Laparoendoscopic Single-site Radical Prostatectomy – Is LESS Really More?
outcomes of LESS-RP to be on par with laparoscopic RP, but they did not demonstrate any clinically meaningful benefit. Future studies will need to assess patient quality of life in order to determine whether there is any advantage to LESS-RP.
LESS urological procedures are much more frequently performed for renal or upper tract interventions than for RP, but there is still relatively poor evidence comparing these interventions. To date there have only been two prospective randomised trials. Togcu et al. demonstrated that LESS simple nephrectomies resulted in favourable outcomes with regard to pain (visual analogue scale), post-operative use of analgesia and return to normal activities when compared with traditional laparoscopic nephrectomy.32
However the results of the study are limited by the small number of patients (27 in all) and the fact that the patients did not complete standardised quality-of-life questionnaires or any objective measure of scar satisfaction. In a second randomised study, 50 renal donors were randomised to standard multiport laparoscopy or LESS.33 The authors found that patients who underwent LESS procedures had lower pain scores after 48 hours and shorter hospital stays but no difference in analgesic use. They also demonstrated, using validated questionnaires, that patients had no perceived difference in quality of life, body image or cosmesis regardless of surgery type.
While some of these studies suggest that LESS procedures may have decreased pain and potentially shortened convalescence, larger studies are needed. These benefits, if demonstrated to be reproducible, must be weighed against the increased cost and increased difficulty that surgeons encounter performing these interventions.32,33
studies will need to specifically assess the impact of LESS-RP on sexual and urinary functional outcomes as well.
1. Walsh PC, Anatomic radical prostatectomy: evolution of the surgical technique, J Urol, 1998;160:2418–24.
2. Parsons JK, Bennett JL, Outcomes of retropubic, laparoscopic, and robotic-assisted prostatectomy, Urology, 2008;72:412–6.
3. Kaouk JH, Goel RK, Haber GP, et al., Single-port laparoscopic radical prostatectomy, Urology, 2008;72:1190–3.
4. White MA, Haber GP, Autorino R, et al., Robotic laparoendoscopic single-site radical prostatectomy: technique and early outcomes, Eur Urol, 2010;58:544–50.
5. Silberstein J, Power N, Touijer K, Laparoendoscopic single site (LESS) radical prostatectomy:a review of the initial experience, Minerva Urol Nefrol, 2011;63:123–9.
6. Gill IS, Advincula AP, Aron M, et al., Consensus statement of the consortium for laparoendoscopic single-site surgery, Surg Endosc, 2010;24:762–8.
7. Botden S, Strijkers R, Fransen S, et al., The use of curved vs. straight instruments in single port access surgery, on standardized box trainer tasks, Surg Endosc, 2011;25:2703–10.
8. Stolzenburg JU, Kallidonis P, Oh MA, et al., Comparative assessment of laparoscopic single-site surgery instruments to conventional laparoscopic in laboratory setting, J Endourol, 2011;24:239–45.
9. Derweesh IH, Silberstein JL, Bazzi W, et al., Laparo-endoscopic single-site surgery for radical and cytoreductive nephrectomy, renal vein thrombectomy, and partial nephrectomy: a prospective pilot evaluation, Diagn Ther Endosc, 2010:2010;1–8.
10. Dindo D, Demartines N, Clavien PA, Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey, Ann Surg, 2004;240:205–13.
11. Bachiller Burgos J, Alonso Flores J, Sanchez De La Vega J, et al., [Early experience in laparoscopic radical prostatectomy using the laparoscopic device for umbilical access SILS Port], Actas Urol Esp, 2010;34:495–9.
12. Ferrara V, Giannubilo W, Azizi B, et al., SILS extraperitoneal radical prostatectomy, Minerva Urol Nefrol, 2010;62:363–9.
13. Stein RJ, White WM, Goel RK, et al., Robotic laparoendoscopic single-site surgery using GelPort as the
LESS-RP is a novel concept that has already resulted in the expansion of new surgical technologies. It is important to note that the primary reason for performing RP is to provide patients with excellent oncological control while minimising impact on quality of life. LESS-RP currently does not offer improved visualisation, it does not facilitate complex interventions and it does not provide improved ergonomics to the surgeon. At best, it may result in slightly shorter convalescence and improved cosmesis. These benefits have yet to be convincingly demonstrated and if they exist, the magnitude and clinical significance is likely small. It is unlikely that the addition of one or two additional 5 mm ports will make large differences with respect to pain or patient satisfaction.
Robot-assisted RP has gained rapid acceptance in the US and this has come at great economic cost to US healthcare. Though robot-assisted laparoscopic prostatectomy (RALP) results in less blood loss and perhaps slightly shorter convalescence than open surgery, the benefits in oncological, sexual or urinary functional outcomes have not been realised. In fact, it has recently been demonstrated that patient satisfaction following RP may be determined more by pre-operative expectations than by surgical approach or incision size.34
for the rapid adoption of RALP despite a lack of important advantages are multiple. Until a high level of evidence (if possible) is available to prove that the new technology offers solutions and ease to surgeons or better outcomes to patients, the enthusiasm may be better served by focusing on problem solving rather than fascination with novelty.35,36 LESS is creative unequivocally. At this time, however, LESS is challenging engineering by posing the question: ‘this is where we want to go, can you get us there safely?’ n
access platform, Eur Urol, 2010;57:132–6.
14. Barret E, Sanchez-Salas R, Cathelineau X, et al., Re: Initial complete laparoendoscopic single-site surgery robotic assisted radical prostatectomy (LESS-RARP), Int Braz J Urol, 2009;35:92–3.
15. Barret E, Sanchez-Salas R, Kasraeian A, et al., A transition to laparoendoscopic single-site surgery (LESS) radical prostatectomy: human cadaver experimental and initial clinical experience, J Endourol, 2009;23:135–40.
16. Leewansangtong S, Vorrakitkatorn P, Amornvesukit T, et al., Laparo-endoscopic single site (LESS) robotic radical prostatectomy in an Asian man with prostate cancer: an initial case report, J Med Assoc Thai, 2010;93:383–7.
17. White WM, Haber GP, Goel RK, et al., Single-port urological surgery: single-center experience with the first 100 cases, Urology, 2009;74:801–4.
18. Leveillee RJ, Castle SM, Gorin MA, et al., Initial Experience with Laparoendoscopic Single-Site Simple Nephrectomy Using the TransEnterix SPIDER Surgical System: Assessing Feasibility and Safety, J Endourol, 2011;25:923–5.
19. Haber GP, Autorino R, Laydner H, et al., SPIDER Surgical System for Urologic Procedures With Laparoendoscopic Single-Site Surgery: From Initial Laboratory Experience to First Clinical Application, Eur Urol, 2011; [Epub ahead of print].
20. Gettman MT, Lotan Y, Napper CA, et al., Transvaginal laparoscopic nephrectomy: development and feasibility in the porcine model, Urology, 2002;59:446–50.
21. Kaouk JH, Haber GP, Goel RK, et al., Pure natural orifice translumenal endoscopic surgery (NOTES) transvaginal nephrectomy, Eur Urol, 2010;57:723–6.
22. Alcaraz A, Peri L, Molina A, et al., Feasibility of transvaginal NOTES-assisted laparoscopic nephrectomy, Eur Urol, 2010;57:233–7.
23. Swain P, Nephrectomy and natural orifice translumenal endoscopy (NOTES): transvaginal, transgastric, transrectal, and transvesical approaches, J Endourol, 2008;22:811–8.
24. Bazzi WM, Wagner O, Stroup SP, et al., Transrectal hybrid natural orifice transluminal endoscopic surgery (NOTES) nephrectomy in a porcine model, Urology, 2011;77:518–23. 25. Humphreys MR, Krambeck AE, Andrews PE, et al., Natural
orifice translumenal endoscopic surgical radical prostatectomy: proof of concept, J Endourol, 2009;23:669–75.
26. Park S, Bergs RA, Eberhart R, et al., Trocar-less instrumentation for laparoscopy: magnetic positioning of intra-abdominal camera and retractor, Ann Surg, 2007;245:37–84.
27. Power N, Power A, Reducing port sites: evaluation and introduction of a novel fan retractor, Presented at: the American Urological Association Annual Meeting, San Antonio, Texas, 21–26 May, 2005.
28. Cadeddu JA, Porcine nephrectomy using magnetically anchored laparoscopic instruments, Presented at: the American Urological Association Annual Meeting, San Antonio, Texas, 21–26 May, 2005.
29. Zeltser IS, Cadeddu JA, A novel magnetic anchoring and guidance system to facilitate single trocar laparoscopic nephrectomy, Curr Urol Rep, 2008;9:62–4.
30. Raman JD, Bergs RA, Fernandez R, et al., Complete transvaginal NOTES nephrectomy using magnetically anchored instrumentation, J Endourol, 2009;23:367–71.
31. Cadeddu J, Fernandez R, Desai M, et al., Novel magnetically guided intra-abdominal camera to facilitate laparoendoscopic single-site surgery: initial human experience, Surg Endosc, 2009;23:1894–9.
32. Tugcu V, Ilbey YO, Mutlu B, et al., Laparoendoscopic single-site surgery versus standard laparoscopic simple nephrectomy: a prospective randomized study, J Endourol, 2010;24:1315–20.
33. Kurien A, Rajapurkar S, Sinha L, et al., First prize: standard laparoscopic donor nephrectomy versus laparoendoscopic single-site donor nephrectomy: a randomized comparative study, J Endourol, 2011;25:365–70.
34. Schroeck FR, Krupski TL, Sun L, et al., Satisfaction and regret after open retropubic or robot-assisted laparoscopic radical prostatectomy, Eur Urol, 2008;54:785.
35. Touijer K, Marketing versus science: a fight between necessary evil and stern good over the adoption of new technology in medicine, Eur Urol, 2010;58:522–4.
36. Leff B, Finucane TE, Gizmo idolatry, JAMA, 2008;299:1830–2.
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