UROLOGICAL SURVEY

ENDOUROLOGY & LAPAROSCOPY

Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, OH, USA

Eur Urol. 2011; 60: 998-1005

BACKGROUND: Laparoendoscopic single-site surgery (LESS) has gained popularity in urology over the last few years.

OBJECTIVE: To report a large multi-institutional worldwide series of LESS in urology.

DESIGN, SETTING, AND PARTICIPANTS: Consecutive cases of LESS done between August 2007 and November 2010 at 18 participating institutions were included in this retrospective analysis.

INTERVENTION: Each group performed a variety of LESS procedures according to its own protocols, entry criteria, and techniques.

MEASUREMENTS: Demographic data, main perioperative outcome parameters, and information related to the surgical technique were gathered and analyzed. Conversions to reduced-port laparoscopy, conventional laparoscopy, or open surgery were evaluated, as were intraoperative and postoperative complications.

RESULTS AND LIMITATIONS: Overall, 1076 patients were included in the analysis. The most common procedures were extirpative or ablative operations in the upper urinary tract. The da Vinci robot was used to operate on 143 patients (13%). A single-port technique was most commonly used and the umbilicus represented the most common access site. Overall, operative time was 160 ± 93 min. and estimated blood loss was 148 ± 234 mL. Skin incision length at closure was 3.5 ± 1.5cm. Mean hospital stay was 3.6 ± 2.7 d with a visual analog pain score at discharge of 1.5 ± 1.4. An additional port was used in 23% of cases. The overall conversion rate was 20.8%; 15.8% of patients were converted to reduced-port laparoscopy, 4% to conventional laparoscopy/robotic surgery, and 1% to open surgery. The intraoperative complication rate was 3.3%. Postoperative complications, mostly low grade, were encountered in 9.5% of cases.

CONCLUSIONS: This study provides a global view of the evolution of LESS in the field of minimally invasive urologic surgery. A broad range of procedures have been effectively performed, primarily in the academic setting, within diverse health care systems around the world. Since LESS is performed by experienced laparoscopic surgeons, the risk of complications remains low when stringent patient-selection criteria are applied.

Editorial comment

Laparoendoscopic Single-site Surgery in Urology has evolved and this manuscript demonstrates the fast pace of implementation of this new minimally invasive surgical technique worldwide.

A total of 1076 patients were included in the analysis between August 2007 and November 2010 at 18 participating institutions. Different ports and instrumentations were used but the common theme seems to be the evolution of surgical technique and experience of urological laparoscopists that can perform these procedures.

Overall operative time was 160 ± 93 min and estimated blood loss was 148 ± 234 ml. Skin incision length at closure was 3.5 ± 1.5 cm. Mean hospital stay was 3.6 ± 2.7 d with a pain VAS at discharge of 1.5 ± 1.4.

A single-port technique was chosen in 77% of cases and the umbilicus was the predominant site of access (71% of cases). In cases in which a single-port platform was used, 46% involved a homemade device and 54% used a commercially available device. An additional port was used in 23% of cases. In 34% of these, a 2- to 3-mm extra port was used, whereas in the remaining 66% of cases, an extra 5- to 12-mm additional port was required. The overall conversion rate was 20.8%, with 15.8% of cases converting to reduced-port laparoscopy, 4% to conventional laparoscopy or robotic surgery, and 1% to open surgery. Reasons for conversion were difficult dissection (37% of converted cases), failure to progress (21%), bleeding (25%), difficult suturing (11%), difficult retraction (3%), and difficult access (3%).

The intraoperative complication rate was 3.3%, with need for conversion to open surgery occurring in three cases and laparoscopy in five cases.

As the authors concluded the Outcomes demonstrate that a broad range of procedures can be effectively and safely done by applying different LESS techniques in a variety of hospital settings. Undeniably, a solid laparoscopic surgical background and stringent patient-selection criteria are critical for successful LESS.

Dr. Fernando J. Kim

Chief of Urology, Denver Health Med. Ctr.

Associate Professor, Univ. Colorado Health Sci. Ctr.

Director of Minimally Invasive Urol. Oncology, UCHSC

Denver, Colorado, USA

E-mail: fernando.kim@dhha.org

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