he presented with a 10-year history of voiding difficulty . before this presentation , a digital rectal examination revealed bilateral enlargement of the prostatic lobes . under a clinical diagnosis of bph , he was administered tamsulosin 0.2 mg once with the insertion of a urethral foley catheter . transrectal ultrasonography revealed that the volume of the prostate was approximately 136 ml ( fig . his prostate - specific antigen level was 2.12 ng / ml . two weeks later , a pressure flow study ( pfs ) was performed to evaluate his voiding symptoms and showed an obstructive pattern and normal detrusor function according to the international continence society and schffer nomogram ( fig . 1c ) . his maximal urine flow rate ( qmax ) was 9 ml / sec on the pfs . simple x - ray and computed tomography ( ct ) scan suggested the presence of several bladder stones . we decided to perform concomitant lessv and step under a diagnosis of bladder stones and bph . informed consent was obtained after a complete description of the less with the use of a homemade single - port device . with the patient under general anesthesia , a midline incision of approximately 3 cm was made at the level of three fingerbreadths above the symphysis pubis , followed by a dissection to reach the bladder . the anterior wall of the bladder was then incised at approximately 2 cm to minimize the bladder wall and port - device . pneumovesicum was formed while maintaining 12 cm h2o pressure . using a 10-mm rigid laparoscope ( conmed linvatec , largo , fl , usa ) , the prostatic adenoma , urethral foley catheter , and bilateral ureteral orifices urinary drainage was halted to prevent gas leakage , and the urethral catheter tip was then moved to the bladder neck . using rigid instruments , the bladder stones were grasped and extracted through a hole in another finger of the glove . after removal of the bladder stones , a dissection was made starting from the right prostatovesical junction using a rigid laparoscopic dissector and an enseal trio tissue sealing device ( ethicon endo - surgery inc . , air ventilation was continuously maintained to minimize vesical neuromuscular trauma due to visual field securing and pneumovesicum . after sufficient dissection of the huge adenoma , the port - device was removed . using ellis forceps , the huge adenoma was pulled outward and the index finger was inserted into the dissection plane as described in a previous report . the suprapubic catheter was used to make up for the obstruction of the urethral catheter . the bladder was sutured with 3 layers , and the skin was approximated by using a skin stapler ( 3 m precise skin stapler , 3 m co. , preston , mn , usa ) . the suprapubic and urethral catheter were removed on the 7th and 8th postoperative day , respectively . first reported step for large bph using an r - port ( advanced surgical concepts , wicklow , ireland ) between 2008 and 2009 . the two groups of desai and sotelo jointly reported 34 cases of step including a case of r - less in 2010 . in their study , the authors conducted the enucleation by using electrocautery and ultrasonic shears under laparoscopic video assistance . interestingly , oh and park   reported 32 cases of f - step in the treatment of a huge prostate following desai et al . in their study , they reported a new enucleation method using fingers and excellent outcomes . after the prostatic capsule was dissected with the use of articulating instruments , traction suturing was performed on the prostatic adenoma . the adenoma was enucleated by using the index finger after removing the homemade single - port device . in our case , we used the same method to remove the prostatic adenoma , because the prostatic adenoma was too large to remove with the use of laparoscopic instruments . in fact , use of less for the primary treatment of urological cancers might be limited because of issues such as the extraction method of the specimen and maintaining oncologic principles . the ideal indications for less may be pediatric urologic diseases and benign , non - life - threatening diseases . recently , kaouk et al .   reported a worldwide multi - institutional analysis of 1,076 cases of less in urology . in their study , malignant disease including renal tumor , adrenal tumor , prostate cancer , and bladder cancer made up approximately 46.6% of the sample . more than half of the cases were benign disease , for which less was performed . in benign urologic disease , there were 42 cases ( 3.9% ) of less for bph including step . to the best of our knowledge , concomitant lessv and f - step have not been reported in previous studies . step was estimated to be a very difficult procedure according to autorino et al . . however , it may be more advantageous for surgeons with experience in less or conventional laparoscopy , but may show a steep learning curve as shown for holmium laser enucleation of the prostate ( holep ) or an even steeper learning curve in surgeons without experience in less or conventional laparoscopy . although step has better cosmesis than open surgery , it may require a suprapubic catheter and may have an external wound compared to turp or holep . however , step or f - step might be a viable treatment option in patients with huge prostate of more than 80 ml . in our case , the concomitant lessv and f - step has some advantages , as follows : urethra and bladder neck injuries may occur due to the long - time use of a rigid resectoscope , but they can be prevented in concomitant lessv and f - step . meanwhile , no suturing with laparoscopic instruments is required in f - step as compared with pyelolithotomy or ureterolithotomy . for a large bladder stone in addition , the single incision in the concomitant lessv and f - step without the need for a position change is an important advantage . our case suggests that concomitant lessv and f - step can be used as an alternative technique in the treatment of huge bph with huge prostate and bladder stones , for which open surgery is usually performed .
transurethral resection of the prostate is the most common surgery for benign prostatic hyperplasia . 
 however , it does n't work best for men with very large prostate and bladder stones . 
 herein we report our initial experience with concomitant laparoendoscopic single - site surgery and finger - assisted single - port transvesical enucleation of the prostate for the treatment of the condition .