Nephron sparing LESS: technique and review of the current literature

Background. Nephron-sparing surgery (NSS)ensures excellent oncological and functional outcomes in treating small renal masses. Laparo- Endoscopic-Single-Site Surgery (LESS)is one of the major advances in the evolution of minimally invasive surgery.

A prospective evaluation of patients underwent LESS NSS at our institutions for a solitary, exophytic, enhancing, small (= 4.0 cm) renal masses and normal controlateral kidney was done. Peri-operative, pathological, hematological data together with a subjective evaluation of the pain (VAS) and the scars were collected. A comprehensive electronic literature search was conducted in May 2011 using the Medline database to identify all publications relating to LESS NSS.

Fourteen patients were operated by a LESS unclamp NSS and 6 patients by a clamp LESS NSS (mean operative time: 125 min and 137.4 min; mean blood loss: 207 ml and 113 ml). The mean warm ischemia time in the LESS clamped NSS was 11.1±2.4 min using an early unclamped technique. Neither conversion to open surgery nor transfusions occurred. Three patients required conversion to standard laparoscopy. Postoperatively, we recorded 1 Clavien II (acute gastritis), 1 Clavien IIIa (urinary fistula after NSS) and 1 Clavien IV (cerebral stroke) complications. Pathology revealed 13 T1a clear cell carcinoma, 4 complex renal cysts, 2 oncocytoma and 1 angiomyolipoma (surgical margin positive). With a minimal postoperative pain (VAP: 1.8 in POD1) the patients were discharged after 4.4 days without variation in eGFR. No local or distant progression was detected. Current literature suggest that LESS NSS can safely and effectively be performed in a variety of urologic settings and represent one of the major interests among the LESS procedures . Although, the quality of evidence of all available studies remains low, mostly being small case series or case control studies from selected centers.

LESS NSS in selected renal masses is feasible, provides postoperative outcomes overlapping the standard counterpart and ensures subjective satisfaction. A more extensive surgical experience and a prolonged follow-up are necessary to point out the role of this technique.