LESS: Upper Tract, Lower Tract, and Robotic Surgery

  • Woong Kyu HanEmail author
  • Young Eun Yoon


Since the beginning of the laparoscopic surgery in urologic field, many kinds of urological surgeries have been performed laparoscopically. A laparo-endoscopic single-site surgery (LESS) using only one access port was devised due to the desire of doctors and patients to leave less wound and postoperative pain than conventional laparoscopic surgery, which needed multi-ports. Almost all urological laparoscopic operations have been tried and reported with single port due to the development of surgical instruments and techniques. However, it is still not mainly performed in many hospitals because of the drawbacks of long operation time and relatively long learning curve compared to conventional laparoscopic surgery. Recently, the frequency of LESS has been more decreasing because robot surgery has replaced many laparoscopic procedures.

However, LESS is still one option of the most minimally invasive surgery for various urologic disease. In recent years, lots of robotic surgical systems are being developed based on single port, further development of LESS is expected. In this chapter, we will learn the history of urologic LESS and basic instruments. Further, most commonly performed urologic LESSs, such as radical nephrectomy, partial nephrectomy, pyeloplasty, and radical prostatectomy, would be described. We will also look into the recent status of robotic LESS and the robotic LESS systems to be developed in the future.


Laparoendoscopic single-site surgery Single-port surgery NOTES Minimal invasive surgery Robot-assisted surgery 



We would like to thank Dr. Hyung Ho Lee, Dr. Joon Chae Na and Dong Soo Jang for their support with medical illustrations.


  1. Aron M, Canes D, Desai MM, Haber GP, Kaouk JH, Gill IS. Transumbilical single-port laparoscopic partial nephrectomy. BJU Int. 2009;103(4):516–21.PubMedGoogle Scholar
  2. Box G, Averch T, Cadeddu J, Cherullo E, Clayman R, Desai M, Frank I, Gettman M, Gill I, Gupta M, Haber GP, Kaouk J, Landman J, Lima E, Ponsky L, Rane A, Sawyer M, Humphreys M. Nomenclature of natural orifice translumenal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS) procedures in urology. J Endourol. 2008;22(11):2575–81.PubMedGoogle Scholar
  3. Brandao LF, Laydner H, Zargar H, Torricelli F, Andreoni C, Kaouk J, Autorino R. Laparoendoscopic single site surgery versus conventional laparoscopy for transperitoneal pyeloplasty: a systematic review and meta-analysis. Urol Ann. 2015;7(3):289–96.PubMedPubMedCentralGoogle Scholar
  4. Buffi NM, Lughezzani G, Fossati N, Lazzeri M, Guazzoni G, Lista G, Larcher A, Abrate A, Fiori C, Cestari A, Porpiglia F. Robot-assisted, single-site, dismembered pyeloplasty for ureteropelvic junction obstruction with the new da Vinci platform: a stage 2a study. Eur Urol. 2015;67(1):151–6.PubMedGoogle Scholar
  5. Canes D, Desai MM, Aron M, Haber GP, Goel RK, Stein RJ, Kaouk JH, Gill IS. Transumbilical single-port surgery: evolution and current status. Eur Urol. 2008;54(5):1020–9.PubMedGoogle Scholar
  6. Cestari A, Buffi NM, Lista G, Lughezzani G, Larcher A, Lazzeri M, Sangalli M, Rigatti P, Guazzoni G. Feasibility and preliminary clinical outcomes of robotic laparoendoscopic single-site (R-LESS) pyeloplasty using a new single-port platform. Eur Urol. 2012;62(1):175–9.PubMedGoogle Scholar
  7. Cheng J, Chen J, Sheng X, Xu Y, Bao Y, Xiao L, Liu B, Wu Z, Wang L, Sun Y. Oncologic and functional outcomes of laparoendoscopic single-site radical nephrectomy for localized kidney cancer: a single surgeon’s series with a minimum of 3-year follow-up. J Endourol. 2015;29(11):1242–7.PubMedGoogle Scholar
  8. Choi KH, Ham WS, Rha KH, Lee JW, Jeon HG, Arkoncel FR, Yang SC, Han WK. Laparoendoscopic single-site surgeries: a single-center experience of 171 consecutive cases. Korean J Urol. 2011;52(1):31–8.PubMedPubMedCentralGoogle Scholar
  9. Chung SD, Huang CY, Wang SM, Tai HC, Tsai YC, Chueh SC. Laparoendoscopic single-site (LESS) retroperitoneal adrenalectomy using a homemade single-access platform and standard laparoscopic instruments. Surg Endosc. 2011;25(4):1251–6.PubMedGoogle Scholar
  10. Clayman RV, Kavoussi LR, Soper NJ, Dierks SM, Meretyk S, Darcy MD, Roemer FD, Pingleton ED, Thomson PG, Long SR. Laparoscopic nephrectomy: initial case report. J Urol. 1991;146(2):278–82.PubMedGoogle Scholar
  11. Cobellis G, Torino G, Noviello C, Cruccetti A, Mastroianni L, Amici G, Martino A. Versatility of one-trocar surgery in children. J Laparoendosc Adv Surg Tech A. 2011;21(6):549–54.PubMedGoogle Scholar
  12. Corcione F, Bracale U, Pirozzi F, Cuccurullo D, Angelini PL. Robotic single-access splenectomy using the Da Vinci Single-Site(R) platform: a case report. Int J Med Robot. 2014;10(1):103–6.PubMedGoogle Scholar
  13. Cox DR, Zeng W, Frisella MM, Brunt LM. Analysis of standard multiport versus single-site access for laparoscopic skills training. Surg Endosc. 2011;25(4):1238–44.PubMedGoogle Scholar
  14. Desai MM, Fareed K, Berger AK, Astigueta JC, Irwin BH, Aron M, Ulchaker J, Sotelo R. Single-port transvesical enucleation of the prostate: a clinical report of 34 cases. BJU Int. 2010;105(9):1296–300.PubMedGoogle Scholar
  15. Gao X, Pang J, Si-tu J, Luo Y, Zhang H, Li LY, Zhang Y. Single-port transvesical laparoscopic radical prostatectomy for organ-confined prostate cancer: technique and outcomes. BJU Int. 2013;112(7):944–52.PubMedGoogle Scholar
  16. Gill IS, Cherullo EE, Meraney AM, Borsuk F, Murphy DP, Falcone T. Vaginal extraction of the intact specimen following laparoscopic radical nephrectomy. J Urol. 2002;167(1):238–41.PubMedGoogle Scholar
  17. Gill IS, Canes D, Aron M, Haber GP, Goldfarb DA, Flechner S, Desai MR, Kaouk JH, Desai MM. Single port transumbilical (E-NOTES) donor nephrectomy. J Urol. 2008;180(2):637–41; discussion 41.PubMedGoogle Scholar
  18. Haber GP, Crouzet S, Kamoi K, Berger A, Aron M, Goel R, Canes D, Desai M, Gill IS, Kaouk JH. Robotic NOTES (Natural Orifice Translumenal Endoscopic Surgery) in reconstructive urology: initial laboratory experience. Urology. 2008;71(6):996–1000.PubMedGoogle Scholar
  19. Han WK, Park YH, Jeon HG, Jeong W, Rha KH, Choi H, Kim HH. The feasibility of laparoendoscopic single-site nephrectomy: initial experience using home-made single-port device. Urology. 2010;76(4):862–5.PubMedGoogle Scholar
  20. Han WK, Kim DS, Jeon HG, Jeong W, Oh CK, Choi KH, Lorenzo EI, Rha KH. Robot-assisted laparoendoscopic single-site surgery: partial nephrectomy for renal malignancy. Urology. 2011;77(3):612–6.PubMedGoogle Scholar
  21. Jeon HG, Jeong W, Oh CK, Lorenzo EI, Ham WS, Rha KH, Han WK. Initial experience with 50 laparoendoscopic single site surgeries using a homemade, single port device at a single center. J Urol. 2010a;183(5):1866–71.PubMedGoogle Scholar
  22. Jeon HG, Kim DS, Jeoung HB, Han SW, Hong CH, Im YJ, Oh YT, Kim MJ, Han WK. Pediatric laparoendoscopic single-site partial nephrectomy: initial report. Urology. 2010b;76(1):138–41.PubMedGoogle Scholar
  23. Joseph RA, Goh AC, Cuevas SP, Donovan MA, Kauffman MG, Salas NA, Miles B, Bass BL, Dunkin BJ. “Chopstick” surgery: a novel technique improves surgeon performance and eliminates arm collision in robotic single-incision laparoscopic surgery. Surg Endosc. 2010;24(6):1331–5.PubMedGoogle Scholar
  24. Ju SH, Lee DG, Lee JH, Baek MK, Jeong BC, Jeon SS, Lee KS, Han DH. Laparoendoscopic single-site pyeloplasty using additional 2 mm instruments: a comparison with conventional laparoscopic pyeloplasty. Korean J Urol. 2011;52(9):616–21.PubMedPubMedCentralGoogle Scholar
  25. Kaouk JH, Goel RK. Single-port laparoscopic and robotic partial nephrectomy. Eur Urol. 2009;55(5):1163–9.PubMedGoogle Scholar
  26. Kaouk JH, Goel RK, Haber GP, Crouzet S, Desai MM, Gill IS. Single-port laparoscopic radical prostatectomy. Urology. 2008;72(6):1190–3.PubMedGoogle Scholar
  27. Kaouk JH, Goel RK, Haber GP, Crouzet S, Stein RJ. Robotic single-port transumbilical surgery in humans: initial report. BJU Int. 2009;103(3):366–9.PubMedGoogle Scholar
  28. Kaouk JH, Haber GP, Autorino R, Crouzet S, Ouzzane A, Flamand V, Villers A. A novel robotic system for single-port urologic surgery: first clinical investigation. Eur Urol. 2014;66(6):1033–43.PubMedGoogle Scholar
  29. Komninos C, Tuliao P, Kim DK, Choi YD, Chung BH, Rha KH. Robot-assisted laparoendoscopic single-site partial nephrectomy with the novel da vinci single-site platform: initial experience. Korean J Urol. 2014;55(6):380–4.PubMedPubMedCentralGoogle Scholar
  30. Kroh M, El-Hayek K, Rosenblatt S, Chand B, Escobar P, Kaouk J, Chalikonda S. First human surgery with a novel single-port robotic system: cholecystectomy using the da Vinci Single-Site platform. Surg Endosc. 2011;25(11):3566–73.PubMedGoogle Scholar
  31. Lee SR. Robotic Single-Site(R) sacrocolpopexy: first report and technique using the Single-Site(R) wristed needle driver. Yonsei Med J. 2016;57(4):1029–33.PubMedPubMedCentralGoogle Scholar
  32. Lim SK, Shin TY, Kim KH, Han WK, Chung BH, Hong SJ, Choi YD, Rha KH. Laparoendoscopic single-site (LESS) robot-assisted nephroureterectomy: comparison with conventional multiport technique in the management of upper urinary tract urothelial carcinoma. BJU Int. 2014;114(1):90–7.PubMedGoogle Scholar
  33. Mathieu R, Verhoest G, Vincendeau S, Manunta A, Bensalah K. Robotic-assisted laparoendoscopic single-site radical nephrectomy: first experience with the novel Da Vinci single-site platform. World J Urol. 2014;32(1):273–6.PubMedGoogle Scholar
  34. Mattevi D, Luciani LG, Vattovani V, Chiodini S, Puglisi M, Malossini G. First case of robotic laparoendoscopic single-site radical prostatectomy with single-site VesPa platform. J Robot Surg. 2018;12(2):381–5.PubMedGoogle Scholar
  35. Maurice MJ, Ramirez D, Kaouk JH. Robotic laparoendoscopic single-site retroperitioneal renal surgery: initial investigation of a purpose-built single-port surgical system. Eur Urol. 2017;71(4):643–7.PubMedGoogle Scholar
  36. Micali S, Isgro G, De Stefani S, Pini G, Sighinolfi MC, Bianchi G. Retroperitoneal laparoendoscopic single-site surgery: preliminary experience in kidney and ureteral indications. Eur Urol. 2011;59(1):164–7.PubMedGoogle Scholar
  37. Morelli L, Guadagni S, Caprili G, Di Candio G, Boggi U, Mosca F. Robotic right colectomy using the Da Vinci Single-Site(R) platform: case report. Int J Med Robot. 2013;9(3):258–61.PubMedGoogle Scholar
  38. Nagele U, Walcher U, Herrmann TR. Initial experience with laparoscopic single-incision triangulated umbilical surgery (SITUS) in simple and radical nephrectomy. World J Urol. 2012;30(5):613–8.PubMedGoogle Scholar
  39. Nguyen NT, Hinojosa MW, Smith BR, Reavis KM. Single laparoscopic incision transabdominal (SLIT) surgery-adjustable gastric banding: a novel minimally invasive surgical approach. Obes Surg. 2008;18(12):1628–31.PubMedGoogle Scholar
  40. Nguyen NT, Reavis KM, Hinojosa MW, Smith BR, Wilson SE. Laparoscopic transumbilical cholecystectomy without visible abdominal scars. J Gastrointest Surg. 2009;13(6):1125–8.PubMedGoogle Scholar
  41. Park YH, Kim KT, Ko K, Kim HH. Prospective randomized controlled trial of conventional laparoscopic versus laparoendoscopic single-site radical nephrectomy for localized renal cell carcinoma: a preliminary report regarding quality of life. World J Urol. 2015;33(3):367–72.PubMedGoogle Scholar
  42. Park J, Lee SB, Cho SY, Jeong CW, Son H, Park YH, Kim HH, Rashid IA, Jeong H. Comparison of the efficacy and safety of laparoendoscopic single-site surgery with conventional laparoscopic surgery for upper ureter or renal pelvis stones in a single institution: a randomized controlled study. Urol J. 2016;13(4):2759–64.PubMedGoogle Scholar
  43. Petrotos AC, Molinelli BM. Single-incision multiport laparoendoscopic (SIMPLE) surgery: early evaluation of SIMPLE cholecystectomy in a community setting. Surg Endosc. 2009;23(11):2631–4.PubMedGoogle Scholar
  44. Pietrabissa A, Abelli M, Spinillo A, Alessiani M, Zonta S, Ticozzelli E, Peri A, Dal Canton A, Dionigi P. Robotic-assisted laparoscopic donor nephrectomy with transvaginal extraction of the kidney. Am J Transplant. 2010;10(12):2708–11.PubMedGoogle Scholar
  45. Ponsky LE, Cherullo EE, Sawyer M, Hartke D. Single access site laparoscopic radical nephrectomy: initial clinical experience. J Endourol. 2008;22(4):663–6.PubMedGoogle Scholar
  46. Ponsky LE, Steinway ML, Lengu IJ, Hartke DM, Vourganti S, Cherullo EE. A Pfannenstiel single-site nephrectomy and nephroureterectomy: a practical application of laparoendoscopic single-site surgery. Urology. 2009;74(3):482–5.PubMedGoogle Scholar
  47. Rabenalt R, Arsov C, Giessing M, Winter C, Albers P. Extraperitoneal laparo-endoscopic single-site radical prostatectomy: first experience. World J Urol. 2010;28(6):705–8.PubMedGoogle Scholar
  48. Rais-Bahrami S, Montag S, Atalla MA, Andonian S, Kavoussi LR, Richstone L. Laparoendoscopic single-site surgery of the kidney with no accessory trocars: an initial experience. J Endourol. 2009;23(8):1319–24.PubMedGoogle Scholar
  49. Rais-Bahrami S, Rizkala ER, Cadeddu JA, Tugcu V, Derweesh IH, Abdel-Karim AM, Kawauchi A, George AK, Autorino R, Bagrodia A, Sonmezay E, Elsalmy S, Liss MA, Harrow BM, Kaouk JH, Richstone L, Stein RJ. Laparoendoscopic single-site pyeloplasty: outcomes of an international multi-institutional study of 140 patients. Urology. 2013;82(2):366–72.PubMedGoogle Scholar
  50. Raman JD, Cadeddu JA, Rao P, Rane A. Single-incision laparoscopic surgery: initial urological experience and comparison with natural-orifice transluminal endoscopic surgery. BJU Int. 2008;101(12):1493–6.PubMedGoogle Scholar
  51. Raman JD, Bagrodia A, Cadeddu JA. Single-incision, umbilical laparoscopic versus conventional laparoscopic nephrectomy: a comparison of perioperative outcomes and short-term measures of convalescence. Eur Urol. 2009;55(5):1198–204.PubMedGoogle Scholar
  52. Ramirez D, Maurice MJ, Kaouk JH. Robotic perineal radical prostatectomy and pelvic lymph node dissection using a purpose-built single-port robotic platform. BJU Int. 2016;118(5):829–33.PubMedGoogle Scholar
  53. Rane A, Rao P, Bonadio F, Rao P. Single port laparoscopic nephrectomy using a novel laparoscopic port (R-port) and evolution of single laparoscopic port procedure (SLIPP). J Endourol. 2007;21.(Suppl. 1:A287.Google Scholar
  54. Rane A, Rao P, Rao P. Single-port-access nephrectomy and other laparoscopic urologic procedures using a novel laparoscopic port (R-port). Urology. 2008;72(2):260–3; discussion 3–4.PubMedGoogle Scholar
  55. Rane A, Ahmed S, Kommu SS, Anderson CJ, Rimington PD. Single-port ‘scarless’ laparoscopic nephrectomies: the United Kingdom experience. BJU Int. 2009;104(2):230–3.PubMedGoogle Scholar
  56. Rao PP, Rao PP. LESS and NOTES: history and introduction. In: Smith AD, Badlani G, Preminger GM, Kavoussi LR, editors. Smith’s textbook of endourology. 3rd ed. Hoboken: Wiley-Blackwell; 2012. p. 1241–7.Google Scholar
  57. Rao P, Rao S, Rane A, Bonadio F, Rao P. Evaluation of the R port for single laparoscopic port procedures (SLAPP): a study of 20 cases. Surg Endosc. 2008;22(1):S279.Google Scholar
  58. Rao A, Kynaston J, MacDonald ER, Ahmed I. Patient preferences for surgical techniques: should we invest in new approaches? Surg Endosc. 2010;24(12):3016–25.PubMedGoogle Scholar
  59. Rehman H, Ahmed I. Technical approaches to single port/incision laparoscopic appendicectomy: a literature review. Ann R Coll Surg Engl. 2011;93(7):508–13.PubMedPubMedCentralGoogle Scholar
  60. Rieger NA, Lam FF. Single-incision laparoscopically assisted colectomy using standard laparoscopic instrumentation. Surg Endosc. 2010;24(4):888–90.PubMedGoogle Scholar
  61. Sendag F, Akdemir A, Oztekin MK. Robotic single-incision transumbilical total hysterectomy using a single-site robotic platform: initial report and technique. J Minim Invasive Gynecol. 2014;21(1):147–51.PubMedGoogle Scholar
  62. Sotelo RJ, Astigueta JC, Desai MM, Canes D, Carmona O, De Andrade RJ, Moreira O, Lopez R, Velasquez A, Gill IS. Laparoendoscopic single-site surgery simple prostatectomy: initial report. Urology. 2009;74(3):626–30.PubMedGoogle Scholar
  63. Stolzenburg JU, Hellawell G, Kallidonis P, Do M, Haefner T, Dietel A, Liatsikos EN. Laparoendoscopic single-site surgery: early experience with tumor nephrectomy. J Endourol. 2009;23(8):1287–92.PubMedGoogle Scholar
  64. Swain P. Nephrectomy and natural orifice translumenal endoscopy (NOTES): transvaginal, transgastric, transrectal, and transvesical approaches. J Endourol. 2008;22(4):811–8.PubMedGoogle Scholar
  65. Tiu A, Kim KH, Shin TY, Han WK, Han SW, Rha KH. Feasibility of robotic laparoendoscopic single-site partial nephrectomy for renal tumors >4 cm. Eur Urol. 2013;63(5):941–6.PubMedGoogle Scholar
  66. Tracy CR, Raman JD, Cadeddu JA, Rane A. Laparoendoscopic single-site surgery in urology: where have we been and where are we heading? Nat Clin Pract Urol. 2008;5(10):561–8.PubMedGoogle Scholar
  67. Tracy CR, Raman JD, Bagrodia A, Cadeddu JA. Perioperative outcomes in patients undergoing conventional laparoscopic versus laparoendoscopic single-site pyeloplasty. Urology. 2009;74(5):1029–34.PubMedGoogle Scholar
  68. Tugcu V, Ilbey YO, Mutlu B, Tasci AI. Laparoendoscopic single-site surgery versus standard laparoscopic simple nephrectomy: a prospective randomized study. J Endourol. 2010;24(8):1315–20.PubMedGoogle Scholar
  69. White MA, Haber GP, Autorino R, Khanna R, Forest S, Yang B, Altunrende F, Stein RJ, Kaouk JH. Robotic laparoendoscopic single-site radical prostatectomy: technique and early outcomes. Eur Urol. 2010;58(4):544–50.PubMedGoogle Scholar
  70. Zeltser IS, Bergs R, Fernandez R, Baker L, Eberhart R, Cadeddu JA. Single trocar laparoscopic nephrectomy using magnetic anchoring and guidance system in the porcine model. J Urol. 2007;178(1):288–91.PubMedGoogle Scholar
  71. Zhu JF. Which term is better: SILS, SPA, LESS, E-NOTES, or TUES? Surg Endosc. 2009;23(5):1164–5.PubMedGoogle Scholar
  72. Zhu JF, Hu H, Ma YZ, Xu MZ, Li F. Transumbilical endoscopic surgery: a preliminary clinical report. Surg Endosc. 2009;23(4):813–7.PubMedGoogle Scholar

Copyright information

© Springer Nature Singapore Pte Ltd. 2019

Authors and Affiliations

  1. 1.Department of UrologyYonsei University College of MedicineSeoulSouth Korea
  2. 2.Department of UrologyHanyang University College of MedicineSeoulSouth Korea

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