Editorial Comment for Ma et al.

A t the outset, I would like to congratulate the authors for conducting laparoendoscopic single-site (LESS) surgery in their country using an indigenous port. In this study, the authors have reported five cases of radical cystectomy and urinary diversion with LESS using a homemade single-port device composed of an inverted cone device of polycarbonate and a powder-free surgical glove at a single institution in China. One of five patients died after surgery and another one had a bowel obstruction. Patients also had a significant postoperative hospital stay of 19.5 (14–28) days. Interestingly, there is no mention of the number of lymph nodes removed, and none of the patients had lymph node positive disease despite T₂ and T_3a stages. The authors also performed an intrafascial nerve-sparing prostatectomy in one patient in this group.

Although it adds little new information to the known literature regarding the feasibility of LESS cystectomy, the current study provides valuable insight about their homemade port for LESS to reduce the cost. I did not observe any substantial benefits of LESS, maybe because of their initial cases or regional practice to keep patients for long time in the hospital.

The seminal work of Gettman and associates ¹ and Clayman and colleagues ² with the feasibility of transvaginal laparoscopic nephrectomy in the porcine model and in a female farm pig, respectively, generated interest for LESS. LESS was developed as a next step to natural orifice translumenal endoscopic surgery to prevent cross collision of instruments with a wider incision. LESS is a tremendous shift from a classic laparoscopy with goals of smaller incision, less pain, shortened convalescence, superior cosmesis with an equivalent efficacy to laparoscopic surgery. To use LESS, changes in laparoscopic instrumentation were needed, and these developments have resulted in a substantial increase in the use of LESS in urology over the past 5 years, although at a slow pace, in selected patients, and in the hands of experienced surgeons.

LESS radical cystoprostatectomy with pelvic lymphadenectomy with 2 years of follow-up has already been described. ³ It has also been reported with hybrid-LESS. ⁴ Desai and associates ⁵ have also reported a successful experience with their initial 100 patients using LESS for a variety of indications. While significant progress is being made in developing new ports and instrumentations, use of magnetic anchoring guidance systems has further augmented LESS. Use of a miniaturized robot and instrumentations will further expand the horizon of LESS.

A recent report of LESS from a worldwide multi-institutional analysis of 1076 cases is a testimony of interest in this field. ⁷ Future research is needed to elucidate differences in the intraoperative, perioperative, and postoperative benefits of LESS besides quality-of-life metrics in comparison with standard laparoscopy especially in major uro-oncology cases such as radical cystoprostatectomy and bilateral extended pelvic lymphadenectomy, where the bar is very high to achieve excellent oncologic and functional outcomes.