8. White MA, Haber GP, Kaouk JH. Robotic single-site surgery.Curr Opin Urol 2010;20:86–91.

9. Best SL, Donnally C, Mir SA, et al. Complications during theinitial experience with laparoendoscopic single-site pyelo-plasty. BJU Int 2011;108:1326–1329.

10. Joseph RA, Goh AC, Cuevas SP, et al. ‘‘Chopstick’’ surgery:A novel technique improves surgeon performance andeliminates arm collision in robotic single-incision laparo-scopic surgery. Surg Endosc 2010;24:1331–1335.

11. Kaouk JH, Goel RK, Haber GP, et al. Robotic single-porttransumbilical surgery in humans: Initial report. BJU Int2009;103:366–369.

12. White MA, Haber GP, Autorino R, et al. Robotic lapar-oendoscopic single-site radical prostatectomy: Techniqueand early outcomes. Eur Urol 2010;58:544–550.

13. Olweny EO, Park SK, Tan YK, et al. Perioperative compar-ison of robotic assisted laparoendoscopic single-site (LESS)pyeloplasty versus conventional LESS pyeloplasty. Eur Urol2012;61:410–414.

14. Stein RJ, White WM, Goel RK, et al. Robotic laparoendo-scopic single-site surgery using GelPort as the access plat-form. Eur Urol 2010;57:132–136.

Address correspondence to:Jeffrey A. Cadeddu, M.D.

Department of UrologyUT Southwestern Medical Center

5323 Harry Hines Blvd, J8.106Dallas, TX 75390-9110

E-mail: Jeffrey.Cadeddu@utsouthwestern.edu

Abbreviations UsedLESS¼ laparoendoscopic single-site

R-LESS¼ robot-assisted laparoendoscopic single-siteUPJ¼ureteropelvic junction

DOI: 10.1089/end.2012.0150

Editorial Comment for Seideman et al.

Lee Richstone, M.D.

Sometimes progress is made in giant leaps. Other times,progress is accomplished through small steps that offer

incremental benefits in their own right, or that ultimately,through a series of such small steps, result in major change.The move from a large open flank incision to three keyholeincisions represented a giant leap, a surgical revolution. Thepursuit of laparoendoscopic single-site (LESS) surgery orrobot-assisted LESS (R-LESS) has not yet proven to be sucha monumental step forward. LESS appears to be more ofan evolutionary step, helping to drive technology and spurinnovation.

The authors present a clear technical road map for how to‘‘take on’’ R-LESS pyeloplasty, but is LESS, or R-LESS, aworthwhile technique for urologists to embrace? Opinionsvary. If one is interested in LESS/R-LESS, however, it is likelyour young healthy patients with ureteropelvic junction ob-struction who are most likely to benefit. As demonstrated bythis same pioneering group, patients with benign diseasehave the most interest in cosmesis and limiting the number ofincisions.1 As endourologists, it would certainly be in keepingwith our central principles to attempt to limit the disfigure-ment associated with our interventions.

The claims presented by the authors are that R-LESS re-duces the difficulty of LESS and shortens the learning curve.The degree to which these conclusions hold true will signifi-cantly impact the diffusion of single-site surgery in urology.Even laparoscopic radical nephrectomy, let alone LESS pye-loplasty, is underutilized.2 This highlights the obvious factthat for a minimally invasive procedure to diffuse widely, itmust not be overly technically demanding, especially if otherforces (financial, industry, and/or marketing) are not putting

pressure on practice patterns.3 For LESS to grow into a com-monplace technique, it simply must be made easier. As it iscurrently practiced, LESS may not produce enough ‘‘juice’’ towarrant ‘‘all the squeezing.’’

Without doubt, robotic systems will be developed that willmake R-LESS simple and straightforward. Until such time, weare left trying to force current robotic platforms to succumb toour will. Do the techniques described here make R-LESS withthe current da Vinci Si system straightforward enough to gainwidespread acceptance? You be the judge.

References

1. Olweny EO, Mir SA, Best SL, et al. Importance of cosmesis topatients undergoing renal surgery: A comparison of lapar-oendoscopic single-site (LESS), laparoscopic and open sur-gery. BJU Int 2011 Dec 16. Epub ahead of print.

2. Miller DC, Saigal CS, Banerjee M, et al, and the UrologicDiseases in America Project. Diffusion of surgical innovationamong patients with kidney cancer. Cancer 2008;112:1708–1717.

3. Richstone L, Kavoussi LR. Barriers to the diffusion of ad-vanced surgical techniques. Cancer 2008;112:1646–1649.

Address correspondence to:Lee Richstone, M.D.

Department of UrologyNorthshore-LIJ Health System

450 Lakeville Road, Suite M41New Hyde Park, NY 11040

E-mail: lrichsto@nshs.edu

974 SEIDEMAN ET AL.