NEAUA 79th Annual Meeting Abstracts

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Background: Laparoendoscopic Single-site Surgery (LESS) is a recent extension of laparoscopy whereby a variety of urologic reconstructive and extirpative procedures are performed through a single skin incision.
We present complications and rates of conversion from LESS to conventional laparoscopy (CL) at the time of upper tract LESS urologic procedures.
Methods: Patients undergoing LESS upper tract procedures between September, 2007 and November, 2008 (n=125) were identified at six high-volume academic centers pioneering urologic LESS procedures. All LESS procedures were performed transperitoneally via a single umbilical incision using either adjacent conventional trocars or a dedicated single-site access device. Reconstructive procedures incorporating a single planned 2mm accessory needle port were included as LESS procedures and were not considered conversions. Patients, undergoing LESS procedures requiring conversion to CL with the placement of additional ports were identified. Conversion was defined as the placement of additional 5 or 10/12 mm ports beyond the primary incision. In each case the operative reports were reviewed, the reason for conversion was determined, and the number and types of additional ports and complications were noted.
Results: Upper tract LESS procedures were performed in 125 patients comprising 13.3% of the total 937 laparoscopic procedures performed at the participating institutions during this time peiord. Conversion to CL was necessary in 7 patients (5.6%) undergoing LESS requiring the addition of 2-5 ports. Reasons for conversion included: facilitate dissection in 3 (43%), facilitate reconstruction in 3 (43%), and control of bleeding in 1 (14%). All attempted LESS cases were completed laparoscopically without need for open conversion. Complications occurred in 15.2% of patients undergoing LESS surgery. Three of the 7 patients that required conversion to CL developed postoperative complications (Clavien grade II in two and IIIa in one). Limitations of this study included the inability to standardize LESS patient selection criteria, instrumentation and surgical technique as well as the lack of available complete data from a CL control group for comparison.
Conclusions: LESS surgery is technically feasible for a variety of upper urinary tract reconstructive and ablative procedures, although it appears to be associated with higher rates of complications than in mature CL series. Conversion to CL occurs infrequently and may be a reflection of stringent patient selection.
atient selection.

Table 1. Patient demographics and perioperative details of LESS procedures requiring conversion to conventional laparoscopy for completion
	Procedure	Age (years)	BMI (kg/m2)	EBL (ml)	Operative Time (min.)	Number of Added Ports	Types of Added Ports	Reason for Conversion	Complications
Case 1	Simple nephrectomy	61	30.3	250	300	3	One 5mm, Two 12mm	Aid in dissection	DVT requiring anticoagulation for 3 monthsII
Case 2	Nephroureterectomy (with open bladder cuff excision)	75	31.6	400	225	3	One 5mm, Two 12mm	Control bleeding	None
Case 3	Renal cyst excision	47	45.7	20	165	2	Two stab incisions	Aid in dissection	None
Case 4	Pyeloplasty	53	23.6	50	240	5	Five 5mm	Aid in reconstruction	None
Case 5	Pyeloplasty	29	35.8	50	248	2	One 5mm, One 12mm	Aid in dissection	None
Case 6	Partial nephrectomy	66	29.3	500	330	2	One 5mm, One 12mm	Aid in reconstruction	Blood loss anemia requiring transfusion of 2 units pRBC’sII
Case 7	Ileal ureteral interposition (with extracorporeal ileal harvest via umbilical incision)	23	23.9	250	420	3	Two 2mm One 5m	Aid in reconstruction	Urine leak resolved with nephrostomy tube placement/ percutaneous urinoma drainageIIIa
Mean (Mode)		50.6	31.4	217	275	(2)

Superscripts indicate complication grade according to Clavien classification system

Table 2. LESS complications - subanalysis by reconstructive nature of procedure
	N	Complications	Types of Complications
Non-reconstructive Procedures	77	6 (7.8)
Simple nephrectomy	37	4 (10.8)	Post-op fever (n=1)I Port-site hematoma (n=1)I DVT (n=1)II Duodenal injury (n=1)IIIb
Donor nephrectomy	18	2 (11.1)	Corneal abrasion (n=1)II Anti-emetic-induced dyskinesia (n=1)I
Cryoablation of renal tumor	12	0 (0)
Radical nephrectomy	5	0 (0)
Renal cyst excision	2	0 (0)
Nephroureterectomy	2	0 (0)
Adrenalectomy	1	0 (0)
Reconstructive Procedures	48	13 (27.1)
Pyeloplasty	35	9 (25.7)	Post-operative obstruction (n=3) • Two clinically insignificant radiographic findings in asymptomatic patients • One required stenting with subsequent resolutionIIIa Urinary tract infection (n=2)II Urine leak (n=2)IIIa Hematuria (n=1)I Upper extremity neuropraxia (n=1)I
Partial Nephrectomy	8	3 (37.5)	Post-operative hemorrhage (n=3) • Two required angioembolizationIIIa • One developed infected hematoma with MRSA bacteremiaIIIa
Ileal ureteral interposition	3	1 (33.3)	Urine leak (n=1)IIIa
Ureteroneocystostomy	2	0 (0)

Superscripts indicate complication grade according to Clavien classification system