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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. [ABSTRACT FROM AUTHOR]

Objective • To report on a large multi-institutional series of laparoendoscopic single-site (LESS) partial nephrectomy (PN) and analyse renal function and short-term oncological outcomes. Material and Methods • We conducted a retrospective analysis of consecutive cases of LESS-PN performed between November 2007 and March 2012 at 11 participating institutions. • Demographic data and data on the main peri-operative outcomes and complications were gathered and analysed. • Kidney function was evaluated by measuring serum creatinine concentration and estimated glomerular filtration rate (eGFR). • Chronic kidney disease was defined in stages for each patient according to the National Kidney Foundation, Kidney Disease Outcomes Quality Initiative. Results • A total of 190 cases were included in this analysis. The mean renal tumour size was 2.6 cm, and the mean PADUA score was 7.2. • The median operating time was 170 min with a median estimated blood loss of 150 mL. A clampless technique was used in 70 cases (36.8%) and the median warm ischaemia time (WIT) was 16.5 min. • PADUA score independently predicted the length of WIT (low vs high score: odds ratio 5.11, CI 1.50-17.41, P = 0.009; intermediate vs high score: odds ratio 5.13, CI 1.56-16.88, P = 0.007). • The overall postoperative complication rate was 14.7%. Where a clamping technique was used, a significant increase in serum creatinine concentration and a significant decrease in eGFR were observed postoperatively and at 6 months. On multivariate analysis PADUA score was the only predicting factor. • Overall survival rates were 99, 97 and 88% at 12-, 24- and 36-month follow-up, respectively, while disease-free survival rates were 98% at 12-month and 97% at 24- and 36-month follow-up. Conclusion • The study showed that LESS-PN is effective in terms of renal function preservation and oncological control at short- and intermediate-term follow-up. [ABSTRACT FROM AUTHOR]

What's known on the subject? and What does the study add? LESS-NU may be an alternative minimally-invasive treatment option for patients eligible to undergo laparoscopic surgery for upper urinary tract urothelial carcinoma., The true benefits of LESS-NU remain to be determined and require randomized control trials in the future. Despite encouraging early findings, clinical trials still are warranted before this procedure is adopted widely, and longer follow-up is needed to determine its oncological durability., Objective To report a large multi-institutional series of laparoendoscopic single-site ( LESS) nephroureterectomy ( NU)., Materials and Methods Data on all cases of LESS-NU performed between 2008 and 2012 at 15 institutions were retrospectively gathered., The main demographic data and perioperative outcomes were analysed., Results The study included 101 patients whose mean ( sd) age was 66.4 (9.9) years and mean ( sd) body mass index was 24.8 (4) kg/m2, and of whom 29.7% had undergone previous abdominal/pelvic surgery., The mean ( sd) operating time was 221.4 (73.7) min, estimated blood loss 231.7 (348.0) mL., A robot-assisted LESS technique was applied in 25.7% of cases. An extra trocar was inserted in 28.7% of cases to complete the procedure. Conversion to open surgery was necessary in three cases (3.0%). There was no bladder cuff excision in 20.8% of cases, and excision was carried out using a variety of techniques in the remaining cases., Six intra-operative complications occurred (5.9%). The mean ( sd) length of hospital stay was 6.3 (3.5) days. The overall postoperative complication rate was 10.0%, and most of the complications were low grade ( Clavien grades 1 and 2)., The mean tumour size was 3.1 (1.9) cm. Pathological staging was pTis in two patients, pTa in 12 patients, pT1 in 42 patients, pT2 in 20 patients, pT3 in 23 patients and pT4 in two patients. Pathological grade was high in 71 and low in 30 patients., At a mean follow-up of 14 months, six patients (5.9%) had died. Disease recurrence (including distant and bladder recurrence) was detected in 22.8% of patients, with a mean time to recurrence of 11.5 months., Conclusions This study reports the largest multi-institutional experience of LESS-NU to date., Peri-operative outcomes mirror those of published standard laparoscopy series., Despite encouraging early findings, longer follow-up is needed to determine the oncological efficacy of the procedure. [ABSTRACT FROM AUTHOR]

What's known on the subject? and What does the study add? Laparoendoscopic single-site ( LESS) surgery has proved to be immediately applicable in the clinical field, being safe and feasible in the hands of experienced laparoscopic surgeons in well-selected patients. All extirpative and reconstructive urological procedures have been described in the literature, but LESS partial nephrectomy ( PN) is one of the most complex procedures and few studies have been published on this subject., The study describes a clampless technique for LESS PN, by reducing the blood pressure and increasing the intra-abdominal pressure of the pneumoperitoneum to 20 mmHg, timed to precisely coincide with excision of the tumour. This technique was found to be safe and feasible in the treatment of low-risk T1a RCC., Objective To describe the technique and report the surgical outcomes of clampless laparoendoscopic single-site ( LESS) partial nephrectomy ( PN) in the treatment of renal cell carcinoma ( RCC) with low PADUA score., Patients and Methods Clampless LESS PN was performed in 14 patients with c T1a renal tumours. Indications to perform a clampless LESS PN were low-risk, laterally based renal tumours, located away from the renal hilum, with a PADUA score ≤7., Demographic data and peri-operative and postoperative variables were recorded and analysed., Kidney function was evaluated by measuring serum creatinine concentration and estimated glomerular filtration rate ( eGFR) pre- and postoperatively and at 6-month follow-up., Results The median operating time was 120 min and warm ischaemia time was zero in all cases. Only one early complication ( Clavien grade 1) was recorded: one patient developed a flank haematoma which it was possible to treat by conservative therapy., Serum creatinine and modification of diet renal disease e GFR were not found to be significantly different pre- and postoperatively and at 6-month follow-up., Definitive pathological results showed 12 pT1a RCCs and two pT1a-chromophobe RCCs. All tumours were removed with negative surgical margins., All patients were satisfied with the cosmetic results., At a median (range) follow-up period of 12 (8-15) months, all patients were alive without evidence of tumour recurrence or port-site metastasis., Conclusion Clampless LESS PN is a safe and feasible surgical procedure in the treatment of low-risk T1a RCC, with excellent cosmetic results. [ABSTRACT FROM AUTHOR]

Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? New techniques and instrumentation in laparoscopy including the use of 'single-port' devices and natural orifice transluminal endoscopic surgery have been proposed to reduce the invasiveness of these procedures. The introduction of small laparoscopic instruments (<3 mm) continues to further the field. To date, mini-laparoscopic instruments have been used in many urological procedures, e.g. pyeloplasty in the paediatric population. However, data of pure mini-laparoscopic pyeloplasty (mLP) for the treatment of pelvi-ureteric junction obstruction in the adult population are lacking. In a selected adult population mLP is feasible and safe. Perioperative and 1-year functional results are comparable with those of standard LP, while cosmetic results of mLP are more appreciated by the patients. OBJECTIVE To evaluate perioperative and cosmetic results after pure mini-laparoscopic pyeloplasty (mLP) compared with standard LP (sLP) in an adult population., PATIENTS AND METHODS From April 2009 to June 2010, 12 patients underwent mLP for pelvi-ureteric junction (PUJ) obstruction (PUJO). For comparison, 24 patients that had previously undergone sLP were pooled from our institutional database., All patients were assessed preoperatively with physical examination, abdominal ultrasonography, intravenous urography or computed tomography and renal scintigraphy (RS). In all cases, an Anderson-Hynes transperitoneal approach was used., After surgery, cosmetic results were assessed using a Patient Scar Assessment Questionnaire (PSAQ), and RS measured reconstructive success at 1-year after LP., Demographic and perioperative variables were recorded. Groups were compared using chi-squared and Wilcoxon-Mann-Whitney tests ( P < 0.05 was considered significant)., RESULTS Baseline characteristics were similar between the groups. There were no differences in operative duration or blood loss. One mLP required conversion to sLP due to minor bleeding., Analgesic consumption and the pain visual analogue scale scores were not significantly different between the sLP and mLP cohorts., The average postoperative hospital stay for the mLP group was significantly shorter than that for the sLP group ( P= 0.024)., Complication and success rates between the groups were not significantly different., PSAQ scores showed that mLP patients were significantly more satisfied with their cosmetic result., CONCLUSIONS mLP appears to be safe, feasible and effective in the treatment of PUJOs., Cosmetically, mLP is better than sLP. [ABSTRACT FROM AUTHOR]

Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Over the last few years, minimally invasive urological surgery has evolved towards less invasive, 'scarless' procedures. New surgical concepts, such as those of natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS) have been introduced. Mini-laparoscopy has been rediscovered in an attempt to reduce the invasiveness of standard laparoscopy. This study is the first to compare the perception of surgeons when first facing three different scarless options for performing a porcine nephrectomy and when dealing with the constraints of each technique. The study findings suggest that: (i) when first approaching these techniques, surgeons tend to perform equally well under expert guidance in the porcine model; (ii) mini-laparoscopy is perceived as less difficult to perform; (iii) for all the techniques, surgeon's impressions are in line with their expectations. OBJECTIVE To evaluate the perception and performance of urological surgeons when first applying scarless surgical techniques., METHODS The study was conducted during the 2nd Minimally Invasive Urological Surgical Week annual course in Braga, Portugal., Fourteen attendees performed three porcine nephrectomies by using each of the following techniques: mini-laparoscopy, laparoendoscopic single-site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES)-assisted laparoscopy., Peri-operative data were recorded, and operating performance was scored by one experienced surgeon for each working station, using a global rating scale., The surgeons' subjective perceptions of degree of difficulty were graded and their expectations before the procedures were recorded., RESULTS Forty-two porcine nephrectomies were performed., There were no differences in overall operating time, or time to dissect and manage the renal vascular hilum, whereas time to gain access was faster for LESS than for mini-laparoscopy or NOTES-assisted laparoscopy (mean [ sd] 8 [6] min vs 10.2 [5.3] min vs 9.9 [5.3] min, respectively; P= 0.59)., A better visualization of the surgical field was obtained with mini-laparoscopy and there was a higher degree of difficulty of bimanual dexterity for LESS, but no significant differences were found among the three techniques for any variable (operating field view: P= 0.52; bimanual dexterity: P= 0.49; efficiency: P= 0.77; tissue handling: P= 0.61; autonomy: P= 0.2)., Subjective perception of the degree of difficulty trended in favour of mini-laparoscopy ( P= 0.17), but no significant difference was found in terms of surgeons' impression as compared with their expectations ( P= 0.34)., CONCLUSIONS When first approaching new scarless techniques, surgeons tend to perform equally well under expert guidance in the porcine model., Mini-laparoscopy is perceived as less difficult to perform and, for all the techniques, surgeons' impressions are in line with their expectations. [ABSTRACT FROM AUTHOR]

Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Single port transvesical enucleation of the prostate (STEP) performed through a solitary suprapubic incision using a single access port inserted directly into the bladder has been demonstrated to be technically feasible but still challenging.3. Despite being feasible and providing adequate relief of bladder outlet obstruction, robotic STEP carries a high risk of complications. Further evolution of the technique is likely to be strictly dependent on the development of instrumentation. OBJECTIVE To report our initial experience with a novel robot assisted single port procedure for the management of benign prostatic hyperplasia (BPH)., METHODS Between March 2009 and July 2010, nine patients with symptomatic BPH were scheduled for robotic single port suprapubic transvesical enucleation of the prostate (R-STEP)., Prior to intervention, all were submitted to preoperative transrectal ultrasound of the prostate and uroflowmetry., The surgical procedure included an initial transurethral incision of the prostatic apex. With the patient in the supine position, an approximate 3 cm lower midline incision was made. A cystotomy was created and a GelPort® laparoscopic system positioned in the bladder. The da Vinci S™ robotic operating system was docked through the GelPort® platform and enucleation was performed., Perioperative outcomes and short-term postoperative functional outcomes were assessed. Intra-operative and postoperative complications, graded according to the Dindo-Clavien system, were recorded., RESULTS One patient was excluded from the analysis as the procedure was aborted and converted to open simple prostatectomy., Median operative time was 3.9 h. Median visual analogue pain scale on discharge was 2. Estimated blood loss was 425 mL. Two patients required intra-operative blood transfusion., Postoperatively, two patients developed clot retention and required evacuation and fulguration (grade IIIb), one of them had a deep vein thrombosis (grade II) and a urinary tract infection (grade II). One patient was admitted to the intensive care unit after a myocardial infarction (grade IVa). All patients were discharged after a median of 4.5 days., There was almost three and four times postoperative improvement in both median maximum flow (Qmax) and average flow (Qave) rates, respectively., CONCLUSION The first series of R-STEP is reported herein. Despite being feasible and providing adequate relief of bladder outlet obstruction, the procedure carries a high risk of complications. Further evolution of the technique is likely to be strictly dependent on the development of instrumentation. Thus, its role in the surgical armamentarium of BPH remains to be determined. [ABSTRACT FROM AUTHOR]

Since the introduction of laparoscopic surgery, the promise of lower postoperative morbidity and improved cosmesis has been achieved. LaparoEndoscopic Single Site (LESS) surgery 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. Technological developments in instrumentation, access and optics devices are overcoming some of the challenges that are raised when operating through a single site. Further advances in the technique have included the incorporation of robotics (R-LESS), which exploit the ergonomic benefits of ex vivo robotic platforms in an attempt to further improve the implementation of LESS procedures. In the future, urologists may be able to benefit from in vivo micro-robots that will allow the manipulation of tissue from internal repositionable platforms. The use of magnetic anchoring and guidance systems (MAGS) might allow the external manoeuvring of intra-corporeal instruments to reduce clashing and facilitate triangulation. However, the final promise in minimally invasive surgery is natural orifice transluminal endoscopic surgery (NOTES), with its scarless technique. It remains to be seen whether NOTES, LESS, or any of these future developments will prove their clinical utility over standard laparoscopic methods. [ABSTRACT FROM AUTHOR]

OBJECTIVE: • To present complications and rates of conversion from LESS to conventional laparoscopy (CL) at the time of upper tract LESS urologic procedures. PATIENTS AND METHODS: • Patients undergoing LESS upper tract procedures between September, 2007 and November, 2008 ( n = 125) were identified at six high-volume academic centers pioneering urologic LESS procedures. All LESS procedures were performed transperitoneally via a single umbilical incision using either adjacent conventional trocars or a dedicated single-site accessdevice. Reconstructive procedures incorporating a single planned 2 mm accessory needle port were included as LESS procedures and were not consideredconversions. • Patients, undergoing LESS procedures requiring conversion to CL with the placement of additional ports were identified. Conversion was defined as the placement of additional 5 or 10/12 mm ports beyond the primary incision. In each case the operative reports were reviewed, the reason for conversion was determined, and the number and types of additional ports and complications were noted. RESULTS: • Upper tract LESS procedures were performed in 125 patients comprising 13.3% of the total 937 laparoscopic procedures performed at the participating institutions during this time period. Conversion to CL was necessary in 7 patients (5.6%) undergoing LESS requiring the addition of 2– 5 ports. • Reasons for conversion included:facilitate dissection in 3 (43%), facilitate reconstruction in 3 (43%), and control of bleeding in 1 (14%). All attempted LESS cases were completed laparoscopically without need for open conversion. • Complications occurred in 15.2% of patients undergoing LESS surgery. Three of the 7 patients that required conversion to CL developed postoperative complications (Clavien grade II in two and IIIa in one). • Limitations of this study included the inability to standardize LESS patient selection criteria, instrumentation andsurgical technique as well as the lack of available complete data from a CL control group for comparison. CONCLUSION: • LESS surgery is technically feasible for a variety of upper urinary tract reconstructive and ablative procedures, although it appears to be associated with higher rates of complications than in mature CL series. Conversion to CL occurs infrequently and may be a reflection of stringent patient selection. [ABSTRACT FROM AUTHOR]

OBJECTIVE We evaluated the feasibility and the potential advantages of a modification of the single-port laparoscopic radical prostatectomy using a periumbilical multichannel port plus a second port placed in the left fossa with the aim of having an adequate working angle during the most critical steps of the procedure. PATIENTS AND METHODS Between March and September 2009 we operated on five patients with early-stage prostate cancer (T1c) and a normal body mass index ( < 25). The procedure was carried out with a specially-designed multichannel trocar which contains two 5mm and one 10mm ports plus a 5mm port placed in the left iliac fossa in order to have an adequate working angle. The first two patients received a nerve sparing radical prostatectomy. RESULTS All cases were completed successfully in a mean operative time of 225 minutes (range 210-250) with blood losses of less than 100ml. All patients were discharged from the hospital in 3rd postoperative day and the catheter was always removed seven days from surgery. No intraoperative complications occurred. The pathological tumour stage revealed pT2bNo prostate cancer in all five cases without positive surgical margins. After a mean follow-up of 4 months (range 1-7) all patients have an undetectable prostate-specific antigen level and no postoperative early major complications. The first two patients were fully continent respectively after 3 and 8 weeks after surgery, the third patient uses one safety pad after three month from surgery. The last two patients have a moderate incontinence and are currently under rehabilitation. Regarding potency the first patient had intercourses without any therapies after two months from surgery while the second one (6 months follow up) has partial penile tumescence using oral vardenafil. CONCLUSION Two ports laparoscopic radical prostatectomy is feasible in very selected cases. However, our pilot study should be still considered a technical report and the limits of the technique must still be defined in a larger population and by other investigators. [ABSTRACT FROM AUTHOR]

The article presents the author views over deployment of minimally invasive surgery (MIS) for treatment of adrenal masses. Topics include illustration of evidence-based systematic review of European Association of Urology (EAU) over MIS adrenalectomy; recommendation for deployment of laparoscopy for benign adrenal masses treatment; enhancement in robot-assisted laparoscopy surgery; and determination of recurrence rate for adrenocortical carcinoma along with peritoneal carcinomatosis risk.

Laparoendoscopic single-site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTESTM) are new approaches to minimally invasive surgery. A number of technical challenges need to be overcome and new developments of equipment are required before widespread acceptance of either modality occurs. In this paper we discuss novel approaches and innovations as well as review examples of equipment and platforms that have previously been used for LESS and NOTES. Emphasis is given to urological applications. [ABSTRACT FROM AUTHOR]

Laparoscopic surgery is frequently used in urology and the introduction of the da Vinci surgical system has served to further increase the demand for these procedures. Yet, laparoscopy is not without its drawbacks including port site complications, such as bleeding, hernia, internal organ damage and scarring. To further decrease morbidity of standard laparoscopy, newer techniques such as laparoendoscopic single-site surgery (LESS) are currently being investigated. LESS is technically challenging and reduces instrument triangulation and robust retraction, and is associated with a steep learning curve. To help overcome current limitations we have introduced the da Vinci surgical system to LESS and report our experience with robotic laparoendoscopic single-site surgery. [ABSTRACT FROM AUTHOR]

We reviewed the preliminary advances in laparo-endoscopic single-site surgery ( LESS) as applied to renal surgery, and analyzed current publications based on animal models and human patients. We searched published reports in major urological meeting abstracts, Embase and Medline (1966 to 25 August 2008), with no language restrictions. Keyword searches included: ‘scarless’, ‘scar free’, ‘single port/trocar/incision’, ‘intraumbilical’, and ‘transumbilical’, ‘natural orifice transluminal endoscopic surgery’ (NOTES), ‘SILS’, ‘OPUS’ and ‘ LESS’. The lessons learnt from the studies using the porcine model are that further advances in instrumentation are essential to achieve optimum results, and that testing survival in animals is also necessary to further expand the NOTES and LESS techniques. Further advances in instrument technology together with increasing experience in NOTES and LESS approaches have driven the transition from porcine models to human patients. In the latter, studies show that the techniques are feasible provided that both optimal surgical technical expertise with advanced skills, and optimal instrumentation, are available. The next step towards minimal access/minimally invasive urological surgery is NOTES and LESS. It is inevitable that LESS will be extended to involve more complex and technically demanding procedures such as laparoscopic radical prostatectomy and partial nephrectomy. [ABSTRACT FROM AUTHOR]