This paper is a matched comparison of laparoendoscopic single-site surgery (LESS) pyeloplasty and laparoscopic multiport pyeloplasty in a small cohort of patients. It comes from the Cleveland Clinic, which has published several preliminary reports on LESS and natural orifice transluminal endoscopic surgery (NOTES). Despite their initial enthusiasm this article has almost ‘killed’ LESS pyeloplasty. What a pity it is retrospective. The authors are to be congratulated for using patient-reported outcome measures (PROMS) in addition to clinical and radiological evaluation. This reduces surgical bias and reflects what our patients really think the outcomes are.

There are several important issues that emerge in this paper. Some may argue that the addition of a 2-mm port for suturing, however tiny, does not make this LESS anymore. Technically speaking this would be correct but in reality it shows the difficulty of laparoscopic suturing through a single port, even by experts. Therefore the authors justify the use of an additional port away from the single port. The operating duration may not be statistically significant between the two groups but the P-value of 0.055 indicates it is clinically significant, i.e., LESS pyeloplasty takes longer than laparoscopic pyeloplasty. I also suspect that if statistically adjusted for body mass index, which was lower in the LESS group, the operating duration would be significant longer for LESS pyeloplasty. In addition to the non-validated questionnaire, a validated tool such as the Client Satisfaction Questionnaire (CSQ-8) or a validated health-related quality-of-life (HRQL) measure, although generic, may have helped. A Borg score of perceived surgical fatigue, as mentioned in the discussion may have been useful. If LESS causes more fatigue, takes longer and does not improve cosmesis or HRQL, it would be dead for pyeloplasty. Perhaps its use would be restricted to those patients who do not want any visible scar where the incision would be completely hidden at the umbilicus. A prospective trial with validated tools is likely to provide the answer.

That being said there have been several recent developments that may make LESS clinically attractive. Our industry partners are pouring considerable resources into LESS. I can remember, until recently, standing in a crowded position with my hands close to each other, straining my shoulders trying to perform LESS cystectomy in a ‘wet lab’. Now there are LESS ports with multiple staggered portals for access that would leave channels free for an assistant to use a sucker, clips and staplers. The lenses are smaller, flexible and offset and the instruments are bent so that the surgeon can stand comfortably and regain the principle of triangulation. The ergonomics of this was evident during a simulation laboratory run at Guy’s Hospital a few weeks ago (Olympus UK; STeLi, Simulation and Technology Enhanced Learning Initiative).

There is renewed interest in LESS robotics (Intuitive Surgical, CA, USA). The lenses are smaller and the ports and instruments are flexible, so as to provide triangulation at the operating site. Although not yet USA Food and Drug Administration approved, several of us tried this new technology at ‘The World Robotics Symposium, Florida 2010’ and it is expected that this platform will available with the da Vinci Si system later this year. The one disadvantage is that while the instruments are smaller and flexible, they are not endowristed at the tips. This means that the robotic surgeon has to re-learn laparoscopic suturing, although it is easier with this technology than pure LESS laparoscopic suturing. Perhaps the answer lies in using a flexible robotic instrument in one hand and a 5-mm endowristed snake-head instrument in the other. The other exciting development is the Insertable Robotic Effector Platform (IREP). This is a straight endoscope that once inserted opens up into a flexible miniature camera and two fully flexible robotic arms. For those interested in flexible robotics, the IREP video is available on YouTube.