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Complications And Conversions Of Upper Tract Urologic Laparoendoscopic Single-Site Surgery (Less): Multi-Center Experience Results from the NOTES Working Group
Brian H. Irwin, MD1, Jeffrey A. Cadeddu, MD2, Chad R. Tracy, MD2, Fernando J. Kim, MD3, Wilson R. Molina, MD3, Abhay Rane, MD4, Chandru P. Sundaram, MD5, James H. Raybourne, III, MD5, Robert J. Stein, MD6, Inderbir S. Gill, MD7, Louis R. Kavoussi, MD8, Lee Richstone, MD8, Mihir M. Desai, MD7.
1University of Vermont College of Medicine, Burlington, VT, USA, 2University of Texas Southwestern Medical Center, Dallas, TX, USA, 3Tony Grampsas Cancer Center, University of Colorado Health Sciences Center, Denver, CO, USA, 4East Surrey Hospital, East Sussex, United Kingdom, 5Indiana University, Indianapolis, IN, USA, 61Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH, USA, 7Keck School of Medicine, University of Southern California, Los Angeles, CA, USA, 8The Smith Institute for Urology, The North-Shore Long Island Jewish Health System, New York, NY, USA.

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
ProcedureAge (years)BMI (kg/m2)EBL (ml)Operative Time (min.)Number of Added PortsTypes of Added PortsReason for ConversionComplications
Case 1Simple nephrectomy6130.32503003One 5mm,
Two 12mm
Aid in dissectionDVT requiring anticoagulation for 3 monthsII
Case 2Nephroureterectomy (with open bladder cuff excision)7531.64002253One 5mm,
Two 12mm
Control bleedingNone
Case 3Renal cyst excision4745.7201652Two stab incisionsAid in dissectionNone
Case 4Pyeloplasty5323.6502405Five 5mmAid in reconstructionNone
Case 5Pyeloplasty2935.8502482One 5mm,
One 12mm
Aid in dissectionNone
Case 6Partial nephrectomy6629.35003302One 5mm,
One 12mm
Aid in reconstructionBlood loss anemia requiring transfusion of 2 units pRBC’sII
Case 7Ileal ureteral interposition (with extracorporeal ileal harvest via umbilical incision)2323.92504203Two 2mm
One 5m
Aid in reconstructionUrine leak resolved with nephrostomy tube placement/ percutaneous urinoma drainageIIIa
Mean (Mode)50.631.4217275(2)

Superscripts indicate complication grade according to Clavien classification system
Table 2. LESS complications - subanalysis by reconstructive nature of procedure
NComplicationsTypes of Complications
Non-reconstructive Procedures776 (7.8)
Simple nephrectomy374 (10.8)Post-op fever (n=1)I
Port-site hematoma (n=1)I
DVT (n=1)II
Duodenal injury (n=1)IIIb
Donor nephrectomy182 (11.1)Corneal abrasion (n=1)II
Anti-emetic-induced dyskinesia (n=1)I
Cryoablation of renal
tumor
120 (0)
Radical nephrectomy50 (0)
Renal cyst excision20 (0)
Nephroureterectomy20 (0)
Adrenalectomy10 (0)
Reconstructive Procedures4813 (27.1)
Pyeloplasty359 (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 Nephrectomy83 (37.5)Post-operative hemorrhage (n=3)
• Two required angioembolizationIIIa
• One developed infected hematoma
with MRSA bacteremiaIIIa
Ileal ureteral
interposition
31 (33.3)Urine leak (n=1)IIIa
Ureteroneocystostomy20 (0)

Superscripts indicate complication grade according to Clavien classification system

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