Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Laparoendoscopic single site surgery (LESS) is a novel technique for performing a variety of procedures including Urological upper tract reconstructive surgery. As of now few studies have compared perioperative factors and outcomes between LESS and standard laparoscopic or robotic approaches. In this comparison between LESS and standard laparoscopic pyeloplasty we identified no significant differences in terms of narcotic requirements, quality of life indicators, and outcomes although prospective evaluation is needed. OBJECTIVE • To compare laparoendoscopic single‐site (LESS) and standard laparoscopic pyeloplasty procedures with the aim of defining whether perioperative, recovery or health‐related quality of life (HRQL) benefits exist for the LESS procedure. PATIENTS AND METHODS • From November 2007 to August 2008, sixteen patients underwent LESS pyeloplasty at a tertiary care referral centre. These patients were compared with a matched cohort of patients undergoing standard laparoscopic pyeloplasty. • Matching criteria included gender and age (within 10 years), as well as preoperative degree of obstruction (T½ within 15 min) and differential renal function (within 10% ipsilaterally) based on diuretic radionuclide scanning. Mean follow‐up was 13 ± 4 months for the LESS group and 17 ± 3 months for the standard laparoscopic group. • LESS pyeloplasty procedures were all performed using a single‐port device in the umbilicus and suturing was assisted with a 2‐mm grasping instrument. Perioperative variables, successful relief of obstruction and HRQL measurements were compared between the two groups. RESULTS • Except for a lower body mass index in the LESS group (23 ± 6 kg/m2 vs 30 ± 7 kg/m2, P= 0.002), no difference was noted for perioperative variables between the two cohorts, including hospital stay and analgesic requirement. • No significant HRQL advantage was noted for either group based on a six‐item non‐validated questionnaire. • All patients in both groups experienced clinical resolution of their symptoms. A patient in the standard laparoscopy group and two patients in the LESS group had T½ > 20 min (0.063% vs 0.125%, P= 1.00) on diuretic radionuclide scanning. • Limitations include the retrospective nature of the present study, as well as the relatively small study population and short follow‐up. CONCLUSIONS • No benefit was noted for LESS pyeloplasty over the standard laparoscopic procedure beyond aesthetic advantages. • Further comparisons are needed to determine whether these results are generalizable to other LESS procedures.
Study Type – Therapy (case series) Level of Evidence 4 OBJECTIVE To present our experience with single‐port transvesical enucleation of the prostate (STEP) in 34 patients with large‐volume benign prostatic hyperplasia (BPH). PATIENTS AND METHODS We performed STEP in 34 patients with large volume (>60 g) BPH (mean age 69 years, body mass index 26 kg/m2, and American Society of Anesthesiology class 2). The mean prostate volume estimated by transrectal ultrasonography was 102.5 mL and the mean baseline prostate‐specific antigen level was 6.7 ng/mL. A novel single‐port device was inserted percutaneously into the bladder through a 2–3 cm incision in the suprapubic skin crease. After establishing pneumovesicum, the prostate adenoma was enucleated transvesically using standard laparoscopic instruments, and the adenoma was extracted in pieces through the port. Digital assistance expedited enucleation of the apical adenoma in 19 (55%) cases. RESULTS Transvesical enucleation was completed in all 34 cases; the mean operative duration was 116 min, and the estimated blood loss was 460 mL. There was one death from postoperative bleeding from uncontrolled coagulopathy in a Jehovah’s Witness who refused a transfusion of blood and blood products. There were three complications during STEP (one death, one bowel injury and one haemorrhage) and five afterwards (four bleeding, one epididymo‐orchitis). Open conversion was necessary in two patients for complications, and extension of the skin incision by 1–2 cm was necessary in two to expedite apical digital enucleation. The mean hospital stay was 3 days and mean analogue pain score at discharge was 2. All 33 patients (excluding the patient who died) were voiding spontaneously at a maximum follow‐up of 8 months, with a mean American Urologic Association symptom score of 3, a maximum urinary flow rate of 44 mL/s, and a postvoid residual of 30 mL at the latest follow‐up. No patient developed urinary incontinence. CONCLUSIONS STEP is an effective treatment option for selected patients with large‐volume obstructive BPH. Under pneumovesicum using laparoscopic visualization, the entire adenoma can be effectively enucleated and expeditiously extracted through the novel single port. Comparison of the STEP procedure with other open and transurethral techniques will determine its place in the surgical treatment of large‐volume BPH.
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