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Sir,

Laparoendoscopic single-site surgery (LESS) and natural orifice translumenal endoscopic surgery (NOTES), are new methods in minimally invasive surgery [1], and have recently been used successfully in many urological procedures in the live human patients [2–6]. LESS encompasses terminology including single-port (access/incision) laparoscopic surgery (SILS), scarless surgery and one-port umbilical surgery (OPUS). It is anticipated that NOTES and LESS will represent a change in urological minimal access surgery since Clayman et al.[7] first described laparoscopic nephrectomy in 1991. We would like to make a few key points of caution about certain training issues.

Skill acquisition and delivery in conventional laparoscopic urological surgery has been noted to be expensive, restrictive, beset with medicolegal issues, and places huge burdens on trainees and mentors. Despite this there is currently an exponential uptake of laparoscopic urological surgery among trainees. With the recent advances of LESS and NOTES in urology, the uptake of skills will be a considerable challenge, as these techniques demand additional skill sets and technical expertise when compared with conventional laparoscopic surgery. This realisation is further reinforced by preliminary data based on training modules, which suggest that the new methods are very difficult to master [8]. LESS and NOTES also require purpose-built instrumentation for optimal performance of a given case. These instruments are expensive and not easily accessible for training in the ex vivo, animal or live human case modules.

To meet the growing challenges of skill acquisition and delivery in the transition from conventional surgery to LESS and NOTES, it is inevitable that further rethinking is required for training, in the form of sequential skills ‘steeplechase’ exercise modules. Additionally dedicated training ‘hot-spots’[9] should be set up in a widespread and easily accessible format. The onus is on programme directors to incorporate these modules for rapid sequential acquisition of skills, in tandem with the continually developing surgical techniques. There is also a need for a global forum in which a standardised format for training in LESS and NOTES can be established. We propose that trainee-directed tools should be made accessible on a much larger scale than currently, to maintain a high and safe level of skill sets. We also propose that consensus groups be established to reach a common and standardised approach geared towards achieving optimal conventional laparoscopic skills in the first instance. This will then present a template and baseline for trainees to advance to the more challenging LESS and NOTES platform. The role of industry sponsorship, coupled with cost-conscious methods of optimal skill acquisition and delivery, should also be explored further.