Prospective evaluation with standardised criteria for postoperative
complications after laparoendoscopic single-site surgery for upper
urinary tract diseases.
Francesco Grecoa*, Luca Cindolob*, Riccardo Autorinoc, Salvatore Micalid, Giampaolo
Bianchid, Caterina Fanizzae, Jihad Kaoukc, Luigi Schipsb, Paolo Fornaraa
a
Department of Urology and renal transplantation, Martin-Luther-University, Halle/Saale,
Germany
b
Department of Urology, “S. Pio da Pietrelcina’’ Hospital, Vasto (CH), Italy
c
Department of Urology, Cleveland Clinic Foundation, Cleveland, USA
d
Department of Urology, University of Modena, Italy
e
Department of Clinical Pharmacology and Epidemiology, Consorzio Mario Negri Sud, Santa
Maria Imbaro, Italy
Keywords: laparoendoscopic single-site surgery, renal diseases, outcomes,
complications
Objectives: LESS has been developed in an attempt to further reduce the morbidity
and scarring associated with surgical intervention. Early clinical series have
demonstrated the feasibility as well as the safe and successful completion of LESS
urologic procedures. Herein, we evaluate the incidence and the risk factors of
complications in a series of patients who have undergone LESS for upper urinary
tract diseases. Materials and Methods: Between September 2007 and February
2011, all consecutive patients underwent LESS for upper urinary tract diseases at
four institutions. Data were collected in a prospective multi-institutional database
(demographic, preoperative and postoperative variables,intraoperative data,
pathological reports. Also postoperative pain by VAPS at the discharge, incision
length and subjective scar satisfaction were collected. All complications classified as
early (onset: <30d), intermediate (onset: 31–90d), or late (onset: >90 d) occurring at
any time after surgery were captured. For late complications, those deemed to be
related or possibly related to LESS were captured, regardless of how long after
surgery the onset occurred. All complications were recorded according to the
modified Clavien classification.
Results: 192 patients were enrolled (84% extripative, 16% reconstructive), mean age
55±18y, mean BMI 26.5±4.8kg/m2. The mean operative time was 164±63min (mean
EBL 147±221ml). In 40% the surgeons required additional ports, with a 6% (12/192)
of standard laparoscopy conversion (4 difficulties during dissection and exposure and
8 cases demanding suture).
Mean hospital stay 3.3±2.3d, mean VAPS 1.7±1.43. The mean length of skin incision
was 3.97± 1.33 cm. 33 complications were recorded (30 early,2 intermediate,1 late)
with a 17% of overall complication rate. Statistically significant associations were
found between the occurrence of a complication and age, ASA score, EBL, LOS, and
malignant disease. Interestingly no associations between complications and BMI,
comorbidities, kind of surgery, use of additional ports, complexity score were
recorded.
The univariate and the multivariate analyses confirmed that higher ASA score (IRR
1.4,CI1.0-2.1 p=0,034) and an oncological indication (IRR 2.5,CI1.3-4.7 p=0,039)
represent risk factor for complications.
Conclusion
The LESS surgery for upper urinary tract is technically feasible for a variety of
ablative and reconstructive applications, offering high patient satisfaction and
shortened convalescence. With proper patient selection, conversion and
complications rates are low. Further clinical research is warranted to determine
selection criteria, to fully prove the benefits over conventional laparoscopy and define
the role of LESS in the field of minimally invasive surgery. Nevertheless malignant
disease at pathology represents a predictive factor for complication so that LESS in
urologic malignancies requires a more careful selection of the patients. In these
cases an additional trocar can be required and reduce the complications rate.