).

CONCLUSIONS

Umbilical LESS surgery with reusable platform enables various surgical techniques to be performed when treating renal masses, with time consumption and safety comparable to conventional laparoscopy. The LESS approach is advantageous in terms of blood loss and hospital stay.

Two-Port Laparoscopic Reconstructive Surgery of the Urinary Tract with Reusable Umbilical System (Hybrid Less): A Proof of Concept Study

OBJECTIVES

We compared perioperative results and complications of reconstructive surgery of the urinary tract performed using a multichannel platform through the umbilicus and one additional 3.5-mm with a cohort of patients simultaneously treated with conventional 4-port laparoscopy.

MATERIALS AND METHODS

Matched-pair study comparing perioperative outcomes, postoperative visual analogue pain scale (VAPS) and morbidity of 2-port (n = 20) and 4-port (n = 10) laparoscopic reconstructive urological surgery. Preoperative and perioperative data compared included demographics, type of surgery, operative time, blood loss, decrease in serum hemoglobin, operative complications, length of stay and postoperative complications according to Clavien-Dindo classification.

RESULTS

There was no significant difference between groups regarding age, gender, body mass index, American Society of Anesthesiologists score, type of surgery, operative time, operative complications and intraoperative or postoperative transfusion. Estimated blood loss was lower using reduced-port approach. VAPS at postoperative day one was significantly lower for 2-port approach and so was the length of stay. Patient satisfaction with the wound was higher for 2-port surgery. Differences were not observed in number and severity of postoperative complications.

CONCLUSIONS

Urological reconstructive operations can be safely performed using the hybrid laparoendoscopic single-site umbilical approach, resulting in lower blood loss, higher patient satisfaction and lower postoperative pain, which also facilitate earlier hospital discharge, than the same reconstructive procedures performed through multiport conventional laparoscopy.

A matched-pair comparison of single plus one port versus standard extraperitoneal laparoscopic radical prostatectomy by a single urologist

We conducted this study to report on our initial experience and assess the safety, feasibility, and efficacy of extraperitoneal single plus one port laparoscopic radical prostatectomy (SPOPL-RP), and determine whether it shows any objective advantage over standard laparoscopic radical prostatectomy. From June 2009 to September 2011, 15 extraperitoneal SPOPL-RPs were performed through a 2-3-cm subumbilical longitudinal incision and another 5-mm trocar placed at the McBurney point. This cohort was compared with 37 contemporary patients who underwent standard extraperitoneal laparoscopic radical prostatectomy performed by the same urologist. Peri- and postoperative outcomes, including continence, potency, and scar length, were statistically analyzed. The two groups were comparable with respect to patient demographics, estimated blood loss, drainage time, duration of catheterization, catheterization rate >14 days, complication rate, postoperative hospitalization, and postoperative functional and oncologic outcomes (p > 0.05). The SPOPL-RP procedures had a longer mean operative time (170.1 minutes vs. 139.5 minutes, p = 0.005), but with fewer patients requiring analgesics (20% vs. 54.1%, p = 0.038) and earlier resumption of oral intake (20.7 hours vs. 26.8 hours, p = 0.037). The mean scar length in the SPOPL-RP group was much smaller (3.4 cm vs. 5.8 cm, p = 0.000) owing to the significant reduction of the skin incision. The peri- and postoperative outcomes of SPOPL-RP for low-risk prostate cancer are comparable to those with the standard laparoscopic approach. In addition, SPOPL-RP provides better postoperative pain control, faster recovery of bowel function, and smaller scar length than standard laparoscopy, albeit with a longer operative time.

[Drainage of amoebic liver abscess by single incision laparoscopic surgery. Report of a case]

BACKGROUND

Single incision laparoscopic surgery has increased recently due to successful results, achieved in several procedures. The aim of the present work is to present the first case in which single incision laparoscopy is used for the drainage of an amoebic liver abscess.

CLINICAL CASE

A 44-year-old man presented with intense right upper quadrant pain, generalised jaundice, tachycardia, fever, hepatomegaly and a positive Murphy's sign. Laboratory results revealed an increased plasma bilirubin, elevated alkaline phosphatase and transaminases, leucocytosis, negative viral panel for hepatitis, and positive antibodies against Entamoeba histolytica. On an abdominal computed tomography a 15 × 12.1 cm hypodense lesion was observed in the patient's liver, identified as an amoebic liver abscess. Analgesics and antibiotics were started and subsequently the patient was submitted to laparoscopic drainage of the abscess using a single port approach. Drainage and irrigation of the abscess was performed. Four days later the patient was discharged without complications.

CONCLUSION

Management of amoebic liver abscess is focused on the elimination of the infectious agent and obliteration of the abscess cavity in order to prevent its complications, especially rupture. Laparoscopic surgery has proved to be a safe and effective way to manage this entity.

Two-Port Approach Compared to Standard Laparoscopic Radical Cystectomy

BACKGROUND AND OBJECTIVES

Two-port laparoscopic radical cystectomy (LRC) using a multichannel platform through the umbilicus and one additional 10-mm in the right iliac fossa has been recently described. We compare the perioperative and early results of this technique with a cohort of patients simultaneously treated in our institution with four-port LRC and a 7 to 10 cm midline incision.

MATERIALS AND METHODS

A matched-pair study comparing perioperative outcomes, postoperative visual analog pain scale (VAPS), and morbidity of two-port (n=30) and four-port (n=30) LRC. Preoperative and perioperative data analyzed and compared included demographics, type of urinary diversion, operative time, blood loss, transfusion requirements, decrease in serum hemoglobin, operative complications, analgesic needs, length of stay, number of nodes removed, and other pathologic information. Complications in the first 3 months were evaluated according to the Clavien-Dindo classification.

RESULTS

There was no significant difference between the two groups regarding patient age, gender, body-mass index, American Society of Anesthesiologists (ASA) score, Charlson comorbidity index, tumor stage, percent of positive nodes, positive margin rate, number of nodes retrieved, proportion of neobladders, secondary carcinoma in situ, incidental prostate cancer, or need of systemic chemotherapy. Median operative time was 20 minutes higher in the two-port procedure, but this difference was not statistically significant (p=0.2). Estimated blood loss and differential hemoglobin change were lower in the two-port technique (each p=0.03), but no difference was detected regarding the intraoperative or postoperative transfusion rate. Length of hospital stay was also equivalent. Differences were not observed either in the number or severity of complications. VAPS at days 2, 3, and 5 was significantly lower for two-port LRC (p<0.01).

CONCLUSIONS

Two-port LRC performed through an umbilical platform and an accessory 10-mm port seems technically equivalent to standard four-port LRC. Perioperative outcomes regarding hospital stay and complications are tantamount. Diminished blood loss and, especially, less postoperative pain favor the reduced-port approach in this complex urologic minimally invasive procedure.

The best option: Umbilical LESS radical nephrectomy with vaginal extraction

INTRODUCTION

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.

PATIENT AND METHOD

We present a 34-year-old patient with a solid mesorenal lesion measuring 8 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.

RESULTS

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 min. The patient was discharged the following day without needing analgesia. A year later, the patient was disease-free and had no complications.

CONCLUSIONS

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.

Development of urologic laparoscopy in Germany, Austria, and Switzerland: a survey among urologists

PURPOSE

Laparoscopy introduction has dramatically changed urology. Novel techniques, such as laparoendoscopic single-site surgery (LESS) and natural orifice translumenal endoscopic surgery (NOTES), might also have substantial influence. This 2012 survey evaluated present laparoscopy use, its appraisal among urologic surgeons, laparoscopy training, and use of new techniques. Results were compared to the previous surveys, demonstrating the 10-year development of laparoscopy.

METHODS

A detailed questionnaire regarding demographic data, laparoscopy use, attitudes concerning laparoscopy, and novel techniques was send to 424 departments in Germany, Austria, and Switzerland. Procedures performed in 25 indications were quantitatively evaluated.

RESULTS

The response rate was 63 % (269). Eighty-six percent of the respondents reported performing laparoscopy, compared to 54 % in 2002. Only 16 % expected economic advantages with laparoscopy, whereas 67 % expected shorter hospitalization. Seventy percent of responders anticipated comparable functional and oncological results between laparoscopic procedures and open surgery. Slow learning curves (81 %) and insufficient training facilities (32 %) were reported to impair laparoscopic surgery. On average, laparoscopic and non-laparoscopic surgical teams consisted of 2.5 and 3.5 members, respectively. LESS procedures were performed at 15 % of institutions. Twenty-two percent of respondents considered NOTES techniques valuable for future urology. Few indications (laparoscopic prostatectomies or nephrectomies) were performed frequently in specialized centers, and the rapidly increasing procedure numbers observed between 2002 and 2007 had dropped to a mild accretion. The results demonstrate broad acceptance of laparoscopy in German urologic surgery, depict the need for structured training facilities, and indicate limited impact of novel techniques (LESS and NOTES).

CONCLUSIONS

The survey demonstrates the 10-year development of urologic laparoscopy and the broad acceptance of laparoscopic techniques.

Umbilical laparoendoscopic urological surgery with a novel reusable device

OBJECTIVE

The aims of this study were to present cumulative experience with umbilical laparoendoscopic urological surgery using a reusable device and to evaluate outcomes and complications in the first 100 patients.

MATERIAL AND METHODS

Patients undergoing umbilical surgery with the KeyPort system and DuoRotate instruments (Richard Wolf, Knittlingen, Germany) were evaluated prospectively. Demographic, intraoperative and postoperative data were assessed.

RESULTS

Between October 2011 and July 2012, 79 pelvic (66 radical prostatectomy, 10 radical cystectomy, one diverticulectomy, one bilateral orchiectomy, one ureter reimplantation) and 21 renal (seven radical nephrectomy, six partial nephrectomy, five nephroureterectomy, two pyeloplasty, one pyelolithotomy) surgeries were performed through the umbilicus using this platform. Follow-up was 56.7 ± 12.6 weeks (mean ± SD). Mean age was 64.3 ± 10.3 years, body mass index 29 ± 4.6 kg/m(2), operative time 232 ± 106 min and estimated blood loss 260 ± 95 ml. Conversion to standard multiport laparoscopy was not necessary. An accessory port was used in 87 cases to facilitate suturing and conduct drainage extraction. Postoperative complications occurred in 24 cases (six Clavien grade I, 12 grade II, one grade IIIa, two grade IIIb, two grade IVa, one grade IVb). Mean hospital stay was 4.2 ± 4 days. Total transfusion rate was 10%. Mean visual analogue pain scale at day 2 was 2.1 ± 1.3 (0-10). Visual analogue wound satisfaction scale at month 1 was 9.2 ± 0.6 (0-10). No cancer-related events occurred during follow-up. Late complications (4%) were not related to the surgical approach.

CONCLUSIONS

Umbilical KeyPort surgery is technically feasible for a great variety of procedures, both ablative and reconstructive. This access offers adequate surgical outcomes, scarce postoperative pain and security for the patient in the short term. Its reusable nature implies a noticeable economic advantage.

Transumbilical single port surgery with conventional laparoscopic instruments in horseshoe kidney

INTRODUCTION

Laparoscopic surgery is following a natural course as it decreases surgical aggression on the abdominal wall without undermining the curative and functional results. Although it is still being developed, single port surgery has meant an advance in this sense.

MATERIAL AND METHODS

We present the first single port laparoscopic pyelolithectomy surgery in horseshoe kidney, using conventional rigid instruments. The case of an 18-year old patient with BMI of 19 in whom the imaging tests (urogram and computed tomography) showed a horseshoe kidney with left coralliform lithiasis and discrete calyceal ectasia is presented. The lithiasis was extracted using umbilical access with single port device and conventional rigid instruments.

RESULTS

The surgery was performed without complications. Surgery time was 110 minutes and bleeding 50 cc. On incision of the urinary system, there was purulent urine extravasation that conditioned fever of 38 °C in the post-operatory period. During the intervention, a double J stent was placed via percutaneous approach. The patient was discharged on the third day of hospitalization.

CONCLUSION

Single port laparoscopic access for pyelolithectomy surgery in horseshoe kidney is a reasonable alterative. The use of conventional rigid instruments facilitates the performance of this surgery with good triangulation, without conflict regarding hands and safety for the patient.

Initial experience of umbilical laparoendoscopic single-site nephron-sparing surgery with KeyPort and DuoRotate system

OBJECTIVES

To present the feasibility of laparoendoscopic single-site (LESS) nephron-sparing surgery (NSS) using new reusable umbilical single-port system and instruments.

METHODS

A prospective study was performed to evaluate operative data and patient outcomes after LESS-NSS with KeyPort®, a tri-channel single-port placed through a 2.5-cm umbilical incision, and specific DuoRotate® instruments. Patient characteristics, operative time, estimated blood loss (EBL), complications, visual analog pain scale (VAPS), and visual analogue wound satisfaction scale (VAWSS) scores were registered.

RESULTS

Six consecutive nonselected patients with indication of NSS and normal contralateral kidney were offered LESS-NSS. An accessory 3.5 mm port that facilitated renoraphy and unclamped technique was used in 4 (66.7%) cases each. Median tumor maximum size was 4.0 (1-7.5) cm; age 64 (31-76) years; body mass index 28.4 (22.1-39.3) kg/m(2); operative time 233.5 (140-250) min; EBL 500 (200-500) mL; difference in hemoglobin 2.3 (0.1-4.6) g/dL. VAPS at day 2 was 0.7/10 and the median length of stay 3 (2-4) days. One case (16.7%) needed transfusion. None required conversion to standard laparoscopy or use of other additional ports. Postoperative complications occurred in 3 (50%) and major complications in 1 (16.7%). Incisions were totally hidden in the umbilicus. Pathology revealed angiomyolipoma (3), renal cell carcinoma (2), and chronic inflammation (1). Tumor margins were negative in all cases with malignancy. VAWSS at first month was 9.4 (8.1-10). At a median follow-up of 24 (10-32) weeks, no patient developed complications related to the approach.

CONCLUSIONS

Umbilical LESS-NSS through a new single-port system of reusable nature, with or without the help of an accessory port and occasionally without clamping, can be effectively and very economically performed with minimum postoperative pain. Good candidates are patients with presumed benign renal masses that appreciate the cosmetic advantage of the approach.

[Current state of single-port transumbilical surgery in urology: challenges and applications]

CONTEXT

Laparoscopic surgery in urology is considered to be an important advance, although it is not exempt from some morbidity associated to the use of multiple trocars and specifically to the extraction of the specimen. In order to decrease this morbidity and improve esthetics, other techniques are being developed, such as natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS). It is aimed to review the current status of laparoendoscopic single site surgery in urology.

ACQUISITION OF EVIDENCE

A nonsystematic review has been carried out by means of the bibliographic search using the terms LESS and Urology from 2007 to 2012. The current LESS experience in urology is described, and its principal indications and the different single site devices and instruments available on the market are described.

SYNTHESIS OF EVIDENCE

LESS surgery arose as one more step in the constant evolution of minimally invasive surgery in an attempt to improve esthetics, reduce surgical trauma and decrease pain and the post-operative complications associated to the conventional laparoscopy with multiple trocars. Since it was first described in 2007, the experience has been increasing exponentially and the LESS technique, whether assisted or not by robot, is becoming consolidated for a large spectrum of urological indications (both in oncological and reconstructive surgery) on a much greater scale than the NOTES technique. Even though most of the existing data are not randomized and very rarely comparative, with the selection bias that this represents, it seems clear that the esthetic benefit and analgesic control associated to the LESS surgery is real and reproducible. The complications associated to it are greater in cases of major oncology surgery and are due more to the technique itself then to the approach.

CONCLUSIONS

Although the real benefit of the LESS surgery in urology cannot be appropriately quantified, the cosmetic improvement, less pain and greater patient satisfaction with their wound are clear. Appropriate training in this type of procedures in centers having large volumes and the continuous technical improvements in the instrumental development by the biomedical industry has resulted in the fact that the transumbilical LESS technique in urology has been born to stay.

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.