title: Nephron sparing LESS: technique and review of the current literature.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Urology Unit, S. Pio da Pietrelcina Hospital, Vasto (CH), Italy. lucacindolo@virgilio.it
authors.forename: Luca
authors.initials: L
authors.lastname: Cindolo
authors.forename: Francesco
authors.initials: F
authors.lastname: Greco
authors.forename: Paolo
authors.initials: P
authors.lastname: Fornara
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Mirone
authors.forename: Luigi
authors.initials: L
authors.lastname: Schips
mesh_terms: D018262:Adenocarcinoma, Clear Cell / Q000601:surgery; D000368:Aged; D002292:Carcinoma, Renal Cell / Q000601:surgery; D016022:Case-Control Studies; D004724:Endoscopy / Q000379:methods*; D005260:Female; D006801:Humans; D007668:Kidney / Q000601:surgery*; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D009392:Nephrectomy / Q000379:methods*; D009399:Nephrons / Q000601:surgery*; D011446:Prospective Studies; D013525:Surgical Instruments; D016896:Treatment Outcome