Editorial Comment on: The Decline of Laparoendoscopic Single-Site Surgery: A Survey of the Endourological Society to Identify Shortcomings and Guidance for Future Directions by Sorokin et al . (From: Sorokin I,Canvasser NE,Irwin B,et al. J Endourol 2017;31:1049–1055)

Laparoendoscopic single-site surgery (LESS) was introduced to urology in 2007 with significant fanfare and enthusiasm as “the next best thing” in minimally invasive surgery (MIS). ^{1 –4} In this issue of the journal, Sorokin et al. provide some sobering realities on the current status of LESS in urology. ⁵ Using a 15-question survey sent to all members of the Endourological Society, the authors have characterized the utilization of LESS as well as factors contributing to future success. Questionnaires were sent to 2800 society members, but only those members who had performed LESS were asked to respond. Indeed, responses were seen from only 106 urologists (<4%). From the low response rate alone, one might argue that the uptake of LESS was never high and that this approach is now largely of historical interest.

Data from the 106 urologists, however, do provide some interesting observations. For instance, significant opportunity still exists to advance MIS when one considers the majority of LESS respondents were from academic practices (85%) and used nonrobotic approaches (78%). Among survey respondents, uptake of LESS was never particularly high with only a minority of urologists (17%) performing >30 procedures in their peak year and 60% (n = 63) indicating that they had not performed any procedures in the last year. In addition, 49% of respondents reported that they have performed <25 procedures in their entire career. Collectively, these data would suggest that LESS still remains largely a nascent field without an adequate sample of cases to fully evaluate the value. In addition, most of the cases performed with LESS have been renal procedures (radical nephrectomy, simple nephrectomy, and pyeloplasty), potentially since the pioneers were predominantly renal surgeons. ^{1 –4,6} This suggests that ideal LESS applications still might not yet be fully understood.

The study found that respondents were initially drawn to LESS mostly with the hope that LESS would improve cosmesis and speed recovery. To date, the literature on the former factor is mixed while postoperative recovery after LESS is largely no different than standard laparoscopy. ⁶ In contrast, motivations such as novelty of the approach, staying current with the field, marketing, and scientific inquiry were also mentioned as justifications for evaluating LESS. As an unintended consequence, LESS has also spurred interest in other ways to advance MIS with contributions such as hidden incision strategies for standard laparoscopic and robotic techniques. ⁷

The current survey has clearly shown that enthusiasm for LESS has dampened over time by patient interest, cost, safety, and robotic adaptability. ⁸ Busy clinical practices and the relatively narrow focus of ideal LESS candidates (patients with body mass index <30 and no prior abdominal surgery) were likely other contributing factors. In addition, the simple fact is that the LESS learning curve is daunting. These realizations did lead to innovation and adaptation of existing robotic systems to facilitate LESS with modest success, yet similar issues with an undesirable learning curve, suboptimal technical functionality, increased costs, and inconclusive patient-related benefits. ⁶ Although the use of a robotic system is reported as the pathway forward for LESS to succeed, ⁵ it also appears that this must be a purpose-built robot with the same or improved performance of the current multiport robots with comparable cost and a very short learning curve.

At the onset of LESS in urology, it was stated that LESS must match or exceed the efficacy and safety of other accepted minimally invasive techniques in the realm of efficiency, effectiveness, economy, and equanimity (i.e., patient convalescence, morbidity, pain, and cosmesis). ¹ Now 10 years later, it would be easy for one to say that LESS has largely missed the mark. By merging anticipated new robotic systems with other exciting technologies (imaging, navigation, and energy ablation), there is renewed hope, however, that the stated goals of LESS may be achieved in the near future.