Editorial Comment for Seideman et al.

S ometimes progress is made in giant leaps. Other times, progress is accomplished through small steps that offer incremental benefits in their own right, or that ultimately, through a series of such small steps, result in major change. The move from a large open flank incision to three keyhole incisions represented a giant leap, a surgical revolution. The pursuit of laparoendoscopic single-site (LESS) surgery or robot-assisted LESS (R-LESS) has not yet proven to be such a monumental step forward. LESS appears to be more of an evolutionary step, helping to drive technology and spur innovation.

The authors present a clear technical road map for how to “take on” R-LESS pyeloplasty, but is LESS, or R-LESS, a worthwhile technique for urologists to embrace? Opinions vary. If one is interested in LESS/R-LESS, however, it is likely our young healthy patients with ureteropelvic junction obstruction who are most likely to benefit. As demonstrated by this same pioneering group, patients with benign disease have the most interest in cosmesis and limiting the number of incisions. ¹ As endourologists, it would certainly be in keeping with our central principles to attempt to limit the disfigurement associated with our interventions.

The claims presented by the authors are that R-LESS reduces the difficulty of LESS and shortens the learning curve. The degree to which these conclusions hold true will significantly impact the diffusion of single-site surgery in urology. Even laparoscopic radical nephrectomy, let alone LESS pyeloplasty, is underutilized. ² This highlights the obvious fact that for a minimally invasive procedure to diffuse widely, it must not be overly technically demanding, especially if other forces (financial, industry, and/or marketing) are not putting pressure on practice patterns. ³ For LESS to grow into a commonplace technique, it simply must be made easier. As it is currently practiced, LESS may not produce enough “juice” to warrant “all the squeezing.”

Without doubt, robotic systems will be developed that will make R-LESS simple and straightforward. Until such time, we are left trying to force current robotic platforms to succumb to our will. Do the techniques described here make R-LESS with the current da Vinci Si system straightforward enough to gain widespread acceptance? You be the judge.