Laparoendoscopic Single Site Surgery in Urology

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Nomenclature

Various terminologies and acronyms have been used to describe surgical procedures that perform laparoscopic surgery through a single incision or surgical site (Box 1). To standardize terminology with regard to scientific communications and performance of clinical trials, LESS was proposed as a common nomenclature by a consortium comprised of experts from various surgical specialties. This term has also been endorsed by the Urologic NOTES Working Group in a recent communication.3 By combining

Development and evolution of laparoendoscopic single-site surgery

The concept of LESS surgery has been around for many years and has been used across many surgical specialties. Gynecologists using a single-puncture laparoscope with an offset eyepiece4 have performed tens of thousands of tubal ligations through the years.5 More recently, single-incision techniques have been reported in the general surgery literature for insertion of peritoneal dialysis catheters in children using only an umbilical port for the laparoscope6 and retroperitoneoscopic

Instruments and technology

Improvements in access devices, optics, and instrumentation have driven the dissemination of this new format of laparoscopic surgery. A brief description of the various new devices that have been used follows (Table 1).

Robotics

With the advent and unprecedented adoption of surgical robotics has come the natural hybridization of the technology with LESS surgery. Kaouk and colleagues23 reported on the use of the DaVinci-S (Intuitive Surgical, Sunnyvale, California) robotic system in conjunction with a TriPort single-port access device to perform a radical prostatectomy, a pyeloplasty, and a radical nephrectomy for a 5.6-cm right-sided renal mass. A 12-mm three-dimensional camera and 5-mm grasping instrument were placed

Clinical experience with urologic laparoendoscopic single-site procedures

The experience in clinical trials has expanded significantly since the application of the technique within the human arena (Table 2). Rane and colleagues17 reported on their experience with five cases in which they performed two simple nephrectomies for end-stage kidney disease consequent to stone disease, one orchiopexy, one orchiectomy, and one ureterolithotomy. All cases were completed successfully with a mean operative time of 83 minutes and without complications. Raman and colleagues12

Novel approaches

LESS surgery has been primarily applied to standard laparoscopic procedures within the peritoneal cavity. With the newer access devices being developed, novel approaches to procedures have been proposed. Transvesical procedures including simple and radical prostatectomy36 and ureteral reimplantation37 have been performed in the past by a combination of conventional robotic and laparoscopic techniques. The complexity of these cases has been prohibitive and often related to the need for multiple

Future directions

Through the development of such groups as the Urologic NOTES working groups and the LESSCAR consortium, the future of LESS surgery is being well documented and promoted. LESSCAR has proposed the creation of a LESS registry to monitor and coordinate the collection of clinical data as they become available. They would be in a position to design and oversee the development and execution of prospective randomized trials needed to determine the effectiveness and potential benefits of such new

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