Editorial Comment on: Evaluation of the Role of Laparoendoscopic Single-Site Surgery vs Minilaparoscopy for Treatment of Upper Urinary Tract Pathologies: Prospective Randomized Comparative Study by Abdel-Karim et al.

Enthusiasts have their own way of “pushing the envelope” for their preferred technique. Ever since our group reported the first ever laparoendoscopic single-site surgery (LESS) nephrectomy in 2007, several case series have been published extolling the advantages of either LESS ¹ or minilaparoscopy, ² but one really could not extrapolate any clear objective evidence of superiority of either technique on the basis of these articles.

It is, therefore, refreshing to comment on level 1 evidence from a properly designed randomized controlled trial comparing LESS with minilaparoscopy. The main author is clearly a skilled laparoscopic surgeon, and his team members are to be commended for putting this trial together in the current era of robot-assisted urologic surgery. They conclude that both techniques are technically challenging, feasible, and safe, with LESS techniques being associated with less postoperative pain, analgesic requirement, and better cosmetic outcome.

I agree with the conclusion with a caveat: this experience reflects the personal skills of the lead author, and as such great caution should be exercised before using the conclusions of this article as leverage to propound the advantages of either technique; simply put, the results may not be easily reproducible elsewhere.

LESS is in decline due in part to the lack of purpose-built instrumentation and the easier availability of robotic technology; the training and skills required to perform effective LESS procedures are arguably of a much higher magnitude than what would be required to become facile with conventional laparoscopy or robotic surgery. LESS will, therefore, continue to struggle to become a mainstream technique, and adoption appears to be restricted to those centers of excellence where the availability of robot-assisted technology is limited for whatever reason.